The contribution of church health services to maternal health care provision in Papua New Guinea

Access to maternal health services is one key to the reduction of maternal mortality in Papua New Guinea. Church health services (CHS) are known to administer around 45% of rural health facilities. We undertook a descriptive analysis based on health facility service provision data for 2009 from the National Health Information System (NHIS), supported by document review and interviews. We recoded NHIS data on facilities by administration by CHS or government health service, judged their capacity for emergency obstetric care (EmOC) and analysed service provision for 2009. For rural services (i.e., outside of provincial capitals), CHS were recorded as providing 58% of health facility childbirth care and 38% of first antenatal visits. Obstetric referral patterns and facility capacity suggested many facilities were likely to have only basic EmOC and limited referral options. Nationally, CHS provided 21% of temporary methods of contraception (measured in couple-year protection) but 85% of referrals for permanent contraception. There was marked variation across provinces with clear implications for where health system strengthening could be beneficial to maternal survival. Our findings also disclosed gaps in the NHIS around monitoring of complicated childbirth and inclusion of community-based care.

Sociodemographic factors associated with maternal health care utilization in Wosera, East Sepik Province, Papua New Guinea

This retrospective study sought to describe the utilization of maternal health services in a rural community in Wosera, East Sepik Province, Papua New Guinea. Interviews were undertaken with a convenience sample of 391 women of reproductive age. We examined the relationship between socioeconomic and demographic characteristics and the use of antenatal clinic services and delivery at a health centre. Despite uptake of antenatal care services by 79% of women, two-thirds of women gave birth at home. Women's education was an independent predictor for maternal health care utilization, for both antenatal care and delivery at a health facility. At least one visit to an antenatal clinic was the strongest predictor of delivering at a health care facility. Women expressed barriers to assisted childbirth such as distance to health facilities, especially when labour came fast, and feelings of shame in presenting to a facility to give birth. This study provides important information relating to the uptake of maternal health care services. Despite the uptake of available antenatal care services, intrapartum services are not well accessed.

ABM clinical protocol #10: breastfeeding the late preterm infant (34(0/7) to 36(6/7) weeks gestation) (first revision June 2011)

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. These guidelines are not intended to be all-inclusive, but to provide a basic framework for physician education regarding breastfeeding.

Mothers' AdvocateS In the Community (MOSAIC)--non-professional mentor support to reduce intimate partner violence and depression in mothers: a cluster randomised trial in primary care

BACKGROUND

Effective interventions to increase safety and wellbeing of mothers experiencing intimate partner violence (IPV) are scarce. As much attention is focussed on professional intervention, this study aimed to determine the effectiveness of non-professional mentor support in reducing IPV and depression among pregnant and recent mothers experiencing, or at risk of IPV.

METHODS

MOSAIC was a cluster randomised trial in 106 primary care (maternal and child health nurse and general practitioner) clinics in Melbourne, Australia. 63/106 clinics referred 215 eligible culturally and linguistically diverse women between January 2006 and December 2007. 167 in the intervention (I) arm, and 91 in the comparison (C) arm. 174 (80.9%) were recruited. 133 (76.4%) women (90 I and 43 C) completed follow-up at 12 months.

INTERVENTION

12 months of weekly home visiting from trained and supervised local mothers, (English & Vietnamese speaking) offering non-professional befriending, advocacy, parenting support and referrals.

MAIN OUTCOME MEASURES

Primary outcomes; IPV (Composite Abuse Scale CAS) and depression (Edinburgh Postnatal Depression Scale EPDS); secondary measures included wellbeing (SF-36), parenting stress (PSI-SF) and social support (MOS-SF) at baseline and follow-up.

ANALYSIS

Intention-to-treat using multivariable logistic regression and propensity scoring.

RESULTS

There was evidence of a true difference in mean abuse scores at follow-up in the intervention compared with the comparison arm (15.9 vs 21.8, AdjDiff -8.67, CI -16.2 to -1.15). There was weak evidence for other outcomes, but a trend was evident favouring the intervention: proportions of women with CAS scores ≥ 7, 51/88 (58.4%) vs 27/42 (64.3%) AdjOR 0.47, CI 0.21 to 1.05); depression (EPDS score ≥ 13) (19/85, 22% (I) vs 14/43, 33% (C); AdjOR 0.42, CI 0.17 to 1.06); physical wellbeing mean scores (PCS-SF36: AdjDiff 2.79; CI -0.40 to 5.99); mental wellbeing mean scores (MCS-SF36: AdjDiff 2.26; CI -1.48 to 6.00). There was no observed effect on parenting stress. 82% of women mentored would recommend mentors to friends in similar situations.

CONCLUSION

Non-professional mentor mother support appears promising for improving safety and enhancing physical and mental wellbeing among mothers experiencing intimate partner violence referred from primary care.

TRIAL REGISTRATION

ACTRN12607000010493http://www.anzctr.org.au.

Pregnant Families' Discussions on the Net-From Virtual Connections Toward Real-Life Community

The aim of this research was to analyze conversations between expectant families (N = 21) in Net Clinic, an Internet-based service designed for patients using public maternity care. The online conversations, shared opinions about experiences of pregnancy, and family life constituted the data for content analysis. The families developed a sense of virtual community, which gradually evolved into a real-life community, by discovering the similarity of their life situations and by giving parent-to-parent support for everyday life events. As a view of daily family life, Net Clinic offers maternity care professionals a deeper understanding of how to enhance safer pregnancy, birth, and growth of the family.

Obstetric Fistula: A Preventable Tragedy

Obstetric fistula disables millions of women and girls in developing countries, primarily in sub-Saharan Africa and South Asia. The United Nations Population Fund (UNFPA) recently launched a global campaign to end fistula, labeling this condition a preventable and treatable tragedy. Obstetric fistula overwhelmingly results from obstructed labor, which occurs in cases of cephalopelvic disproportion and malpresentation. Cephalopelvic disproportion often complicates deliveries in young, primiparous women of low gynecologic age. Social factors, including young age at marriage and malnutrition of girl children, can also contribute to cephalopelvic disproportion. These social etiologies must be addressed by prevention campaigns. Direct prevention of fistula can occur during delivery when skilled providers identify women and girls at risk for obstetric fistula and link them with innovative interventions, such as Fistula Prevention Centers, through which they can more readily access emergency obstetric care, and by setting strict time limits for laboring at home without progress. Community-based programs, such as the Tostan program in West Africa, use social education to prevent fistula. Moreover, effective surgical techniques for fistula repair are available in some settings and should be expanded to reach those in need. Midwives can play a key role in the prevention and treatment of this tragic obstetric complication.

CEU; Collaborative Management of Women with Bipolar Disorder During Pregnancy and Postpartum: Pharmacologic Considerations

Bipolar disorder is a chronic condition characterized by periods of mania, depression, or mixed states (co-occurring mania and depression). The postpartum period is associated with a high risk for symptom relapse or intensification, which can be reduced with the use of medications. Abrupt discontinuation of these medications increases the probability of relapse, which is associated with high-risk behaviors, significant family dysfunction, and suicide. Drugs used to treat patients with bipolar disorder vary in teratogenic potential. Although first trimester lithium use is associated with Ebstein's anomaly, the risk was overestimated in the past. Valproate and its derivatives and carbamazepine are human teratogens. Lamotrigine does not negatively impact major reproductive outcomes, but the data are limited. Typical antipsychotic medications are relatively well studied and the data do not identify major morphologic teratogenicity. There are fewer studies of newer atypical antipsychotic medications, and registries have been developed to collect prospective data. Clinical management of bipolar disorder during pregnancy, postpartum, and lactation requires a careful balancing of maternal and fetal risks and benefits. Communication and careful comanagement between the obstetric and psychiatric team is essential when treating women with bipolar disorder during the reproductive years.

Communities, birth attendants and health facilities: a continuum of emergency maternal and newborn care (the Global Network's EmONC trial)

BACKGROUND

Maternal and newborn mortality rates remain unacceptably high, especially where the majority of births occur in home settings or in facilities with inadequate resources. The introduction of emergency obstetric and newborn care services has been proposed by several organizations in order to improve pregnancy outcomes. However, the effectiveness of emergency obstetric and neonatal care services has never been proven. Also unproven is the effectiveness of community mobilization and community birth attendant training to improve pregnancy outcomes.

METHODS/DESIGN

We have developed a cluster-randomized controlled trial to evaluate the impact of a comprehensive intervention of community mobilization, birth attendant training and improvement of quality of care in health facilities on perinatal mortality in low and middle-income countries where the majority of births take place in homes or first level care facilities. This trial will take place in 106 clusters (300-500 deliveries per year each) across 7 sites of the Global Network for Women's and Children's Health Research in Argentina, Guatemala, India, Kenya, Pakistan and Zambia. The trial intervention has three key elements, community mobilization, home-based life saving skills for communities and birth attendants, and training of providers at obstetric facilities to improve quality of care. The primary outcome of the trial is perinatal mortality. Secondary outcomes include rates of stillbirth, 7-day neonatal mortality, maternal death or severe morbidity (including obstetric fistula, eclampsia and obstetrical sepsis) and 28-day neonatal mortality.

DISCUSSION

In this trial, we are evaluating a combination of interventions including community mobilization and facility training in an attempt to improve pregnancy outcomes. If successful, the results of this trial will provide important information for policy makers and clinicians as they attempt to improve delivery services for pregnant women and newborns in low-income countries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01073488.

Impact of community-based maternal health workers on coverage of essential maternal health interventions among internally displaced communities in eastern Burma: the MOM project

BACKGROUND

Access to essential maternal and reproductive health care is poor throughout Burma, but is particularly lacking among internally displaced communities in the eastern border regions. In such settings, innovative strategies for accessing vulnerable populations and delivering basic public health interventions are urgently needed.

METHODS

Four ethnic health organizations from the Shan, Mon, Karen, and Karenni regions collaborated on a pilot project between 2005 and 2008 to examine the feasibility of an innovative three-tiered network of community-based providers for delivery of maternal health interventions in the complex emergency setting of eastern Burma. Two-stage cluster-sampling surveys among ever-married women of reproductive age (15-45 y) conducted before and after program implementation enabled evaluation of changes in coverage of essential antenatal care interventions, attendance at birth by those trained to manage complications, postnatal care, and family planning services.

RESULTS

Among 2,889 and 2,442 women of reproductive age in 2006 and 2008, respectively, population characteristics (age, marital status, ethnic distribution, literacy) were similar. Compared to baseline, women whose most recent pregnancy occurred during the implementation period were substantially more likely to receive antenatal care (71.8% versus 39.3%, prevalence rate ratio [PRR] = 1.83 [95% confidence interval (CI) 1.64-2.04]) and specific interventions such as urine testing (42.4% versus 15.7%, PRR = 2.69 [95% CI 2.69-3.54]), malaria screening (55.9% versus 21.9%, PRR = 2.88 [95% CI 2.15-3.85]), and deworming (58.2% versus 4.1%, PRR = 14.18 [95% CI 10.76-18.71]. Postnatal care visits within 7 d doubled. Use of modern methods to avoid pregnancy increased from 23.9% to 45.0% (PRR = 1.88 [95% CI 1.63-2.17]), and unmet need for contraception was reduced from 61.7% to 40.5%, a relative reduction of 35% (95% CI 28%-40%). Attendance at birth by those trained to deliver elements of emergency obstetric care increased almost 10-fold, from 5.1% to 48.7% (PRR = 9.55 [95% CI 7.21-12.64]).

CONCLUSIONS

Coverage of maternal health interventions and higher-level care at birth was substantially higher during the project period. The MOM Project's focus on task-shifting, capacity building, and empowerment at the community level might serve as a model approach for similarly constrained settings.

Improving implementation: building research capacity in maternal, neonatal, and child health in Africa

As part of a series on maternal, neonatal, and child health in sub-Saharan Africa, Valerie Snewin and colleagues discuss the challenges of implementation and research capacity in Africa.

Ethnographic evaluation of a research partnership between two African American communities and a university

Public health anthropologists at a large urban university and a community advisory board (CAB) representing two African American communities partnered to find clues to the high incidence of African American low birth weight, preterm delivery and infant mortality. Collaborating as equal partners, the Healthy African American Families (HAAF) project ethnographically explored what it means to be African American, pregnant and living in the urban inner city. A team of evaluators used ethnographic methods to study the partnership over a continuous four-year period. The objectives of the evaluation were to study the: a) collaborative partnership; b) levels of community involvement/participation; and c) openness and interactiveness within the partnership. Focusing primarily on the African American communities' contributions to the research partnership, this article also identifies what worked, what didn't work, and what sometimes worked for the partnership as a whole, including the funder's role. The evaluation of university researchers as they conduct their work in partnership with and within communities of color is a new way of learning about partnered research. Findings from this evaluation inform the social science community about: what happened, how it happened, the quality of interaction of professional researchers as they worked cross-culturally, the broader context that impacted the research, the confidence one can have in the quality of the data, and the cultural relevance and contextual appropriateness of the research interpretations.

Postpartum depression: a chronicle of health policy development

The current report presents an example of the path taken from identification of a public health problem at the primary health service level, to conducting research documenting the scope of the problem and nature of the risk factors, disseminating the findings, and fostering development and application of relevant policy. The example presented is the case of postpartum depression, an issue with bio-psycho-social implications. Public health nurses identified the problem, prompting epidemiological research. The findings encouraged the Ministry of Health (MOH) to conduct a pilot program for screening and early intervention among pregnant and postpartum women reporting depressive symptoms. Based on the results of the pilot program, the MOH is expanding the program to all Mother-Child Health (MCH) clinics. Israel?s largest Health Maintenance Organization has followed suit and is including this program in its own clinics. This Israeli experience may serve as an instructive example of a locally identified problem evolving into a national policy.