Long-term follow-up and pregnancy after complete sacrectomy with lumbopelvic reconstruction: case report and literature review

Revisiting the patriarchal bargain: The intergenerational power dynamics of household money management in rural Nepal

Although power struggles between daughters-in-law and mothers-in-law in the South Asian household remain an enduring theme of feminist scholarship, current policy discourse on 'women's economic empowerment' in the Global South tends to focus on married women's power over their husband; this neglects intergenerational power dynamics. The aim of this study was to describe and analyze the processes involved in young, married women's negotiations of control over cash inside the extended household in a contemporary rural Nepali setting. We conducted a grounded theory study of 42 households from the Plains of Nepal. Our study uncovered multiple ways in which junior wives and husbands in the extended household became secret allies in seeking financial autonomy from the rule of the mother-in-law to the wife. This included secretly saving up for a household separation from the in-laws. We argue these secret financial strategies constitute a means for junior couples to renegotiate the terms of Kandiyoti's (1988) 'patriarchal bargain' wherein junior wives traditionally had to accept subservience to their husband and mother-in-law in exchange for economic security and eventual authority over their own daughters-in-law. Researchers, activists and policy-makers concerned with women's economic empowerment in comparable contexts should consider the impact of intergenerational power relations on women's control over cash.

Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis

BACKGROUND

This paper responds to the global call to action for respectful maternity care (RMC) by examining whether and how gender inequalities and unequal power dynamics in the health system undermine quality of care or obstruct women's capacities to exercise their rights as both users and providers of maternity care.

METHODS

We conducted a mapping review of peer-reviewed and gray literature to examine whether gender inequality is a determinant of mistreatment during childbirth. A search for peer-reviewed articles published between January 1995 and September 2017 in PubMed, Embase, SCOPUS, and Web of Science databases, supplemented by an appeal to experts in the field, yielded 127 unique articles. We reviewed these articles using a gender analysis framework that categorizes gender inequalities into four key domains: access to assets, beliefs and perceptions, practices and participation, and institutions, laws, and policies. A total of 37 articles referred to gender inequalities in the four domains and were included in the analysis.

RESULTS

The mapping indicates that there have been important advances in documenting mistreatment at the health facility, but less attention has been paid to addressing the associated structural gender inequalities. The limited evidence available shows that pregnant and laboring women lack information and financial assets, voice, and agency to exercise their rights to RMC. Women who defy traditional feminine stereotypes of chastity and serenity often experience mistreatment by providers as a result. At the same time, mistreatment of women inside and outside of the health facility is normalized and accepted, including by women themselves. As for health care providers, gender discrimination is manifested through degrading working conditions, lack of respect for their abilities, violence and harassment,, lack of mobility in the community, lack of voice within their work setting, and limited training opportunities and professionalization. All of these inequalities erode their ability to deliver high quality care.

CONCLUSION

While the evidence base is limited, the literature clearly shows that gender inequality-for both clients and providers-contributes to mistreatment and abuse in maternity care. Researchers, advocates, and practitioners need to further investigate and build upon lessons from the broader gender equality, violence prevention, and rights-based health movements to expand the agenda on mistreatment in childbirth and develop effective interventions.

A global view of severe maternal morbidity: moving beyond maternal mortality

BACKGROUND

Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs).

SEVERE MATERNAL MORBIDITY IN HIGH-INCOME COUNTRIES

Since the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify "high risk" status, delays in diagnosis, and delays in treatment.

SEVERE MATERNAL MORBIDITY IN LOW AND MIDDLE INCOME COUNTRIES

The highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity.

EFFECTS OF SMM ON DELIVERY OUTCOMES AND INFANTS

Severe maternal morbidity not only puts the woman's life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn.

CONCLUSION

Increasing global maternal morbidity is a failure to achieve broad public health goals of improved women's and infants' health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.

The application of implementation science theories for population health: A critical interpretive synthesis

BACKGROUND AND PURPOSE

Over the last decade, the field of implementation science (IS) has yielded an array of theoretical approaches to clarify and understand how factors influence the application and scaling-up of evidence-based practice in health care. These developments have led to questions about whether IS theories and frameworks might be of value to population health researchers and decision makers. The purpose of this research was to conduct a critical interpretive synthesis to explore, if, and how, key IS theories and frameworks might inform population health interventions aimed at reducing the burden of illness across populations.

METHODS

An initial list of theories and frameworks was developed based on previous published research and narrowed to focus on theories considered as formative for the field of IS. A standardized data extraction form was used to gather key features of the theories and critically appraise their relevance to population health interventions.

RESULTS

Ten theories were included in the review and six deemed most applicable to population health based on their consideration of broader contextual and system-level factors. The remaining four were determined to have less relevant components for population health due to their limited consideration of macro-level factors, often focusing on micro (individual) and meso (organizational) level factors.

CONCLUSIONS

Theories and frameworks are important to guide the implementation and sustainability of population health interventions. The articulation of meso level factors common in IS theories may be of value to interventions targeted at the population level. However, some of the reviewed theories were limited in their consideration of broader contextual factors at the macro level (community, policy or societal). This critical interpretive synthesis also found that some theories lacked provision of practical guidance to address interventions targeting structural factors such as key social determinants of health (e.g., housing, income).

Factors influencing the use of contraceptives through the lens of teenage women: a qualitative study in Iran

BACKGROUND

One out of seven teenage girls in developing countries marries before the age of 15. While the fertility rate of teenage girls is high, the rate of contraceptive use remains low; therefore, this group of teenagers needs reproductive healthcare. This study was undertaken to explore factors influencing the use of contraceptives from the perspective of teenage women living in the city of Ardabil in Iran.

METHODS

This qualitative study was conducted with 14 married women aged 13-19 years who attended in urban-rural healthcare centers in Ardabil. Eligible women were recruited using purposive sampling and were invited to take part in individual in-depth semi-structured interviews. The duration of the interviews varied from 45 to 90 min with an average of 55 min. Sampling continued until data saturation was reached and no new data was collected. Each interview was tape-recorded after obtaining the participant's permission, transcribed verbatim and analyzed for identifying categories and themes using conventional content analysis.

RESULTS

Three themes and eight subthemes were developed. The themes were as follows: "insufficient familiarity with contraceptive methods", "pressure to become pregnant" and "misconceptions".

CONCLUSION

Despite the high prevalence of early marriage in Iranian society, teenage women are not empowered or prepared for marriage and birth control. Sexual and reproductive healthcare services to teenage women should be improved to meet their needs.

Who benefits from free institutional delivery? evidence from a cross sectional survey of North Central and Southwestern Nigeria

Background

The reasons for low utilisation of maternal health services in settings where the user-fee removal policy has been implemented continue to generate scholarly debates. Evidence of whether user-fee removal benefits the poor women in underserved settings is scanty and inconsistent. This article examines use of maternal health care services in the context of free maternal healthcare and profiles the beneficiaries of user-fee removal.

Methods

The study adopted a descriptive design. A three-stage cluster sampling method was used to select a representative sample of 1227 women who gave birth between 2011 and 2015. Questionnaires were administered using a face-to-face interview approach and data generated were analysed using descriptive and inferential statistics.

Results

The analysis shows that the use of maternal healthcare services has improved considerably in North Central and Southwestern Nigeria. While socioeconomic and geographical inequality in the use of maternal healthcare services appear to be disappearing in Southwestern Nigeria, it appears to be widening in North Central Nigeria. The findings indicate that 33.6% of women reported to have benefitted from the free child-delivery programme; however, substantial variation exists across the two regions. The proportion of beneficiaries of user-fee removal policy was highest in urban areas (35.9%), among women belonging to the middle income category (38.3%), among women who gave birth in primary health centres (63.1%) and among women who resided in communities where there was availability of health facilities (37.2%).

Conclusion

The study concludes that low coverage of the free maternal health programme, especially among women of low socioeconomic status residing in underserved settings is among the reasons for persistent poor maternal health outcomes in the context of free maternal healthcare. A model towards improving maternal health in underserved settings, especially in North Central Nigeria, would entail provisioning of health facilities as well as focusing on implementing equitable maternal health policies.

Hemisacrectomy with preservation of the contralateral sacral nerve roots and sacroiliac joint for pelvic neurofibrosarcoma in a 7-year-old child: case report with 2-year follow-up

Neurofibrosarcoma is rare in the pediatric age group. A malignant tumor of the sacrum presents significant challenges, especially if the goals are to resect with wide and clean surgical margins and to achieve acceptable functional outcomes. The authors report a case of this rare tumor affecting the sacrum and sacral nerve roots of a 7-year-old girl and review the role of total hemisacrectomy sparing the contralateral sacral nerve roots and lumbopelvic reconstruction in the treatment of this disease. This patient is, to the best of the authors' knowledge, the youngest to be treated in this manner.