Community midwives' acceptability in their communities: A qualitative study from two provinces of Pakistan

Objectivesthis study was aimed to understand in depth how the community midwives (CMWs) in Pakistan perceive are the important factors for their acceptability and community related barriers to their practice of maternal and child health care services.Designqualitative study design using in-depth interviews (IDIs) and focus group discussions (FGDs).Settingtwo districts in Khyber Pakhtunkhwa and Punjab provinces in Pakistan.Participantswe used qualitative study design and conducted 34 in depth interviews (IDIs) and 9 focus group discussions (FGDs) with 100 participants which included CMWs, lady health supervisors (LHSs) and managers in maternal neonatal and child health (MNCH) program of two provinces of Pakistan.Measurementscontent analysis of the findings was performed manually and findings were arranged in relevant themes originating from the study.FindingsCMWs in our study experienced restrictions from their families, especially husbands and in-laws, to be independently available to attend to women during pregnancy and delivery. Communication between the communities and MNCH program was found to be weak therefore CMWs had to struggle to win the trust of and persuade pregnant women to use their services. Most CMWs attributed low utilization of their services to inherent taboos prevalent in the communities under which they relied more on unskilled traditional birth attendants (TBAs). Gender sensitivity and fears of insecurity in many conflict hit areas affected CMWs' mobility within their own communities which affected the access of rural women to skilled maternal and child care.     

Severe maternal morbidity among immigrant women in the Netherlands: patients' perspectives

This 2006 study investigated ethnicity-related factors contributing to sub-standard maternity care and the effects on severe maternal morbidity among immigrant women in the Netherlands. In-depth interviews were carried out with 40 immigrant and 10 native Dutch women. The immigrant women reported that health care providers often paid insufficient attention to their pregnancy-related complaints, especially in cases of pre-eclampsia. They also reported delays in receiving information about diagnosis and treatment. Obstetricians who reviewed 20 of these cases judged sub-standard care to have played a role in the development of complications in 16 of them. The women themselves had problems identifying medically significant complications, presenting their complaints to health care providers effectively, and taking an active role as patients. Even highly educated migrant women showed low health literacy skills in their interaction with doctors. Patients' perspectives are valuable as one of the tools to evaluate the quality of maternity care. Communication by maternal health professionals can be improved through more sensitivity to social factors that affect immigrant women's health problems. Women with limited health literacy should be empowered through education about danger signs in pregnancy and information about preferences and policies in obstetrics in the Netherlands. They should also be invited to participate in medical decision-making.     

Trial protocol OPPTIMUM– Does progesterone prophylaxis for the prevention of preterm labour improve outcome?

Background

Maternal, neonatal and child health outcomes are worse in families from black and ethnic minority groups and disadvantaged backgrounds. There is little evidence on whether lay support improves maternal and infant outcomes among women with complex social needs within a disadvantaged multi-ethnic population in the United Kingdom (UK).

Method/Design

The aim of this study is to evaluate a lay Pregnancy Outreach Worker (POW) service for nulliparous women identified as having social risk within a maternity service that is systematically assessing social risks alongside the usual obstetric and medical risks. The study design is a randomised controlled trial (RCT) in nulliparous women assessed as having social risk comparing standard maternity care with the addition of referral to the POW support service. The POWs work alongside community midwifery teams and offer individualised support to women to encourage engagement with services (health and social care) from randomisation (before 28 weeks gestation) until 6 weeks after birth. The primary outcomes have been chosen on the basis that they are linked to maternal and infant health. The two primary outcomes are engagement with antenatal care, assessed by the number of antenatal visits; and maternal depression, assessed using the Edinburgh Postnatal Depression Scale at 8-12 weeks after birth. Secondary outcomes include maternal and neonatal morbidity and mortality, routine child health assessments, including immunisation uptake and breastfeeding at 6 weeks. Other psychological outcomes (self efficacy) and mother-to-infant bonding will also be collected using validated tools. A sample size of 1316 will provide 90% power (at the 5% significance level) to detect increased engagement with antenatal services of 1.5 visits and a reduction of 1.5 in the average EPDS score for women with two or more social risk factors, with power in excess of this for women with any social risk factor. Analysis will be by intention to treat. Qualitative research will explore the POWs' daily work in context. This will complement the findings of the RCT through a triangulation of quantitative and qualitative data on the process of the intervention, and identify other contextual factors that affect the implementation of the intervention.

Discussion

The trial will provide high quality evidence as to whether or not lay support (POW) offered to women identified with social risk factors improves engagement with maternity services and reduces numbers of women with depression.

MREC number

10/H1207/23

Trial registration number

ISRCTN: ISRCTN35027323     

Towards elimination of maternal deaths: maternal deaths surveillance and response

Current methods for estimating maternal mortality lack precision, and are not suitable for monitoring progress in the short run. In addition, national maternal mortality ratios (MMRs) alone do not provide useful information on where the greatest burden of mortality is located, who is concerned, what are the causes, and more importantly what sub-national variations occur. This paper discusses a maternal death surveillance and response (MDSR) system. MDSR systems are not yet established in most countries and have potential added value for policy making and accountability and can build on existing efforts to conduct maternal death reviews, verbal autopsies and confidential enquiries. Accountability at national and sub-national levels cannot rely on global, regional and national retrospective estimates periodically generated from academia or United Nations organizations but on routine counting, investigation, sub national data analysis, long term investments in vital registration and national health information systems. Establishing effective maternal death surveillance and response will help achieve MDG 5, improve quality of maternity care and eliminate maternal mortality (MMR?≤?30 per 100,000 by 2030).     

Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome

Rates of maternal morbidity and mortality are rising in the United States. Non-Hispanic Black women are at highest risk for these outcomes compared to those of other race/ethnicities. Black women are also more likely to be late to prenatal care or be inadequate users of prenatal care. Prenatal care can engage those at risk and potentially influence perinatal outcomes but further research on the link between prenatal care and maternal outcomes is needed. The objective of this article is to review literature illuminating the relationship between prenatal care utilization, social determinants of health, and racial disparities in maternal outcome. We present a theoretical framework connecting the complex factors that may link race, social context, prenatal care utilization, and maternal morbidity/mortality. Prenatal care innovations showing potential to engage with the social determinants of maternal health and address disparities and priorities for future research are reviewed.     

Barriers to access adequate maternal care in Romania,Bulgaria, and Moldova: A cross-country comparison

Background

Eastern European health system indicators (e.g., number of health workers and care coverage) suggest well-resourced maternity care systems, but maternal health outcomes compare poorly with those in Western Europe. Often, poor maternal health outcomes are linked to inequities in accessing adequate maternal care. This study investigates access-related barriers (availability, appropriateness, affordability, approachability, and acceptability) to maternity care in Romania, Bulgaria, and Moldova.

Methods

This cross-country study (n = 7345) is based on an online survey where women who received maternity care and gave birth in 2015–2018 in Bulgaria (n = 4951), Romania (n = 2018), and Moldova (n = 376) provided information on their experiences with the care received. We used regression analysis to identify factors associated with accessing maternity care across the three countries.

Results

Results show high rates of cesarean births (CB) and a low number of antenatal and postnatal care visits. Informal payments and use of personal connections are common practices. Formal and informal out-of-pocket payments create a financial burden for women with health complications. Women who had health complications, those who gave birth by cesarean, and women who gave birth in a public facility and had fewer antenatal check-ups, were more likely to describe facing access-related barriers.

Conclusions

This study identifies several barriers to high-quality maternity care in Romania, Bulgaria and Moldova. More attention should be paid to the appropriateness of care provided to women with complicated pregnancies, to those who have CBs, to women who give birth in public facilities, and to those who receive fewer antenatal care visits.     

Childbirth traditions and cultural perceptions of safety in Nepal: Critical spaces to ensure the survival of mothers and newborns in remote mountain villages

Objective

to uncover local beliefs regarding pregnancy and birth in remote mountainous villages of Nepal in order to understand the factors which impact on women's experiences of pregnancy and childbirth and the related interplay of tradition, spiritual beliefs, risk and safety which impact on those experiences.

Design

this study used a qualitative methodological approach with in-depth interviews framework within social constructionist and feminist critical theories.

Setting

the setting comprised two remote Nepalese mountain villages where women have high rates of illiteracy, poverty, disadvantage, maternal and newborn mortality, and low life expectancy. Interviews were conducted between February and June, 2010.

Participants

twenty five pregnant/postnatal women, five husbands, five mothers-in-law, one father-in-law, five service providers and five community stakeholders from the local communities were involved.

Findings

Nepalese women, their families and most of their community strongly value their childbirth traditions and associated spiritual beliefs and they profoundly shape women's views of safety and risk during pregnancy and childbirth, influencing how birth and new motherhood fit into daily life. These intense culturally-based views of childbirth safety and risk conflict starkly with the medical view of childbirth safety and risk.

Key conclusions and implications for practice

if maternity services are to improve maternal and neonatal survival rates in Nepal, maternity care providers must genuinely partner with local women inclusive of their cultural beliefs, and provide locally based primary maternity care. Women will then be more likely to attend maternity care services, and benefit from feeling culturally safe and culturally respected within their spiritual traditions of birth supported by the reduction of risk provided by informed and reverent medicalised care.     

Consequences of birth policies and practices in post-reform China

This paper comments on the provision of birthing services in Sichuan and Shanxi Provinces in China within a policy context. The goal was to understand possible unintended and harmful health outcomes for women in the light of international evidence, to better inform practice and policy development. Data were collected from October 2005 to April 2007 in 25 hospitals across 13 counties and one city. Normal and caesarean birth records were audited, observations made of facilities and interviews conducted with officials, administrators, health workers, women who delivered in hospital facilities and women who delivered at home. We argue that in the context of a neo-liberal health economy with poorly developed government regulatory policies, those with the power to pay for maternity care may be vulnerable to a new range of risks to their health from those positioned to make a profit. While poor communities may lack access to basic services, wealthier socio-economic groups may risk an increase in maternal morbidity and mortality through the overuse of avoidable intervention. We recommend a stronger evidence base for hospital maternity services and changes to the role of the State in countering systemic problems.     

The Effect of Language on Lesbian Nonbirth Mothers

ObjectiveTo explore how language affects the transition of social (nonbirth) mothers into motherhood.DesignNonexperimental, qualitative design.SettingThis study took place in large, urban city located on the East Coast. Interviews were conducted in a private location within the social mother's home or in a private room at a coffee shop.ParticipantsTwenty women who became social mothers through donor insemination with their female partners within the previous 24 months.MethodsIn depth, semistructured interviews lasting from 45 minutes to 90 minutes.ResultsThe transition to motherhood for social mothers is influenced by the use of language at the individual (social mother), family (mommy, mama, or something else), community (heterosexism of health care providers), and societal (education equals validation) levels. At present, a common language for or understanding of nonbirth mothers and their motherhood roles does not exist. Health care providers, including doctors, nurses, and office personnel working in maternal and child health settings, can help social mothers transition into motherhood by validating and recognizing their maternal roles through the use of written and spoken language.ConclusionBy understanding how language affects the transition of social mothers to motherhood and by addressing their needs, health care providers can deliver better support to social mothers and their families.     

Delivering Diversity: Newly Regulated Midwifery Returns to Manitoba,Canada, One Community at A Time

Through its publicly funded health care system, Canada is committed to offering accessible, quality maternity health services to all its citizens, yet this remains a challenge in its First Nations, rural and immigrant communities. With the implementation of midwifery as a self‐regulating health profession in Manitoba, Canada, in 2000, initiatives were incorporated into the structure of the profession to try to address this issue. This qualitative investigation documents and explores these initiatives through a case study combining semistructured interviews and documentary sources. The innovations discussed include the development of an Aboriginal midwifery degree program, the supports put in place to assist rural midwifery practices, and the efforts to increase ethnic diversity and cultural competence within the midwifery profession. What unites these efforts is a community building approach which attempts to strengthen communities through local midwifery services and midwives drawn from community members.     

A Planning Checklist for Interprofessional Consultations for Women in Midwifery Care

Team‐based, interprofessional models of maternity care can allow women to receive personalized care based on their health needs and personal preferences. However, involvement of multiple health care providers can fragment care and increase communication errors, which are a major cause of preventable maternal morbidity and mortality. In order to improve communication within one health system, a community‐engaged approach was used to develop a planning checklist for the care of women who began care with midwives but developed risks for poor perinatal outcomes. The planning checklist was constructed using feedback from women, nurses, midwives, and physicians in one interprofessional, collaborative network. In feasibility testing during 50 collaborative visits, the planning checklist provided a prompt to generate a comprehensive plan for maternity care and elucidate the rationale for interventions to women and future health care providers. In interviews after implementation of the checklist within a new collaborative format of prenatal physician consultations, women were pleased with the information received, and nurses, midwives, and physicians were positive about improved communication. This tool, developed with stakeholder input, was easy to implement and qualitatively beneficial to satisfaction and health system function. This article details the creation, implementation, and qualitative evaluation of the planning checklist. The checklist is provided and can be modified to meet the needs of other health systems.     

Stillbirth, neonatal death and reproductive rights in Indonesia

Globally, newborn deaths account for two-thirds of all deaths in the first year of life and 40% of under-five mortality. As infant mortality declines, the proportion of neonatal deaths has been increasing because of the failure to address the causes. The data in this paper derive from a longitudinal study of motherhood and emotional well-being of women in Indonesia; 488 women were interviewed in late pregnancy, and 290 at six weeks post-partum. This paper reports on in-depth interviews with four women who reported a stillbirth and six who reported a neonatal or infant death. They were asked about their understanding of why their baby had died and the information, care and support given to them. The study suggests that maternal and child health clinics fail to protect and fulfill pregnant women's reproductive rights, specifically the right to information and care for themselves and their infants, informed consent, counselling and to be treated with respect. This can be achieved through training and education for health professionals and policymakers, and by educating women about their rights as patients. It is essential that countries with high infant and maternal mortality provide post-partum care that includes support for those who experience stillbirth and neonatal death, including information, counselling and home visits.     

The safety and quality of childbirth in the context of health systems: mapping maternal health provision in Lebanon

Objective

to provide basic information on the distribution (public/private and geographically) and the nature of maternity health provision in Lebanon, including relevant health outcome data at the hospital level in order to compare key features of provision with maternal/neonatal health outcomes.

Design

a self-completion questionnaire was sent to private hospitals by the Syndicate of Private Hospitals in collaboration with the study team and to all public hospitals in Lebanon with a functioning maternity ward by the study team in cooperation with the Ministry of Public Health.

Setting

childbirth in an institutional setting by a trained attendant is almost universal in Lebanon and the predominant model of care is obstetrician-led rather than midwife-led. Yet due to a 15-year-old civil war and a highly privatised health sector, Lebanon lacks systematic or publically available data on the organisation, distribution and quality of maternal health services. An accreditation system for private hospitals was recently initiated to regulate the quality of hospital care in Lebanon.

Participants

in total, 58 (out of 125 eligible) hospitals responded to the survey (46% total response rate). Only hospital-level aggregate data were collected.

Measurements

the survey addressed the volume of services, mode of payment for deliveries, number of health providers, number of labour and childbirth units, availability of neonatal intensive care units, fetal monitors and infusion rate regulation pumps for oxytocin, as well as health outcome data related to childbirth care and stillbirths for the year 2008.

Findings

the study provides the first data on maternal health provision from a survey of all eligible hospitals in Lebanon. More than three-quarters of deliveries occur in private hospitals, but the Ministry of Public Health is the single most important source of payment for childbirth. The reported hospital caesarean section rate is high at 40.8%. Essential equipment for safe maternal and newborn health care is widely available in Lebanon, but over half of the hospitals that responded lack a neonatal intensive care unit. The ratio of reported numbers of midwives to deliveries is three times that of obstetricians to deliveries.

Key conclusions and implications for practice

there is a need for greater interaction between maternal/neonatal health, health system specialists and policy makers on how the health system can support both the adoption of evidence-based interventions and, ultimately, better maternal and perinatal health outcomes.     

Linkages among reproductive health, maternal health, and perinatal outcomes

Some interventions in women before and during pregnancy may reduce perinatal and neonatal deaths, and recent research has established linkages of reproductive health with maternal, perinatal, and early neonatal health outcomes. In this review, we attempted to analyze the impact of biological, clinical, and epidemiologic aspects of reproductive and maternal health interventions on perinatal and neonatal outcomes through an elucidation of a biological framework for linking reproductive, maternal and newborn health (RHMNH); care strategies and interventions for improved perinatal and neonatal health outcomes; public health implications of these linkages and implementation strategies; and evidence gaps for scaling up such strategies. Approximately 1000 studies (up to June 15, 2010) were reviewed that have addressed an impact of reproductive and maternal health interventions on perinatal and neonatal outcomes. These include systematic reviews, meta-analyses, and stand-alone experimental and observational studies. Evidences were also drawn from recent work undertaken by the Child Health Epidemiology Reference Group (CHERG), the interconnections between maternal and newborn health reviews identified by the Global Alliance for Prevention of Prematurity and Stillbirth (GAPPS), as well as relevant work by the Partnership for Maternal, Newborn and Child Health. Our review amply demonstrates that opportunities for assessing outcomes for both mothers and newborns have been poorly realized and documented. Most of the interventions reviewed will require more greater-quality evidence before solid programmatic recommendations can be made. However, on the basis of our review, birth spacing, prevention of indoor air pollution, prevention of intimate partner violence before and during pregnancy, antenatal care during pregnancy, Doppler ultrasound monitoring during pregnancy, insecticide-treated mosquito nets, birth and newborn care preparedness via community-based intervention packages, emergency obstetrical care, elective induction for postterm delivery, Cesarean delivery for breech presentation, and prophylactic corticosteroids in preterm labor reduce perinatal mortality; and early initiation of breastfeeding and birth and newborn care preparedness through community-based intervention packages reduce neonatal mortality. This review demonstrates that RHMNH are inextricably linked, and that, therefore, health policies and programs should link them together. Such potential integration of strategies would not only help improve outcomes for millions of mothers and newborns but would also save scant resources. This would also allow for greater efficiency in training, monitoring, and supervision of health care workers and would also help families and communities to access and use services easily.     

Decision making by auxiliary nurses to assess postpartum bleeding in a Dominican Republic maternity ward

OBJECTIVE: To understand the process of decision making by auxiliary nurses regarding postpartum bleeding among women in the Dominican Republic. DESIGN: An ethnographic qualitative design of semistructured interviews and participant observation. PARTICIPANTS: Twenty four auxiliary nurses on a maternity unit of a referral hospital in the Dominican Republic. FINDINGS: Auxiliary nurses use specific criteria and logic to decide if postpartum maternal bleeding is excessive. However, systematic postpartum assessments are not routinely conducted on every woman. MAIN OUTCOME MEASURES: A decision tree that traces how auxiliary nurses evaluate postpartum bleeding indicates that they have knowledge of contemporary obstetric nursing care, but the organization of care delivery is not structured for them to apply it routinely. CONCLUSIONS: A collaboration of U.S. midwives and Dominican nurses will build on the assets of the auxiliary nurses. Rather than focusing the content of educational conferences on current knowledge of labor and delivery, an important next step is modeling woman- and family-centered care. The U.S. midwives and Dominican nurses are committed to finding empowering and effective ways to improve maternity care.     

The maternal experience of kangaroo holding

OBJECTIVE: To describe the maternal experience of kangaroo holding premature infants in the neonatal intensive care unit. Design: Qualitative, naturalistic inquiry design using open-ended, transcribed audiotaped face-to-face interviews. SETTING: Level III 70-bed tertiary care neonatal intensive care unit in Delaware. PARTICIPANTS: Eighteen mothers who kangaroo held their premature infants were interviewed over a 5-month period of time. INTERVENTION: Mothers were interviewed following a 60-minute kangaroo holding session in the neonatal intensive care unit. Additionally, unobtrusive detailed observation of each mother's kangaroo holding experience was recorded and analyzed. MAIN OUTCOME MEASURE: Maternal behaviors and interactions and related nursing and environmental interactions. RESULTS: Triangulation of demographic data, observation data, and themes of the interviews supports the use of kangaroo holding as a method to improve maternal confidence in caring for premature infants. Mothers reported feelings of "being needed" and "feeling comfortable" with the holding experience regardless of the infant's physical health status. CONCLUSIONS: Results identify maternal experiences of and responses to kangaroo holding in the intensive care environment, leading to the increased understanding of the multifaceted advantages of kangaroo holding on maternal attachment behaviors.     

Observations from a maternal and infant hospital in Kabul, Afghanistan--2003

Afghanistan is believed to have one of the highest infant and maternal mortality rates in the world. As a result of decades of war and civil unrest, Afghan women and children suffer from poor access to health services, harsh living conditions, and insufficient food and micronutrient security. To address the disproportionately high infant and maternal mortality rates in Afghanistan, the US Department of Health and Human Services pledged support to establish a maternal health facility and training center. Rabia Balkhi Hospital in Kabul, Afghanistan, was selected because this hospital admits approximately 36,000 patients and delivers more than 14,000 babies annually. This article reports the initial observations at Rabia Balkhi Hospital and describes factors that influenced women's access, the quality of care, and the evaluation health care services. This observational investigation examined areas of obstetric, laboratory and pharmacy, and ancillary services. The investigators concluded that profound changes were needed in the hospital's health care delivery system to make the hospital a safe and effective health care facility for Afghan women and children and an appropriate facility in which to establish an Afghan provider training program for updating obstetric skills and knowledge.