Perinatal and maternal outcomes in planned home and obstetric unit births in women at 'higher risk' of complications: secondary analysis of the Birthplace national prospective cohort study

OBJECTIVE

To explore and compare perinatal and maternal outcomes in women at 'higher risk' of complications planning home versus obstetric unit (OU) birth.

DESIGN

Prospective cohort study.

SETTING

OUs and planned home births in England.

POPULATION

8180 'higher risk' women in the Birthplace cohort.

METHODS

We used Poisson regression to calculate relative risks adjusted for maternal characteristics. Sensitivity analyses explored possible effects of differences in risk between groups and alternative outcome measures.

MAIN OUTCOME MEASURES

Composite perinatal outcome measure encompassing 'intrapartum related mortality and morbidity' (intrapartum stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus or clavicle) and neonatal admission within 48 hours for more than 48 hours. Two composite maternal outcome measures capturing intrapartum interventions/adverse maternal outcomes and straightforward birth.

RESULTS

The risk of 'intrapartum related mortality and morbidity' or neonatal admission for more than 48 hours was lower in planned home births than planned OU births [adjusted relative risks (RR) 0.50, 95% CI 0.31-0.81]. Adjustment for clinical risk factors did not materially affect this finding. The direction of effect was reversed for the more restricted outcome measure 'intrapartum related mortality and morbidity' (RR adjusted for parity 1.92, 95% CI 0.97-3.80). Maternal interventions were lower in planned home births.

CONCLUSIONS

The babies of 'higher risk' women who plan birth in an OU appear more likely to be admitted to neonatal care than those whose mothers plan birth at home, but it is unclear if this reflects a real difference in morbidity. Rates of intrapartum related morbidity and mortality did not differ statistically significantly between settings at the 5% level but a larger study would be required to rule out a clinically important difference between the groups.

Perinatal experiences of Somali couples in the United States

OBJECTIVE

To explore the perspectives of Somali couples on care and support received during the perinatal period in the United States.

DESIGN

Descriptive phenomenology.

SETTING

A private room at the participants' homes or community center.

PARTICIPANTS

Forty-eight immigrant women and men from Somalia (26 women and 22 men) who arrived in the United States within the past 5 years and had a child or children born in their homelands or refugee camps and at least one child born in the United States. All of the participants resided in the Pacific Northwest.

METHODS

Semistructured individual interviews, interviews with couples, and a follow-up phone interview. Colaizzi's method guided the research process.

RESULTS

Data analysis revealed an overarching theme of Navigating through the conflicting values, beliefs, understandings and expectations that infiltrated the experiences captured by the three subthemes: (a) Feeling vulnerable, uninformed, and misunderstood, (b) Longing for unconditional respect and acceptance and (c) Surviving and thriving as the recipients of health care.

CONCLUSIONS

Integration of new Somali immigrant couples into the Western health care system can present many challenges. The perinatal experience for new Somali immigrant couples is complicated by cultural and language barriers, limited access to resources, and commonly, an exclusion of husbands from prenatal education and care. Nurses and other health care providers can play an important role in the provision of services that integrate Somali women and men into the plan of care and consider their culture-based expectations to improve childbirth outcomes.

Assessment of maternal satisfaction with facility-based childbirth care in the rural region of Tambacouda, Senegal

In Senegal, only 60% of mothers in rural areas deliver in health facilities. Mothers' satisfaction with their facility-based childbirth experience is one of the factors in their choosing to deliver in such facilities in subsequent pregnancies. The objective of this study was to assess whether compliance with childbirth care based on the mothers' perception of facility-based childbirth care contributes to the degree of maternal satisfaction. We conducted a secondary analysis of cross-sectional survey data collected from 259 mothers who had normal deliveries at facilities in rural areas of Senegal in 2011. The association between overall maternal satisfaction with childbirth care and 23 standard care survey items was assessed. The results showed that the degree of compliance with standard care and eight of 23 survey items were associated with maternal satisfaction. We conclude that to improve maternal satisfaction, facilities need to guarantee compliance with standard care.

Improvements in newborn care and newborn resuscitation following a quality improvement program at scale: results from a before and after study in Tanzania

BACKGROUND

Every year, more than a million of the world's newborns die on their first day of life; as many as two-thirds of these deaths could be saved with essential care at birth and the early newborn period. Simple interventions to improve the quality of essential newborn care in health facilities - for example, improving steps to help newborns breathe at birth - have demonstrated up to 47% reduction in newborn mortality in health facilities in Tanzania. We conducted an evaluation of the effects of a large-scale maternal-newborn quality improvement intervention in Tanzania that assessed the quality of provision of essential newborn care and newborn resuscitation.

METHODS

Cross-sectional health facility surveys were conducted pre-intervention (2010) and post intervention (2012) in 52 health facilities in the program implementation area. Essential newborn care provided by health care providers immediately following birth was observed for 489 newborns in 2010 and 560 in 2012; actual management of newborns with trouble breathing were observed in 2010 (n = 18) and 2012 (n = 40). Assessments of health worker knowledge were conducted with case studies (2010, n = 206; 2012, n = 217) and a simulated resuscitation using a newborn mannequin (2010, n = 299; 2012, n = 213). Facility audits assessed facility readiness for essential newborn care.

RESULTS

Index scores for quality of observed essential newborn care showed significant overall improvement following the quality-of-care intervention, from 39% to 73% (p <0.0001). Health worker knowledge using a case study significantly improved as well, from 23% to 41% (p <0.0001) but skills in resuscitation using a newborn mannequin were persistently low. Availability of essential newborn care supplies, which was high at baseline in the regional hospitals, improved at the lower-level health facilities.

CONCLUSIONS

Within two years, the quality improvement program was successful in raising the quality of essential newborn care services in the program facilities. Some gaps in newborn care were persistent, notably practical skills in newborn resuscitation. Continued investment in life-saving improvements to newborn care through the health services is a priority for reduction of newborn mortality in Tanzania.

Improvement of maternal and newborn health through midwifery

In the concluding paper of this Series about midwifery, we look at the policy implications from the framework for quality maternal and newborn care, the potential effect of life-saving interventions that fall within the scope of practice of midwives, and the historic sequence of health system changes that made a reduction in maternal mortality possible in countries that have expanded their midwifery workforce. Achievement of better health outcomes for women and newborn infants is possible, but needs improvements in the quality of reproductive, maternal, and newborn care, alongside necessary increases in universal coverage. In this report, we propose three priority research areas and outline how national investment in midwives and in their work environment, education, regulation, and management can improve quality of care. Midwifery and midwives are crucial to the achievement of national and international goals and targets in reproductive, maternal, newborn, and child health; now and beyond 2015.

Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care

In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of women's views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen women's capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.

Maternal mortality at Muhimbili National Hospital in Dar-es-Salaam, Tanzania in the year 2011

BACKGROUND

Improving maternal health is one of the eight millennium development goals adopted at the millennium summit in the year 2000. Within this frame work, the international community is committed to reduce the maternal mortality ratio by 75% between 1990 and 2015. The objective of this study was to determine the maternal mortality ratio, classify causes of maternal deaths and assess substandard care factors at Muhimbili National Hospital (MNH), Dar-es-Salaam in Tanzania.

METHODS

A retrospective review of all maternal death records of cases that occurred from 1st January to 31st December 2011 was done.

RESULTS

There were 10,057 live births, 155 maternal deaths and hence MMR of 1,541 per 100,000 live births. Direct causes of maternal deaths were classified in 69.5% of the maternal deaths. Of the direct causes, preeclampsia/eclampsia was the major cause (19.9% of all deaths), followed by post partum haemorrhage (14.9%), abortion complications (9.9%) and sepsis (9.2%). Among the indirect causes anaemia was the leading cause (11.3%) of all deaths, followed by HIV/AIDS (9.9%). Substandard care factors contributing to deaths were identified in 116 (82.3%) of all cases. Among these 28 had patient factors only, 71 medical service factors while 17 had both patient and medical service substandard care factors. The common factors from the woman's side included delay in seeking care (73.3%) and complete lack of antenatal care (11.1%). Of the medical service factors, inadequate (26.1%) or no blood for transfusion (19.3%), delay in receiving treatment (18.3%) and mismanagement (17%) were the common factors.

CONCLUSION

There is a high maternal mortality ratio at MNH. Hypertensive disorders of pregnancy, post partum haemorrhage and anaemia are the leading causes of maternal deaths in this institution. Multiple substandard care factors identified both at individual and health care service levels that contributed to maternal deaths. There is a need for increasing efforts in the fight to reduce maternal deaths at the institution. A more pro-active role from the referring facilities in the region is needed.

Evidence from facility level inputs to improve quality of care for maternal and newborn health: interventions and findings

Most of the maternal and newborn deaths occur at birth or within 24 hours of birth. Therefore, essential lifesaving interventions need to be delivered at basic or comprehensive emergency obstetric care facilities. Facilities provide complex interventions including advice on referrals, post discharge care, long-term management of chronic conditions along with staff training, managerial and administrative support to other facilities. This paper reviews the effectiveness of facility level inputs for improving maternal and newborn health outcomes. We considered all available systematic reviews published before May 2013 on the pre-defined facility level interventions and included 32 systematic reviews. Findings suggest that additional social support during pregnancy and labour significantly decreased the risk of antenatal hospital admission, intrapartum analgesia, dissatisfaction, labour duration, cesarean delivery and instrumental vaginal birth. However, it did not have any impact on pregnancy outcomes. Continued midwifery care from early pregnancy to postpartum period was associated with reduced medical procedures during labour and shorter length of stay. Facility based stress training and management interventions to maintain well performing and motivated workforce, significantly reduced job stress and improved job satisfaction while the interventions tailored to address identified barriers to change improved the desired practice. We found limited and inconclusive evidence for the impacts of physical environment, exit interviews and organizational culture modifications. At the facility level, specialized midwifery teams and social support during pregnancy and labour have demonstrated conclusive benefits in improving maternal newborn health outcomes. However, the generalizability of these findings is limited to high income countries. Future programs in resource limited settings should utilize these findings to implement relevant interventions tailored to their needs.

Evidence from community level inputs to improve quality of care for maternal and newborn health: interventions and findings

Annually around 40 million mothers give birth at home without any trained health worker. Consequently, most of the maternal and neonatal mortalities occur at the community level due to lack of good quality care during labour and birth. Interventions delivered at the community level have not only been advocated to improve access and coverage of essential interventions but also to reduce the existing disparities and reaching the hard to reach. In this paper, we have reviewed the effectiveness of care delivered through community level inputs for improving maternal and newborn health outcomes. We considered all available systematic reviews published before May 2013 on the pre-defined community level interventions and report findings from 43 systematic reviews. Findings suggest that home visitation significantly improved antenatal care, tetanus immunization coverage, referral and early initiation of breast feeding with reductions in antenatal hospital admission, cesarean-section rates birth, maternal morbidity, neonatal mortality and perinatal mortality. Task shifting to midwives and community health workers has shown to significantly improve immunization uptake and breast feeding initiation with reductions in antenatal hospitalization, episiotomy, instrumental delivery and hospital stay. Training of traditional birth attendants as a part of community based intervention package has significant impact on referrals, early breast feeding, maternal morbidity, neonatal mortality, and perinatal mortality. Formation of community based support groups decreased maternal morbidity, neonatal mortality, perinatal mortality with improved referrals and early breast feeding rates. At community level, home visitation, community mobilization and training of community health workers and traditional birth attendants have the maximum potential to improve a range of maternal and newborn health outcomes. There is lack of data to establish effectiveness of outreach services, mass media campaigns and community education as standalone interventions. Future efforts should be concerted on increasing the availability and training of the community based skilled health workers especially in resource limited settings where the highest burden exists with limited resources to mobilize.

Developing a process to support perinatal nurses after a critical event

The work of perinatal nurses sometimes includes emergencies involving death, or near death, which can leave health care providers with feelings of stress and grief. After experiencing a particularly stressful period, nurses at our organization identified processes to help themselves recover and to support each other. The result of this work is a written plan to facilitate the support of perinatal nurses after critical events. This article describes the development and implementation of this plan.

Maternal health practices, beliefs and traditions in southeast Madagascar

Contextualising maternal health in countries with high maternal mortality is vital for designing and implementing effective health interventions. A research project was therefore conducted to explore practices, beliefs and traditions around pregnancy, delivery and postpartum in southeast Madagascar. Interviews and focus groups were conducted with 256 pregnant women, mothers of young children, community members and stakeholders; transcripts were analysed to identify and explore predetermined and emerging themes. A questionnaire was also conducted with 373 women of reproductive age from randomly selected households. Data was analysed using STATA. Results confirmed high local rates of maternal mortality and morbidity and revealed a range of traditional health care practices and beliefs impacting on women's health seeking behaviours. The following socio-cultural barriers to health were identified: 1) lack of knowledge, 2) risky practices, 3) delays seeking biomedical care, and 4) family and community expectations. Recommendations include educational outreach and behaviour change communications targeted for women, their partners and family, increased engagement with traditional midwives and healers, and capacity building of formal health service providers.

Obstetric danger signs and factors affecting health seeking behaviour among the Kassena-Nankani of Northern Ghana: a qualitative study

Improving community members' knowledge of obstetric danger signs is one strategy for increasing the use of skilled care during pregnancy and the puerperium. This study explored knowledge of obstetric danger signs among a range of community members, examined the sources of their information, and the perceived factors that affect health seeking behaviour in rural northern Ghana. We conducted 72 in-depth interviews and 18 focus groups with community members. All interactions were audio taped, transcribed verbatim and analysed using NVivo 9.0. Community members demonstrated knowledge of a wide range of obstetric danger signs, including excessive bleeding, stomach aches, waist pains, vomiting and fever. Pregnant women learn about danger signs from a range of providers, and regular contact with formal providers typically coincided with increased knowledge of danger signs. Traditional remedies for problems in obstetrics are plentiful and cultural beliefs often restrict the use of allopathic medicine. Increasing knowledge of obstetric danger signs is necessary but not sufficient to overcome cultural preferences for traditional treatments for pregnancy danger signs.

Adherence to evidence based care practices for childbirth before and after a quality improvement intervention in health facilities of Rajasthan, India

BACKGROUND

After the launch of Janani Suraksha Yojana, a conditional cash transfer scheme in India, the proportion of women giving birth in institutions has rapidly increased. However, there are important gaps in quality of childbirth services during institutional deliveries. The aim of this intervention was to improve the quality of childbirth services in selected high caseload public health facilities of 10 districts of Rajasthan. This intervention titled "Parijaat" was designed by Action Research & Training for Health, in partnership with the state government and United Nations Population Fund.

METHODS

The intervention was carried out in 44 public health facilities in 10 districts of Rajasthan, India. These included district hospitals (9), community health centres (32) and primary health centres (3). The main intervention was orientation training of doctors and program managers and regular visits to facilities involving assessment, feedback, training and action. The adherence to evidence based practices before, during and after this intervention were measured using structured checklists and scoring sheets. Main outcome measures included changes in practices during labour, delivery or immediate postpartum period.

RESULTS

Use of several unnecessary or harmful practices reduced significantly. Most importantly, proportion of facilities using routine augmentation of labour reduced (p = 0), episiotomy for primigravidas (p = 0.0003), fundal pressure (p = 0.0003), and routine suction of newborns (0 = 0.0005). Among the beneficial practices, use of oxytocin after delivery increased (p = 0.0001) and the practice of listening foetal heart sounds during labour (p = 0.0001). Some practices did not show any improvements, such as dorsal position for delivery, use of partograph, and hand-washing.

CONCLUSIONS

An intervention based on repeated facility visits combined with actions at the level of decision makers can lead to substantial improvements in quality of childbirth practices at health facilities.

Can training in advanced clinical skills in obstetrics, neonatal care and leadership, of non-physician clinicians in Malawi impact on clinical services improvements (the ETATMBA project): a process evaluation

OBJECTIVES

The 'enhancing human resources and the use of appropriate technologies for maternal and perinatal survival in sub-Saharan Africa' (ETATMBA) project is training emergency obstetric and new-born care (EmONC) non-physician clinicians (NPCs) as advanced clinical leaders. Our objectives were to evaluate the implementation and changes to practice.

DESIGN

A mixed methods process evaluation with the predominate methodology being qualitative.

SETTING

Rural and urban hospitals in 8 of the 14 districts of northern and central Malawi.

PARTICIPANTS

54 EmONC NPCs with 3 years' plus experience.

INTERVENTION

Training designed and delivered by clinicians from the UK and Malawi; it is a 2-year plus package of training (classroom, mentorship and assignments).

RESULTS

We conducted 79 trainee interviews over three time points during the training, as well as a convenience sample of 10 colleagues, 7 district officers and 2 UK obstetricians. Trainees worked in a context of substantial variation in the rates of maternal and neonatal deaths between districts. Training reached trainees working across the target regions. For 46 trainees (8 dropped out of the course), dose delivered in terms of attendance was high and all 46 spent time working alongside an obstetrician. In early interviews trainees recalled course content unprompted indicating training had been received. Colleagues and district officers reported cascading of knowledge and initial changes in practice indicating early implementation. By asking trainees to describe actual cases we found they had implemented new knowledge and skills. These included life-saving interventions for postpartum haemorrhage and eclampsia. Trainees identified the leadership training as enabling them to confidently change their own practice and initiate change in their health facility.

CONCLUSIONS

This process evaluation suggests that trainees have made positive changes in their practice. Clear impacts on maternal and perinatal mortality are yet to be elucidated.