Quality along the continuum: a health facility assessment of intrapartum and postnatal care in Ghana

Objective

To evaluate quality of routine and emergency intrapartum and postnatal care using a health facility assessment, and to estimate “effective coverage” of skilled attendance in Brong Ahafo, Ghana.

Methods

We conducted an assessment of all 86 health facilities in seven districts in Brong Ahafo. Using performance of key signal functions and the availability of relevant drugs, equipment and trained health professionals, we created composite quality categories in four dimensions: routine delivery care, emergency obstetric care (EmOC), emergency newborn care (EmNC) and non-medical quality. Linking the health facility assessment to surveillance data we estimated “effective coverage” of skilled attendance as the proportion of births in facilities of high quality.

Findings

Delivery care was offered in 64/86 facilities; only 3-13% fulfilled our requirements for the highest quality category in any dimension. Quality was lowest in the emergency care dimensions, with 63% and 58% of facilities categorized as “low” or “substandard” for EmOC and EmNC, respectively. This implies performing less than four EmOC or three EmNC signal functions, and/or employing less than two skilled health professionals, and/or that no health professionals were present during our visit. Routine delivery care was “low” or “substandard” in 39% of facilities, meaning 25/64 facilities performed less than six routine signal functions and/or had less than two skilled health professionals and/or less than one midwife. While 68% of births were in health facilities, only 18% were in facilities with “high” or “highest” quality in all dimensions.

Conclusion

Our comprehensive facility assessment showed that quality of routine and emergency intrapartum and postnatal care was generally low in the study region. While coverage with facility delivery was 68%, we estimated “effective coverage” of skilled attendance at 18%, thus revealing a large “quality gap.” Effective coverage could be a meaningful indicator of progress towards reducing maternal and newborn mortality.

Exclusive breastfeeding practices in relation to social and health determinants: a comparison of the 2006 and 2011 Nepal Demographic and Health Surveys

BACKGROUND

Exclusive breastfeeding (EBF) for the first six months can have a significant impact on reducing child morbidity and mortality rates. The objective of this study was to compare the determinants of and trends in EBF in infants ≤ 5 months from the 2006 and 2011 Nepal Demographic and Health Surveys.

METHODS

Data on mother/infant pairs having infants of ≤ 5 months from 2006 (n = 482) and 2011 (n = 227) were analysed. The EBF rate, determinants of EBF, and changes in EBF rates between the 2006 and 2011 surveys were examined using Chi-square test and multiple logistic regression.

RESULTS

The EBF rate for ≤ 5 months in 2006 was 53.2% (95% CI, 47.1%-59.3%) and 66.3% (95% CI, 56.6%-74.8%) in 2011. In 2006, infants ≤ 4 months were more likely to be EBF [(aOR) 3.086, 95% CI (1.825-5.206)] after controlling for other factors. A geographic effect was also found in this study, with the odds of EBF higher for infants from the Hills [aOR 3.426, 95% CI (1.568-7.474)] compared to those form the mountains. The odds of EBF were also higher for higher order infants [aOR 1.968, 95% CI (1.020-3.799)]. Infants whose fathers belonged to non-agricultural occupation were less likely to be provided with EBF. Infants who were delivered in the home were more likely to experience EBF [aOR 1.886; 95% CI (1.044-3.407)]. In 2011, infants of age ≤ 4 months were more likely [aOR 4.963, 95% CI (2.317-10.629)] to have been breastfed exclusively. While there was an increase in the EBF rate between 2006 and 2011 surveys, the significant increase was noticed only among the infants of four months [32.0%; 95% CI (19.9%-47.0%)] in 2006 to [65.5%; 95% CI (48.1-79.6)] in 2011.

CONCLUSIONS

The proportion of infants who were EBF was higher in Nepal in 2011survey compared to 2006 survey; however, this is still below the recommended WHO target of 90%. Infant's age, ecological region, parity and father's occupation were associated with EBF. Further interventions such as peer counselling, antenatal counselling and involving fathers in the community to promote EBF in Nepal are recommended.

Women with disability: the experience of maternity care during pregnancy, labour and birth and the postnatal period

BACKGROUND

It has been estimated that 9.4% of women giving birth in the United Kingdom have one or more limiting longstanding illness which may cause disability, affecting pregnancy, birth and early parenting. No large scale studies on a nationally representative population have been carried out on the maternity experiences of disabled women to our knowledge.

METHOD

Secondary analysis of data from a survey of women in 2010 by English National Health Service Trusts on behalf of the Care Quality Commission was undertaken. 144 trusts in England took part in the postal survey.Women self-identified with disability and were excluded if less than 16 years of age or if their baby had died. The 12 page structured questionnaire with sections on antenatal, labour and birth and postnatal care covered access, information, communication and choice. Descriptive and adjusted analyses compared disabled and non-disabled groups. Comparisons were made separately for five disability subgroups: physical disability, sensory impairment, mental health conditions, learning disability and women with more than one type of disability.

RESULTS

Disabled women comprised 6.14% (1,482) of the total sample (24,155) and appeared to use maternity services more than non-disabled women. Most were positive about their care and reported sufficient access and involvement, but were less likely to breastfeed. The experience of women with different types of disability varied: physically disabled women used antenatal and postnatal services more, but had less choice about labour and birth; the experience of those with a sensory impairment differed little from the non-disabled women, but they were more likely to have met staff before labour; women with mental health disabilities also used services more, but were more critical of communication and support; women with a learning disability and those with multiple disabilities were least likely to report a positive experience of maternity care.

CONCLUSION

This national study describes disabled women's experiences of pregnancy, child birth and postnatal care in comparison with non-disabled women. While in many areas there were no differences, there was evidence of specific groups appropriately receiving more care. Areas for improvement included infant feeding and better communication in the context of individualised care.

Uptake, outcomes, and costs of antenatal, well-baby, and prevention of mother-to-child transmission of HIV services under routine care conditions in Zambia

Background

Zambia adopted Option A for prevention of mother-to-child transmission of HIV (PMTCT) in 2010 and announced a move to Option B+ in 2013. We evaluated the uptake, outcomes, and costs of antenatal, well-baby, and PMTCT services under routine care conditions in Zambia after the adoption of Option A.

Methods

We enrolled 99 HIV-infected/HIV-exposed (index) mother/baby pairs with a first antenatal visit in April-September 2011 at four study sites and 99 HIV-uninfected/HIV-unexposed (comparison) mother/baby pairs matched on site, gestational age, and calendar month at first visit. Data on patient outcomes and resources utilized from the first antenatal visit through six months postpartum were extracted from site registers. Costs in 2011 USD were estimated from the provider’s perspective.

Results

Index mothers presented for antenatal care at a mean 23.6 weeks gestation; 55% were considered to have initiated triple-drug antiretroviral therapy (ART) based on information recorded in site registers. Six months postpartum, 62% of index and 30% of comparison mother/baby pairs were retained in care; 67% of index babies retained had an unknown HIV status. Comparison and index mother/baby pairs utilized fewer resources than under fully guideline-concordant care; index babies utilized more well-baby resources than comparison babies. The average cost per comparison pair retained in care six months postpartum was $52 for antenatal and well-baby services. The average cost per index pair retained was $88 for antenatal, well-baby, and PMTCT services and increased to $185 when costs of triple-drug ART services were included.

Conclusions

HIV-infected mothers present to care late in pregnancy and many are lost to follow up by six months postpartum. HIV-exposed babies are more likely to remain in care and receive non-HIV, well-baby care than HIV-unexposed babies. Improving retention in care, guideline concordance, and moving to Option B+ will result in increased service delivery costs in the short term.

Schedules for home visits in the early postpartum period

BACKGROUND

Maternal complications including psychological and mental health problems and neonatal morbidity have been commonly observed in the postpartum period. Home visits by health professionals or lay supporters in the weeks following the birth may prevent health problems from becoming chronic with long-term effects on women, their babies, and their families.

OBJECTIVES

To assess outcomes for women and babies of different home-visiting schedules during the early postpartum period. The review focuses on the frequency of home visits, the duration (when visits ended) and intensity, and on different types of home-visiting interventions.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2013) and reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) (including cluster-RCTs) comparing different types of home-visiting interventions enrolling participants in the early postpartum period (up to 42 days after birth). We excluded studies in which women were enrolled and received an intervention during the antenatal period (even if the intervention continued into the postnatal period) and studies recruiting only women from specific high-risk groups. (e.g. women with alcohol or drug problems).

DATA COLLECTION AND ANALYSIS

Study eligibility was assessed by at least two review authors. Data extraction and assessment of risk of bias were carried out independently by at least two review authors. Data were entered into Review Manager software.

MAIN RESULTS

We included data from 12 randomised trials with data for more than 11,000 women. The trials were carried out in countries across the world, and in both high- and low-resource settings. In low-resource settings women receiving usual care may have received no additional postnatal care after early hospital discharge.The interventions and control conditions varied considerably across studies with trials focusing on three broad types of comparisons: schedules involving more versus fewer postnatal home visits (five studies), schedules involving different models of care (three studies), and home versus hospital clinic postnatal check-ups (four studies). In all but two of the included studies, postnatal care at home was delivered by healthcare professionals. The aim of all interventions was broadly to assess the wellbeing of mothers and babies, and to provide education and support, although some interventions had more specific aims such as to encourage breastfeeding, or to provide practical support.For most of our outcomes only one or two studies provided data, and overall results were inconsistent.There was no evidence that home visits were associated with improvements in maternal and neonatal mortality, and no strong evidence that more postnatal visits at home were associated with improvements in maternal health. More intensive schedules of home visits did not appear to improve maternal psychological health and results from two studies suggested that women receiving more visits had higher mean depression scores. The reason for this finding was not clear. There was some evidence that postnatal care at home may reduce infant health service utilisation in the weeks following the birth, and that more home visits may encourage more women to exclusively breastfeed their babies. There was some evidence that home visits are associated with increased maternal satisfaction with postnatal care.

AUTHORS' CONCLUSIONS

Overall, findings were inconsistent. Postnatal home visits may promote infant health and maternal satisfaction. However, the frequency, timing, duration and intensity of such postnatal care visits should be based upon local needs. Further well designed RCTs evaluating this complex intervention will be required to formulate the optimal package.

The effect of prenatal and postnatal care on childhood obesity

Childhood obesity continues to be a major public health problem in the United States. If this problem is unresolved, some children will be at risk for disorders such as type 2 diabetes, high blood pressure, and cancer and will become a high economic and social burden for society. Using the National Longitudinal Survey of Youth, Child and Young Adult sample (N = 6,643), this study examined the relationship between the effect of pre- and postnatal characteristics and obesity. The findings of this study show that the probability of childhood obesity can be lessened if pregnant women do not smoke and do not gain significant pregnancy-related weight. Moreover, breast feeding and health insurance were also found to be correlated to avoiding childhood obesity.

Differentials in receiving postpartum care of infants and its determinants in Turkey

The aim of this paper was to analyze the differentials in receiving postpartum care of infants in Turkey and the determinants of receiving postpartum care by infants in Turkey, using data from the 2008 Turkey Demographic and Health Survey and multivariate logistic analyses accounting for the complex sample design. The descriptive analyses indicated that the majority of infants receive postpartum care in Turkey, although there are disadvantaged groups. Analysis of the determinants of receiving postpartum care of infants indicated that the variables having the most explanatory power are bio-demographic or health-related variables that are directly related to health and/or birth. Following these variables, economic characteristics such as maternal health coverage and maternal educational level were observed to be effective, and additionally the demographic region.

A rapid assessment of the quality of neonatal healthcare in Kilimanjaro region, northeast Tanzania

BACKGROUND

While child mortality is declining in Africa there has been no evidence of a comparable reduction in neonatal mortality. The quality of inpatient neonatal care is likely a contributing factor but data from resource limited settings are few. The objective of this study was to assess the quality of neonatal care in the district hospitals of the Kilimanjaro region of Tanzania.

METHODS

Clinical records were reviewed for ill or premature neonates admitted to 13 inpatient health facilities in the Kilimanjaro region; staffing and equipment levels were also assessed.

RESULTS

Among the 82 neonates reviewed, key health information was missing from a substantial proportion of records: on maternal antenatal cards, blood group was recorded for 52 (63.4%) mothers, Rhesus (Rh) factor for 39 (47.6%), VDRL for 59 (71.9%) and HIV status for 77 (93.1%). From neonatal clinical records, heart rate was recorded for3 (3.7%) neonates, respiratory rate in 14, (17.1%) and temperature in 33 (40.2%). None of 13 facilities had a functioning premature unit despite calculated gestational age <36 weeks in 45.6% of evaluated neonates. Intravenous fluids and oxygen were available in 9 out of 13 of facilities, while antibiotics and essential basic equipment were available in more than two thirds. Medication dosing errors were common; under-dosage for ampicillin, gentamicin and cloxacillin was found in 44.0%, 37.9% and 50% of cases, respectively, while over-dosage was found in 20.0%, 24.2% and 19.9%, respectively. Physician or assistant physician staffing levels by the WHO indicator levels (WISN) were generally low.

CONCLUSION

Key aspects of neonatal care were found to be poorly documented or incorrectly implemented in this appraisal of neonatal care in Kilimanjaro. Efforts towards quality assurance and enhanced motivation of staff may improve outcomes for this vulnerable group.

MALE INVOLVEMENT IN MATERNAL HEALTHCARE AS A DETERMINANT OF UTILISATION OF SKILLED BIRTH ATTENDANTS IN KENYA

OBJECTIVE

To determine whether there is a relationship between male involvement in maternal health and utilisation of skilled birth attendants (SBAs) after controlling for socio-demographic and maternal characteristics.

DESIGN

Data from the Kenya Demographic and Health Survey (KDHS) conducted in 2008-09 were analysed.

SETTING

Nationally representative survey in Kenya.

SUBJECTS

The unit of analysis was couples who met the inclusion criteria of being married and having had a child in the three years before the survey.

RESULTS

The adjusted odds ratio after controlling for other factors indicates that women whose husbands attended at least one ANC visit were more likely to have skilled birth attendance than those whose husbands did not attend any ANC visits [AOR, 1.9; 95 percent CI, 1.09-3.32]. Maternal characteristics that had a statistically significant association with delivery by an SBA included educational level, employment, number of ANC visits, and parity. The province where the couple resided also was statistically significant.

CONCLUSION

In Kenya a male partner's participation, through attending ANC visits, is associated with a woman's use of an SBA during delivery.

Acculturation and health care utilization among Mexican heritage women in the United States

With the increasing Latino population in the United States, it is critical to examine the influence of the process of acculturation on health care practices and utilization. The purpose of this study was to evaluate the relationship between acculturation level and post-partum visit (PPV) compliance among Latinas participating in a larger psycho-educational intervention aimed at encouraging women to engage in positive healthcare practices. Acculturation was measured with the Bicultural Involvement Questionnaire which assigned participants to five categories: Assimilated, Separated, Moderate, Bicultural and Alienation. Logistic Regression analyses were conducted to predict post-partum visit attendance. Odds ratios and relative risk of not attending the post-partum visit are presented. Results suggest women in the Separation and Assimilation groups were less likely than bicultural group members to attend the PPV. The only other variable that was significant in this analysis is the group condition, indicating that the intervention group was more likely to attend the PPV than the control group. Women identifying as bicultural seem to participate more actively in their own healthcare as they draw on the cultural assets that have a positive influence on informal health practices, such as healthy eating and refraining from drug use. Bicultural group members can also use formal skills related to language and knowledge of the dominant culture to help effectively navigate the healthcare system. Implications for research, intervention and practice are discussed to improve healthcare practices and increase utilization among Latinas.

Supporting safe motherhood services in Diyarbakir: a community-based distribution project

To provide pregnant and puerperal women experiencing problems with receiving health care in Diyarbakir, Turkey, with an education program and counseling to help them attain appropriate health behaviors and to support receiving health care through a community based distribution model. This article is a descriptive report of a qualitative community based distribution project conducted in cooperation with the Women's Research and Implementation Centre (WRIC) of Diyarbakir Metropolitan Municipality (DMM) and Turkish Family Health and Planning Foundation. The study was carried out between March 2007 and April 2008 in six districts of Diyarbakir, a region with a population of 37,000 people of low socio-economic status and who immigrated from the surrounding villages. A total of 6,029 families were visited and 1,119 pregnant and puerperal women were contacted, provided with education and counseling and referred to primary health care clinics at home visits. Seven women living in the region were selected and educated so that they could offer peer education and educational material was prepared for the target group. The pregnant and puerperal women living in the study area were recorded and referred to primary health care clinics. They were visited four times during pregnancy and three times during puerperium and were provided an education program and counseling. Data were collected from the records made during monitoring the women and focus group discussions with women, peer trainers and health care staff. They were found to acquire appropriate health behaviors, 36.2 % women started to receive health care from primary health care clinics for the first time and 86.9 % of the deliveries were performed at health centers. The pregnant and puerperal women were satisfied with home visits, felt special and put the information about self-care into practice. The number of the women receiving iron supplements and vaccine against tetanus and receiving regular care increased.

Reducing postnatal morbidity

There is evidence from large observational studies that women experience a range of physical and psychological health problems after birth, many of which do not resolve within the postnatal period. The current content, duration and definitions of postnatal care are not appropriate to meet the increasingly complex health and social needs of women giving birth in the UK today. Despite evidence of how the revisions to the content and timing of care could improve the clinical and cost effectiveness of universal NHS postnatal services, and positive policy support for evidence based care, there is evidence that postnatal standards are declining.

Socio-economic inequalities in the use of postnatal care in India

OBJECTIVES

First, our objective was to estimate socio-economic inequalities in the use of postnatal care (PNC) compared with those in the use of care at birth and antenatal care. Second, we wanted to compare inequalities in the use of PNC between facility births and home births and to determine inequalities in the use of PNC among mothers with high-risk births.

METHODS AND FINDINGS

Rich-poor ratios and concentration indices for maternity care were estimated using the third round of the District Level Household Survey conducted in India in 2007-08. Binary logistic regression models were used to examine the socio-economic inequalities associated with use of PNC after adjusting for relevant socio-economic and demographic characteristics. PNC for both mothers and newborns was substantially lower than the care received during pregnancy and child birth. Only 44% of mothers in India at the time of survey received any care within 48 hours after birth. Likewise, only 45% of newborns received check-up within 24 hours of birth. Mothers who had home births were significantly less likely to have received PNC than those who had facility births, with significant differences across the socio-economic strata. Moreover, the rich-poor gap in PNC use was significantly wider for mothers with birth complications.

CONCLUSIONS

PNC use has been unacceptably low in India given the risks of mortality for mothers and babies shortly after birth. However, there is evidence to suggest that effective use of pregnancy and childbirth care in health facilities led to better PNC. There are also significant socio-economic inequalities in access to PNC even for those accessing facility-based care. The coverage of essential PNC is inadequate, especially for mothers from economically disadvantaged households. The findings suggest the need for strengthening PNC services to keep pace with advances in coverage for care at birth and prenatal services in India through targeted policy interventions.

Systematic review of peer support for breastfeeding continuation: metaregression analysis of the effect of setting, intensity, and timing

OBJECTIVE

To examine the effect of setting, intensity, and timing of peer support on breast feeding.

DESIGN

Systematic review and metaregression analysis of randomised controlled trials.

DATA SOURCES

Cochrane Library, Medline, CINAHL, the National Research Register, and British Nursing Index were searched from inception or from 1980 to 2011. Review methods Study selection, data abstraction, and quality assessment were carried out independently and in duplicate. Risk ratios and 95% confidence intervals were calculated for individual studies and pooled. Effects were estimated for studies grouped according to setting (high income countries, low or middle income countries, and the United Kingdom), intensity (<5 and ≥5 planned contacts), and timing of peer support (postnatal period with or without antenatal care), and analysed using metaregression for any and exclusive breast feeding at last study follow-up.

RESULTS

Peer support interventions had a significantly greater effect on any breast feeding in low or middle income countries (P<0.001), reducing the risk of not breast feeding at all by 30% (relative risk 0.70, 95% confidence interval 0.60 to 0.82) compared with a reduction of 7% (0.93, 0.87 to 1.00) in high income countries. Similarly, the risk of non-exclusive breast feeding decreased significantly more in low or middle income countries than in high income countries: 37% (0.63, 0.52 to 0.78) compared with 10% (0.90, 0.85 to 0.97); P=0.01. No significant effect on breast feeding was observed in UK based studies. Peer support had a greater effect on any breastfeeding rates when given at higher intensity (P=0.02) and only delivered in the postnatal period (P<0.001), although no differences were observed of its effect on exclusive breastfeeding rates by intensity or timing.

CONCLUSION

Although peer support interventions increase breastfeeding continuation in low or middle income countries, especially exclusive breast feeding, this does not seem to apply in high income countries, particularly the United Kingdom, where breastfeeding support is part of routine postnatal healthcare. Peer support of low intensity does not seem to be effective. Policy relating to provision of peer support should be based on more specific evidence on setting and any new peer services in high income countries need to undergo concurrent evaluation.

Determinants of antenatal and postnatal care visits among Indigenous people in Bangladesh: a study of the Mru community

INTRODUCTION

Antenatal and postnatal care services are significant interventions to improve maternal health and prevent maternal and infant deaths. However, these services are poorly developed in Bangladesh, particularly among Indigenous women. This study examined factors associated with antenatal and postnatal care visits among the Mru, the most underprivileged Indigenous people in Bangladesh.

METHODS

This cross-sectional study used both quantitative and qualitative methods. In total, 374 currently married Mru women with at least one child aged 5 years or younger were selected from 3 upazilas (sub-districts) of Bandarban District, Bangladesh for survey. In addition, in-depth interviews were performed with 26 Mru leaders, Mru women, traditional midwives, village 'doctors', school teachers, health and non-government organization workers. Associations between antenatal and postnatal care visits and the women's backgrounds characteristics were assessed by bivariate and multivariate analyses.

RESULTS

The traditional Mru prenatal and postnatal practices potentially inhibited women from seeking care. Both antenatal (11.2%) and postnatal (6.4%) care visits among the Mru women were lower than the national level. Most visits were to traditional midwives in their rural villages, rather than to health complexes or hospitals. The main reasons for lack of antenatal and postnatal care were travelling distance to care and transportation problems. Multivariate analysis revealed factors associated with antenatal care were the respondent's place of residence, age, level of education, distance to the service centers and exposure to any mass media. Similar results were obtained with regard to postnatal care visits.

CONCLUSIONS

This study suggests that cultural issues, distance, infrastructure and socioeconomic status are important determinants of maternal healthcare-seeking behavior. Healthcare delivery systems and appropriate education programs should be developed at the village level to improve the health of mothers and children in the Mru community.

Postpartum depression according to time frames and sub-groups: a survey in primary health care settings in Rio de Janeiro, Brazil

This study aimed at estimating the prevalence of postpartum depression (PPD) according to postpartum periods and sub-groups in public primary health care settings in Rio de Janeiro, Brazil. A cross-sectional survey was carried out in five primary health care units and included 811 participants randomly selected among mothers of children up to five postpartum months. Women were classified as depressed and given scores on Edinburgh Postnatal Depression Scale (EPDS) above 11. The overall estimate of PPD was 24.3% (95% CI, 21.4-27.4). However, estimates were not homogeneous during the first 5 months postpartum (p value = 0.002). There was a peak of depressive symptoms around 3 months postpartum, when 128 women (37.5%, 95% CI, 29.1-46.5) disclosed scores above 11 on EPDS. Regarding the magnitude of PPD according to some maternal and partners' characteristics, it was consistently higher among women with low schooling, without a steady partner, and whose partners misused alcohol or used illicit drugs. The prevalence of PPD among women attending primary health care units in Rio de Janeiro seems to be higher than general estimates of 10-15%, especially among mothers with low schooling and that receive little (if any) support from partners. Also, the "burden" of PPD may be even higher around 3 months postpartum. These results are particularly relevant for public health policies. Evaluation of maternal mental health should be extended at least until 3 to 4 months postpartum, and mothers presenting a high-risk profile deserve special attention.

Postpartum follow-up rates before and after the postpartum follow-up initiative at Queen Emma Clinic

OBJECTIVE

To study postpartum follow-up rates, as well as counseling opportunities, among Queen Emma Clinic patients before and after the implementation of the Queen Emma Clinic Postpartum Follow-up Initiative.

METHODS

This was a retrospective chart review of 221 women who received prenatal care at the Queen Emma Clinic and gave birth between April 2006 and April 2008. In April 2007 the postpartum initiative was started. The primary outcome was the number of postpartum follow-up visits. Secondary outcomes included breastfeeding, contraceptive use, depression screening and referral, follow-up screening for patien ts with gestational diabetes and subsequent pregnancy.

RESULTS

Postpartum follow-up rates were significantly higher after the Postpartum Follow-up Initiative (86.1% compared with 71.7%, P =.012). When comparing timing of follow-up, the first postpartum visit occurred approximately one week sooner in the post intervention group (2.96 weeks compared with 3.73 weeks, P=0.38) with no difference in timing of the second postpartum visit (6.62 weeks compared with 6.42 weeks, P=.72). In the post intervention group there were more patients breastfeeding at the first postpartum visit (28.7% compared with 16%, P=.015), as well as the second postpartum visit (28.7% compared with 12.3%, P=0.01). There were also more women using contraception in the post intervention group (84.3% compared with 71.7%, P=.009). There was no difference in depression screening or referral, follow-up screening for gestational diabetes, or timing of subsequent pregnancies.

CONCLUSION

The Postpartum Follow-Up Initiative improved postpartum follow-up rates, as well as breastfeeding, and contraceptive use.

Factors affecting the utilisation of postpartum care among young mothers in Bangladesh

This article addresses the hypothesis that predisposing, enabling and need factors of households influence utilisation of postpartum care among the young mothers according to the timing and type of providers. To reach our goal Bangladesh Demographic and Health Survey of 2007 data (n = 2376) were used. Findings revealed that only one-third of the young mothers received postpartum care. Postpartum care by medically trained personnel and within the most critical period (within 48 h after delivery) was found to be very low (25.5 and 16.6%). Regarding postpartum morbidities, only one-fifth to one-half of the women reporting a complication consulted medically trained providers. Indeed, between one third and two thirds did not seek any postpartum care. The highest percentages contacting healthcare providers were for convulsions and the lowest was when the baby's hands or feet came first. The stronger influence of the mother's education and antenatal care on the utilisation of postpartum care is consistent with findings from other studies. Concern of the husband or family about pregnancy complications showed a significant and positive impact on the utilisation of postpartum care. Multivariate analysis showed that mother's age at delivery, residence, education, antenatal care, place of delivery, wealth, husband's occupation, husband's concern about pregnancy complications and mother's permission to go to a health centre alone were likely to affect utilisation of postpartum care services. The results indicate urgent needs in Bangladesh for an awareness-raising program highlighting the importance and availability of postpartum care; for strategies to improve the availability and accessibility of antenatal care services and skilled birth attendance, including focused financial support; for women's education to be given high priority; and to enable women to exercise their rights to control their freedom of movement, own health care and access to economic resources.

A Description of the Management and Outcomes of Vaginal Birth After Cesarean Birth in the Homebirth Setting

Our objective was to describe the outcomes of intended home birth among 57 women with a previous cesarean birth. Data were drawn from a larger prospective study of intended homebirth in nurse-midwifery practice. Available data included demographics, perinatal risk information, and outcomes of prenatal, intrapartum, postpartum, and neonatal care. The hospital course was reviewed for those transferred to the hospital setting. Fifty-three of 57 women (93%) had a spontaneous vaginal birth, 1 had a vacuum-assisted birth, and 3 (5.3%) had a repeat cesarean birth. Thirty-one of 32 (97%) women who had a previous vaginal birth after cesarean birth (VBAC) had a successful VBAC; 22 of 25 (88%) women without a history of VBAC successfully delivered vaginally. Fifty (87.7%) of these women delivered in the home setting, whereas 7 (12.3%) delivered in the hospital setting. None of the women experienced uterine rupture or dehiscence. One infant was stillborn. This event was attributed to a postdates pregnancy with meconium. Certified nurse-midwives with homebirth practices must be knowledgeable about the risks for mother and baby, screen clientele appropriately, and be able to counsel patients with regard to potential adverse outcomes. Given what is presently known, VBAC is not recommended in the homebirth setting. It is imperative in the light of current evidence and practice climate to advocate for the availability of certified nurse-midwife services and woman-centered care in the hospital setting.

Management of gestational diabetes by physicians in Turkey

AIMS

We sought to investigate the practice patterns of clinicians (family physicians, internists and obstetricians) in Turkey in screening for gestational diabetes mellitus (GDM), management and monitoring of hyperglycaemia in pregnant women with GDM, and assessment of glucose tolerance in the postpartum state.

METHODS

Between January and December 2007, current practices of Turkish physicians (n=434) were assessed by a questionnaire which was concerned with physician demographics and clinical practice including screening and diagnostic methods for GDM, management of GDM during pregnancy and postpartum assessment of glucose tolerance. The questionnaire was developed in respect to the recommendation of the Fifth International Workshop-Conference on GDM and the standards of the American Diabetes Association (ADA).

RESULTS

Although most of the physicians stated that they performed screening for GDM and postpartum screening for glucose intolerance in women with GDM, their screening practices vary. The proportion of women who were provided with a nutrition counselling by a registered dietician and a patient education by a trained nurse was low, especially in women treated by the family physicians. Home glucose monitoring was widely used in the management of GDM, however, postprandial glucose assays were used occasionally. Regular and NPH insulin preparations were the most preferred drugs to treat GDM. Internists were more likely to use insulin analogues. On the other hand, a significant number of physicians stated that they used oral antidiabetics (OADs). A considerable number of family physicians used OADs which have not been proved to be safe in pregnancy.

CONCLUSIONS

Our results suggest that there is considerable variation in the clinical practice patterns of physicians. An education program to enhance the clinical aptitude of physicians, particularly family physicians, in the medical management of GDM should be designed throughout the country.