Barriers to increasing hospital birth rates in rural Shanxi Province, China

PM2.5-related neonatal encephalopathy due to birth asphyxia and trauma: a global burden study from 1990 to 2019

Long-term exposure to fine particulate matter (PM_2.5) may increase the risk of neonatal encephalopathy due to birth asphyxia and trauma. However, little is known about the trends of PM_2.5-related neonatal encephalopathy burden under different levels of social and economic development. We studied the burden of PM_2.5-related neonatal encephalopathy due to birth asphyxia and trauma measured by the age-standardized mortality rate (ASMR) and the age-standardized disability-adjusted life years rate (ASDR), and its trends with the socio-demographic index (SDI) in 192 countries and regions from 1990 to 2019. This is a retrospective study using the Global Burden of Disease Study 2019 (GBD2019) database. The age-standardized mortality rate (ASMR) and age-standardized disability-adjusted life years rate (ASDR) are used to measure the burden of PM_2.5-related neonatal encephalopathy in different countries and regions. The mortality rate (per 100 thousand) is used to evaluate the differences of PM_2.5-related neonatal encephalopathy burden in sex and age. The annual percentage changes (APCs) and the average annual percentage changes (AAPCs) are used to reflect the trends of PM_2.5-related neonatal encephalopathy burden over years (1990-2019) and are calculated using a Joinpoint model. The relationship of the socio-demographic index with the ASMR and ASDR is calculated using Gaussian process regression. In summary, the global burden of PM_2.5-related neonatal encephalopathy increased since 1990, especially in boys, early neonates, and regions with low-middle SDI. Globally, the ASMR and ASDR of PM_2.5-related neonatal encephalopathy burden in 2019 were 0.59 (95% CI: 0.40, 0.83) per 100,000 people and 52.59 (95% CI: 35.33, 73.67) per 100,000 people, respectively. From 1990 to 2019, the ASMR and ASDR of PM_2.5-related neonatal encephalopathy increased by 44.39% and 44.19%, respectively. The global average annual percentage changes of ASMR and ASDR were 1.3 (95% CI: 1.0, 1.6). The relationship between the socio-demographic index and the burden of PM_2.5-related neonatal encephalopathy presented negative correlation when the socio-demographic index was more than 0.60. Middle, high-middle, and high SDI regions had decreasing trends of PM_2.5-related neonatal encephalopathy, of which the AAPCs for both ASMR and ASDR ranged from - 0.3 to - 3.1. Besides improving the progress in national policy and the coverage rate of maternal and neonatal health care and facility-based delivery, air pollution control may also be a better way for countries with large and increasing amounts of exposure to PM_2.5 pollution to reduce neonatal encephalopathy. And our results also suggest that low and low-middle SDI countries should appropriately pay more attention to early newborns and boys.

“We Beat Them to Help Them Push”: Midwives’ Perceptions on Obstetric Violence in the Ashante and Western Regions of Ghana

Obstetric violence has been recognized as a major impediment to facility-based delivery, increasing the risk of preventable complications and maternal mortality. In Ghana, studies on women’s birth experiences reveal enormous and brutal acts of violence during delivery; however, inquiries into why midwives abuse women have not been extensively studied. This study explored the perspectives of midwives on the drivers of obstetric violence in the Western and Ashante Regions of Ghana. A qualitative study was conducted involving 30 in-depth interviews with midwives in eight health facilities. The data were analyzed thematically using NVivo 12. The results of the study reveal a normalization of violence in the delivery room and the intensity of violence is heightened during the second stage of labor. Midwives reported perpetrating or witnessing physical violence, abandonment of women, stigmatization of HIV women, verbal abuses such as shouting, and the detention of women in the health facilities. Midwives abuse women as a result of the pressures of the midwifery profession, poor maternal efforts of women, disrespect of midwives, women’s disobedience, and uncooperative attitudes. The culture of acceptability of obstetric violence is a major driver, contributing to its normalization. Midwives do not consider obstetric violence as abuse, but rather, as a delivery strategy which aids a successful delivery. It is therefore justified and viewed as a necessary part of the delivery process. There is a critical need for retraining midwives on alternative birthing strategies devoid of violence.

The Association between the Burden of PM2.5-Related Neonatal Preterm Birth and Socio-Demographic Index from 1990 to 2019: A Global Burden Study

BACKGROUND

Preterm birth (PTB) leads to short-term and long-term adverse effects on newborns. Exposure to fine particulate matter (PM_2.5) was positively related to PTB. However, the global annual average PM_2.5 was three times than the recommended value in 1998-2014. Socio-demographic index (SDI) is a new indicator that comprehensively reflects the overall development level of a country, partly because of "the epidemiological transition". Among other countries with higher and similar SDI levels, policy makers have the opportunity to learn from their successful experiences and avoid their mistakes by identifying whether their burdens of disease are higher or lower than the expected. However, it is unclear about the trends of the burden of PM_2.5-related preterm birth in different countries and different levels of SDI regions. Additionally, the relationship between the SDI and the burden in 1990-2019 is also unclear.

METHODS

This was a retrospective study based on the Global Burden of Disease Study 2019 (GBD2019) database from 1990 to 2019. The burden of PM_2.5-related PTB was measured by the age-standardized mortality rate (ASMR), age-standardized disability-adjusted life years rate (ASDR), mortality rate, and the disability-adjusted life years (DALYs). The annual percentage changes (APCs) and the average annual percentage changes (AAPCs) were used to reflect the trends over the past 30 years, which were calculated using a joinpoint model. The relationships between the ASMR, ASDR, and SDI were calculated using a Gaussian process regression.

FINDINGS

In 2019, the entire burden of PM_2.5-related PTB was relatively high, where the ASMR and the ASDR were 0.76 and 67.71, increasing by 7.04% and 7.12%, respectively. It mainly concentrated on early neonates, boys, and on low-middle SDI regions. The increase in the burden of PM_2.5-related PTB in low and low-middle SDI regions is slightly higher than the decrease in other SDI regions. In 2019, the burden varied greatly among different levels of SDI regions where ASMRs varied from 0.13 in high SDI regions to 1.19 in low-middle regions. The relationship between the expected value of the burden of PM_2.5-related PTB and SDI presented an inverted U-shape, and it reached the maximum when SDI is around 0.50. The burdens in four regions (South Asia, North Africa and the Middle East, western sub-Saharan Africa, and southern sub-Saharan Africa) were much higher than the mean value. Boys bore more burden that girls. The sex ratio (boys:girls) of the burden showed a dramatically increasing trend in low SDI regions and a decreasing trend in middle SDI regions and high-middle SDI regions. These differences reflect the huge inequality among regions, countries, ages, and sex in the burden of PM_2.5-related PTB.

CONCLUSION

The overall burden of PM_2.5-related PTB in 2019 was relatively high, mainly concentrated on early neonates, boys, and on low-middle SDI regions. It showed an increasing trend in low-middle and low SDI regions. The association between the burden and the SDI presented an inverted U-shape. It is very necessary to promulgate policies to prevent and control air pollution in countries with large and increasing exposure to PM_2.5 pollution because it does not need action at an individual level. Focusing on public educational interventions, public and professional policies, and improving accessibility of prenatal care are other feasible ways for low and low-middle SDI countries. Policy makers should also appropriately allocate medical resources to boys and early newborns.

Demographic characteristics of women that use traditional birth attendants in Bongo District, Ghana

INTRODUCTION

Over the last decade, the government of Ghana has implemented several interventions aimed at increasing access to skilled birth-care services from trained professionals. Despite these efforts, there is a wide gap between antenatal care attendance and skilled delivery attendance, particularly in rural areas. Evidence shows that many women in rural and deprived communities in Ghana rely on traditional birth attendant (TBA) delivery services. This has created a gap where antenatal attendance is high while skilled delivery is relatively low. The purpose of this study is to identify and analyse the sociodemographic characteristics of women who use the services of TBAs in Bongo District, Ghana.

METHODS

Using a descriptive study design, a survey was conducted involving 330 mothers randomly selected from 1685 mothers who delivered at home by 2014 in Bongo District. The questionnaire for mothers who delivered at home by a TBA comprised 28 questions.

RESULTS

The results show that women who used TBA were older, without formal education, married, predominantly farmers, married to spouses who were farmers without formal education. Most of the sampled women were co-currently covered by the national health insurance.

CONCLUSIONS

This study describes the demographic characteristics of women who use a TBA. Therefore, ongoing efforts aimed at increasing access to and use of professional antenatal services should incorporate sociodemographic factors in the rural context.

Persistent barriers to the use of maternal, newborn and child health services in Garissa sub-county, Kenya: a qualitative study

Background

North Eastern Kenya has persistently had poor maternal, new-born and child health (MNCH) indicators. Barriers to access and utilisation of MNCH services are structural, individual and community-level factors rooted in sociocultural norms. A package of interventions was designed and implemented in Garissa sub-County aimed at creating demand for services. Community Health Volunteers (CHVs) were trained to generate demand for and facilitate access to MNCH care in communities, while health care providers were trained on providing culturally acceptable and sensitive services. Minor structural improvements were made in the control areas of two facilities to absorb the demand created. Community leaders and other social actors were engaged as influencers for demand creation as well as to hold service providers accountable. This qualitative research was part of a larger mixed methods study and only the qualitative results are presented. In this paper, we explore the barriers to health care seeking that were deemed persistent by the end of the intervention period following a similar assessment at baseline.

Methods

An exploratory qualitative research design with participatory approach was undertaken as part of an impact evaluation of an innovation project in three sites (two interventions and one control). Semi-structured interviews were conducted with women who had given birth during the intervention period. Focus group discussions were conducted among the wider community members and key informant interviews among healthcare managers and other stakeholders. Participants were purposively selected. Data were analysed using content analysis by reading through transcripts. Interview data from different sources on a single event were triangulated to increase the internal validity and analysis of multiple cases strengthened external validity.

Results

Three themes were pre-established: 1) barriers and solutions to MNCH use at the community and health system level; 2) perceptions about women delivering in health facilities and 3) community/social norms on using health facilities. Generally, participants reported satisfaction with services offered in the intervention health facilities and many indicated that they would use the services again. There were notable differences between the intervention and control site in attitudes towards use of services (skilled birth attendance, postnatal care). Despite the apparent improvements, there still exist barriers to MNCH services use. Persistent barriers identified were gender of service provider, insecurity, poverty, lack of transport, distance from health facilities, lack of information, absence of staff especially at night-time and quality of maternity care.

Conclusion

Attitudes towards MNCH services are generally positive, however some barriers still hinder utilization. The County health department and community leaders need to sustain the momentum gained by ensuring that service access and quality challenges are continually addressed.

Narratives of Women Using a 24-Hour Ride-Hailing Transport System to Increase Access and Utilization of Maternal and Newborn Health Services in Rural Western Kenya: A Qualitative Study

Between 1990 and 2015, Kenya had a 0.9% annual reduction in maternal mortality, one of the lowest reductions globally. This slow decline was linked to the relatively low utilization of delivery services. We designed a mobile phone-enhanced 24-hour transport navigation system coupled with personalized and interactive gestation-based text messages (MAccess) to address maternal child health service utilization. The primary purpose of this analysis is to explore the ways in which pregnant and postnatal women made decisions regarding care-seeking for pregnancy and childbirth services, the processes of getting care from home to the hospital as well their perceptions on how the MAccess intervention affected their pregnancy and childbirth care-seeking and utilization experience. We conducted semistructured, individual interviews with 18 postpartum women. Participants were purposively sampled. Interviews were audiotaped, transcribed, and analyzed using thematic analysis. For participants in this study, all three delays interacted in a complex manner to affect women's utilization of pregnancy and childbirth services. Even though women were aware of the benefits of skilled birth attendance, other health system factors such as opening hours, or health workers' attitudes still deterred women from delivering in health facilities. The MAccess innovation was highly acceptable to women throughout pregnancy and childbirth and helped them navigate the complex and layered individual, infrastructural, and health system factors that put them at risk of adverse maternal and newborn outcomes. These findings emphasize that an integrated approach, which addresses all delays simultaneously, is important for reducing perinatal morbidity and mortality.

A critical interpretive synthesis of informal payments in maternal health care

Informal payments for healthcare are widely acknowledged as undercutting health care access, but empirical research is somewhat limited. This article is a critical interpretive synthesis that summarizes the evidence base on the drivers and impact of informal payments in maternal health care and critically interrogates the paradigms that are used to describe informal payments. Studies and conceptual articles identified both proximate and systems drivers of informal payments. These include norms of gift giving, health workforce scarcity, inadequate health systems financing, the extent of formal user fees, structural adjustment and the marketization of health care, and patient willingness to pay for better care. Similarly, there are proximal and distal impacts, including on household finances, patient satisfaction and provider morale. Informal payments have been studied and addressed from a variety of different perspectives, including anti-corruption, ethnographic and other in-depth qualitative approaches and econometric modelling. Summarizing and discussing the advantages and disadvantages of these and other paradigms illustrates the value of an inter-disciplinary approach. The same tacit, hidden attributes that make informal payments hard to measure also make them hard to discuss and address. A multidisciplinary health systems approach that leverages and integrates positivist, interpretivist and constructivist tools of social science research can lead to better insight. With this, we can challenge ‘master narratives’ and meet universalistic, equity-oriented global health objectives.

Correlates of continuum of maternal health services among Nepalese women: Evidence from Nepal Multiple Indicator Cluster Survey

Continuum of Care (CoC) is an essential strategy to prevent maternal and child deaths where health services are arranged in a pathway throughout pregnancy, childbirth and after delivery. However, CoC is still a challenge in Nepal. This study aimed to investigate the correlates of CoC from pregnancy to the postnatal period in Nepalese women aged 15 to 49 years. Secondary analysis was performed on the data from Nepal Multiple Indicator Cluster Survey. This led to a sample size of 2086 women who had a live birth within two years preceding the survey. We constructed three outcome models and conducted multivariable logistic regression, to assess socio-economic and demographic correlates of CoC from pregnancy to childbirth to postnatal period. Overall, 41% of the women received Antenatal Care (ANC), delivery from Skilled Birth Attendant (SBA) as well as the Postnatal Care (PNC) during their most recent birth. Women from rural areas (aOR 0.25, 95%CI: 0.18, 0.36) had reduced odds of receiving CoC while women belonging to advantaged ethnic group (aOR 1.61, 95%CI: 1.18 2.19), from middle wealth status (aOR 2.56, 95%CI: 1.68, 3.91) and upper (aOR 4.50, 95%CI: 3.07, 6.59) wealth status, and women having access to media (aOR 1.76, 95%CI: 1.31, 2.37) had higher odds of receiving CoC from pregnancy to postnatal period. Having more than two births reduced the odds of CoC by 30% (aOR 0.70, 95%CI: 0.50, 0.98). These factors were also significantly associated with ANC services and the continuum from ANC to delivery SBA. The findings suggest that the majority of Nepalese women lack a continuity of care during their pregnancy and childbirth, and several socioeconomic factors affect the spectrum of CoC. Efforts to improve maternal health services utilization in a continuum require strategies that remove demand and supply barriers of health care utilization.

Effect of China's maternal health policy on improving rural hospital delivery: Evidence from two cross-sectional surveys

This population-based cross-sectional study aims to explore the effect of China’s Rural Hospital Delivery Subsidy (RHDS) policy on the utilization of women’s hospital delivery between rural and urban areas. A total of 2398 women were drawn from the Fourth and Fifth National Health Service Surveys, from the Shaanxi province. A generalized linear mixed model was used to analyze the influence of the RHDS policy on the hospital delivery rate. Concentration index and decomposition methods were used to explore the equity of hospital delivery utilization. Prior to introduction of the RHDS policy, the difference in hospital delivery rates was −0.09 (95% CL: −0.16, −0.01) between rural and urban women when adjusting the influence of socioeconomic factors on hospital delivery; after implementation of the policy, the difference was reduced to 0.02 (95% CL: −0.01, 0.06). The horizontal inequity index was reduced from 0.084 to 0.009 for rural women and from 0.070 to 0.011 for urban women. China’s Rural Hospital Delivery Subsidy policy had some positive effect on reducing the gap between rural and urban women’s hospital delivery rate and inequity. However, there is still a pro-rich inequity of hospital delivery utilization for both rural and urban women.

Initiation of traditional birth attendants and their traditional and spiritual practices during pregnancy and childbirth in Ghana

Background

Prior to the advent of modern obstetric services, traditional birth attendants (TBAs) have rendered services to pregnant women and women in labour for a long time. Although it is anticipated that women in contemporary societies will give birth in hospitals and clinics, some women still patronize the services of TBAs. The study therefore sought to gain an in-depth understanding of the initiation of TBAs and their traditional and spiritual practices employed during pregnancy and childbirth in Ghana.

Methods

The design was an exploratory qualitative one using in-depth individual interviews. Data saturation was reached with 16 participants who were all of Christian faith. Interviews were conducted with a semi-structured interview guide, audiotaped and transcribed verbatim. Content analysis was employed to generate findings.

Results

The findings showed that TBAs were initiated through apprenticeship from family members who were TBAs and other non-family TBAs as well as through dreams and revelations. They practice using both spiritual and physical methods and their work was founded on spiritual directions, use of spiritual artefacts, herbs and physical examination. TBAs delay cutting of the cord and disposal of the placenta was associated with beliefs which indicated that when not properly disposed, it will have negative consequences on the child during adulthood.

Conclusion

Although, TBAs like maternal health professionals operate to improve maternal health care, some of their spiritual practices and beliefs may pose threats to their clients. Nonetheless, with appropriate initiation and training, they can become useful.

Women's perspectives on quality of maternal health care services in Malawi

Despite promotion by many stakeholders to improve maternal health outcome in many developing countries including Malawi, many analysts agree that the utmost success in maternal health will arise if maternal health care services are an unparallel led source for women’s health care solutions for any problem related to childbirth. Health advocates worldwide claim that even though maternal services are provided, women’s utilization of such services has not been ascertained. The objective of this study was to explore women’s perspectives on the quality of health care service delivery in Malawi. This article therefore investigates women’s perspectives on the quality of maternal health care services in Malawi. We used six focus group discussions in six health facilities that were selected across Malawi. We found that erratic availability of medical resources and unethical practices among health workers adversely affected quality of maternal health care service delivery. We concluded that the expensive routine operational audits of medical resources and service delivery across health facilities are imperative if women’s health outcomes are to be enhanced in Malawi.

A Qualitative Study on Women's Experiences of Intrapartum Nursing Care at Tamale Teaching Hospital (TTH), Ghana

Introduction: Labor and delivery process is an exciting, anxiety-provoking, but rewarding time for a woman and her family after successful delivery of a newborn. The intrapartum period is the time where mothers expect more care. Taking care of a mother through delivery with no side effects is the task of a professional midwife who is trained with the skill to take the responsibility of caring for mothers and babies. Therefore, the aim of this study was to explore mother's experiences regarding quality of intrapartum nursing/midwifery care. Methods: Focused ethnographic study was employed. Data were collected from May to June 2016 TTH, Ghana using semi structured interview guide. Purposive sampling was employed to recruit 20 participants. Eight individual interviews were conducted in the post natal ward after 48 hours of delivery, followed by three focus group discussions two weeks after delivery when mothers visited post natal clinic. Interviews lasted for about 30-45 minutes during each session. Data were analyzed using thematic analysis. Results: The average age of women were 29 years with ranging from 19-43 years. Participants' experiences of nursing/midwifery care during birth were influenced by reception and respect, provision of information, technical skill, providers' behavior, pain management and availability of nurses/midwives. Conclusion: The study findings have revealed that women's experience of care is affected by a wide range of determinants. Therefore, maternal health programs and policies in Ghana must take into account women's perspective on the care they need and their feedback on services they receive. Nursing education should re-enforce communication/relational skills.

Continuum of care in maternal, newborn and child health in Pakistan: analysis of trends and determinants from 2006 to 2012

BACKGROUND

Pakistan, being a developing country, presents the dismal picture of maternal and neonatal mortality and morbidity. The majority of maternal and neonatal deaths could be avoided if Continuum of Care (CoC) is provided in a structured pathway from pregnancy to birth and to the first week of life of the newborn child. This study aimed to analyse the trends of CoC at all three levels (antenatal care, skilled delivery and postpartum care) and to identify various factors affecting the continuation in receiving CoC in Pakistan during 2006 to 2012.

METHODS

Secondary data analysis was performed on nationally representative data from the last two iterations of Pakistan Demographic and Health Survey (PDHS), conducted during 2006/07 to 2012/13. The analysis is limited to women of the reproductive age group (15-49 years) who gave birth during the last five years preceding both surveys. This leads to a sample size of 5,724 and 7,461 respondents from PDHS 2006/07 and 2012/13 respectively. The association between CoC and several factors, including individual attributes (reproductive status), family influences, community context, as well as cultural and social values was assessed in bivariate analyses in a first step. Furthermore, odds ratios and adjusted odds ratios with 95% confidence intervals using a binary and multivariable logistic regression were calculated.

RESULTS

Our research presents the trends of a composite measure of CoC including antenatal care, delivery assistance and postpartum care. The largest gap in CoC was observed at antenatal care followed by delivery and postnatal care within 48 h after delivery. Results show that CoC completion rate has increased from 15% to 27% amongst women in Pakistan over time from 2006 to 2012. Women with high age at first birth, having less number of children, with higher education, belonging to richest quintile, living in Sindh province and urban areas, having high autonomy and exposure to mass media were most likely to avail complete CoC.

CONCLUSIONS

The findings show that women in Pakistan still lack the CoC. This calls for attention to develop and implement tailored interventions, focusing on the needs of women in Pakistan to provide CoC in an integrated manner, involving both public and private sectors by appropriately addressing the factors hindering CoC completion rates.

Determinants of institutional birth among women in rural Nepal: a mixed-methods cross-sectional study

Background

Encouraging institutional birth is an important component of reducing maternal mortality in low-resource settings. This study aims to identify and understand the determinants of persistently low institutional birth in rural Nepal, with the goal of informing future interventions to reduce high rates of maternal mortality.

Methods

Postpartum women giving birth in the catchment area population of a district-level hospital in the Far-Western Development Region of Nepal were invited to complete a cross-sectional survey in 2012 about their recent birth experience. Quantitative and qualitative methods were used to determine the institutional birth rate, social and demographic predictors of institutional birth, and barriers to institutional birth.

Results

The institutional birth rate for the hospital’s catchment area population was calculated to be 0.30 (54 home births, 23 facility births). Institutional birth was more likely as age decreased (ORs in the range of 0.20–0.28) and as income increased (ORs in the range of 1.38–1.45). Institutional birth among women who owned land was less likely (OR = 0.82 [0.71, 0.92]). Ninety percent of participants in the institutional birth group identified safety and good care as the most important factors determining location of birth, whereas 60 % of participants in the home birth group reported distance from hospital as a key determinant of location of birth. Qualitative analysis elucidated the importance of social support, financial resources, birth planning, awareness of services, perception of safety, and referral capacity in achieving an institutional birth.

Conclusion

Age, income, and land ownership, but not patient preference, were key predictors of institutional birth. Most women believed that birth at the hospital was safer regardless of where they gave birth. Future interventions to increase rates of institutional birth should address structural barriers including differences in socioeconomic status, social support, transportation resources, and birth preparedness.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1022-9) contains supplementary material, which is available to authorized users.

Barriers to Hospital Deliveries among Ethnic Minority Women with Religious Beliefs in China: A Descriptive Study Using Interviews and Survey Data

Background: China has made great progress in improving hospital delivery-the coverage of hospital delivery has increased to above 95% in most regions- some regions lag behind owing to geographic and economic inequality, particularly the poor ethnic minority areas of the Sichuan Province. This study explores factors which may influence hospital delivery from multiple perspectives, with implications for practice and policy. Methods: A framework analysis approach was used to identify and categorize the main barriers and levers to hospital delivery. Our analysis draws on basic information from the sampled counties (Butuo and Daofu). Results: The hospital delivery rate was below 50% in the two sampled areas. In both areas, the “New Rural Cooperative Medical Scheme” and “Rural hospital delivery subsidy” were introduced, but only Butuo county had a transportation subsidy policy. Socioeconomically disadvantaged women in both counties who delivered their babies in hospitals could also apply for financial assistance. A lack of transport was among the main reasons for low hospital delivery rates in these two counties. Furthermore, while the hospital delivery costs could be mostly covered by “New Rural Cooperative Medical Scheme” or “Rural Hospital Delivery Subsidy”, reimbursement was not guaranteed. People in Daofu county might be affected by their Buddhism religion for hospital delivery. Women in Butuo following the Animism religion would refuse delivery in hospitals because of language barriers. Traditional lay beliefs were the main factor that influenced hospital delivery; their understandings of reproductive health varied, and many believed that childbirth should not be watched by strangers and that a home delivery was safe. Conclusions: This study has highlighted a number of barriers and levers to hospital delivery in rural poor ethnic minority areas which could inform and improve the access and rate of hospital delivery rate; thereby reducing health inequalities in maternal and child health in China.

Continuum of Care in a Maternal, Newborn and Child Health Program in Ghana: Low Completion Rate and Multiple Obstacle Factors

Background

Slow progress has been made in achieving the Millennium Development Goals 4 and 5 in Ghana. Ensuring continuum of care (at least four antenatal visits; skilled birth attendance; postnatal care within 48 hours, at two weeks, and six weeks) for mother and newborn is crucial in helping Ghana achieve these goals and beyond. This study examined the levels and factors associated with continuum of care (CoC) completion among Ghanaian women aged 15–49.

Methods

A retrospective cross-sectional survey was conducted among women who experienced live births between January 2011 and April 2013 in three regions of Ghana. In a two-stage random sampling method, 1,500 women with infants were selected and interviewed about maternal and newborn service usage in line with CoC. Multiple logistic regression models were used to assess factors associated with CoC completion.

Results

Only 8.0% had CoC completion; the greatest gap and contributor to the low CoC was detected between delivery and postnatal care within 48 hours postpartum. About 95% of women had a minimum of four antenatal visits and postnatal care at six weeks postpartum. A total of 75% had skilled assisted delivery and 25% received postnatal care within 48 hours. Factors associated with CoC completion at 95% CI were geographical location (OR = 0.35, CI 0.13–0.39), marital status (OR = 0.45; CI 0.22–0.95), education (OR = 2.71; CI 1.11–6.57), transportation (OR = 1.97; CI 1.07–3.62), and beliefs about childhood illnesses (OR = 0.34; CI0.21–0.61).

Conclusion

The continuum of care completion rate is low in the study site. Efforts should focus on increasing postnatal care within 48 hours and overcoming the known obstacles to increasing the continuum of care completion rate.

Reducing high maternal mortality rates in western China: a novel approach

Among the Millennium Development Goals, maternal mortality reduction has proven especially difficult to achieve. Unlike many countries, China is on track to meeting these goals on a national level, through a programme of institutionalizing deliveries. Nonetheless, in rural, disadvantaged, and ethnically diverse areas of western China, maternal mortality rates remain high. To reduce maternal mortality in western China, we developed and implemented a three-level approach as part of a collaboration between a regional university, a non-profit organization, and local health authorities. Through formative research, we identified seven barriers to hospital delivery in a rural Tibetan county of Qinghai Province: (1) difficulty in travel to hospitals; (2) hospitals lack accommodation for accompanying families; (3) the cost of hospital delivery; (4) language and cultural barriers; (5) little confidence in western medicine; (6) discrepancy in views of childbirth; and (7) few trained community birth attendants. We implemented a three-level intervention: (a) an innovative Tibetan birth centre, (b) a community midwife programme, and (c) peer education of women. The programme appears to be reaching a broad cross-section of rural women. Multilevel, locally-tailored approaches may be essential to reduce maternal mortality in rural areas of western China and other countries with substantial regional, socioeconomic, and ethnic diversity.

Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review

Background

High maternal mortality and morbidity persist, in large part due to inadequate access to timely and quality health care. Attitudes and behaviours of maternal health care providers (MHCPs) influence health care seeking and quality of care.

Methods

Five electronic databases were searched for studies from January 1990 to December 2014. Included studies report on types or impacts of MHCP attitudes and behaviours towards their clients, or the factors influencing these attitudes and behaviours. Attitudes and behaviours mentioned in relation to HIV infection, and studies of health providers outside the formal health system, such as traditional birth attendants, were excluded.

Findings

Of 967 titles and 412 abstracts screened, 125 full-text papers were reviewed and 81 included. Around two-thirds used qualitative methods and over half studied public-sector facilities. Most studies were in Africa (n = 55), followed by Asia and the Pacific (n = 17). Fifty-eight studies covered only negative attitudes or behaviours, with a minority describing positive provider behaviours, such as being caring, respectful, sympathetic and helpful. Negative attitudes and behaviours commonly entailed verbal abuse (n = 45), rudeness such as ignoring or ridiculing patients (n = 35), or neglect (n = 32). Studies also documented physical abuse towards women, absenteeism or unavailability of providers, corruption, lack of regard for privacy, poor communication, unwillingness to accommodate traditional practices, and authoritarian or frightening attitudes. These behaviours were influenced by provider workload, patients’ attitudes and behaviours, provider beliefs and prejudices, and feelings of superiority among MHCPs. Overall, negative attitudes and behaviours undermined health care seeking and affected patient well-being.

Conclusions

The review documented a broad range of negative MHCP attitudes and behaviours affecting patient well-being, satisfaction with care and care seeking. Reported negative patient interactions far outweigh positive ones. The nature of the factors which influence health worker attitudes and behaviours suggests that strengthening health systems, and workforce development, including in communication and counselling skills, are important. Greater attention is required to the attitudes and behaviours of MHCPs within efforts to improve maternal health, for the sake of both women and health care providers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12992-015-0117-9) contains supplementary material, which is available to authorized users.

The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review

BACKGROUND

Despite growing recognition of neglectful, abusive, and disrespectful treatment of women during childbirth in health facilities, there is no consensus at a global level on how these occurrences are defined and measured. This mixed-methods systematic review aims to synthesize qualitative and quantitative evidence on the mistreatment of women during childbirth in health facilities to inform the development of an evidence-based typology of the phenomenon.

METHODS AND FINDINGS

We searched PubMed, CINAHL, and Embase databases and grey literature using a predetermined search strategy to identify qualitative, quantitative, and mixed-methods studies on the mistreatment of women during childbirth across all geographical and income-level settings. We used a thematic synthesis approach to synthesize the qualitative evidence and assessed the confidence in the qualitative review findings using the CERQual approach. In total, 65 studies were included from 34 countries. Qualitative findings were organized under seven domains: (1) physical abuse, (2) sexual abuse, (3) verbal abuse, (4) stigma and discrimination, (5) failure to meet professional standards of care, (6) poor rapport between women and providers, and (7) health system conditions and constraints. Due to high heterogeneity of the quantitative data, we were unable to conduct a meta-analysis; instead, we present descriptions of study characteristics, outcome measures, and results. Additional themes identified in the quantitative studies are integrated into the typology.

CONCLUSIONS

This systematic review presents a comprehensive, evidence-based typology of the mistreatment of women during childbirth in health facilities, and demonstrates that mistreatment can occur at the level of interaction between the woman and provider, as well as through systemic failures at the health facility and health system levels. We propose this typology be adopted to describe the phenomenon and be used to develop measurement tools and inform future research, programs, and interventions.

Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis

High-quality obstetric delivery in a health facility reduces maternal and perinatal morbidity and mortality. This systematic review synthesizes qualitative evidence related to the facilitators and barriers to delivering at health facilities in low- and middle-income countries. We aim to provide a useful framework for better understanding how various factors influence the decision-making process and the ultimate location of delivery at a facility or elsewhere. We conducted a qualitative evidence synthesis using a thematic analysis. Searches were conducted in PubMed, CINAHL and gray literature databases. Study quality was evaluated using the CASP checklist. The confidence in the findings was assessed using the CERQual method. Thirty-four studies from 17 countries were included. Findings were organized under four broad themes: (1) perceptions of pregnancy and childbirth; (2) influence of sociocultural context and care experiences; (3) resource availability and access; (4) perceptions of quality of care. Key barriers to facility-based delivery include traditional and familial influences, distance to the facility, cost of delivery, and low perceived quality of care and fear of discrimination during facility-based delivery. The emphasis placed on increasing facility-based deliveries by public health entities has led women and their families to believe that childbirth has become medicalized and dehumanized. When faced with the prospect of facility birth, women in low- and middle-income countries may fear various undesirable procedures, and may prefer to deliver at home with a traditional birth attendant. Given the abundant reports of disrespectful and abusive obstetric care highlighted by this synthesis, future research should focus on achieving respectful, non-abusive, and high-quality obstetric care for all women. Funding for this project was provided by The United States Agency for International Development (USAID) and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization.

Why do women not deliver in health facilities: a qualitative study of the community perspectives in south central Ethiopia?

BACKGROUND

In Ethiopia most childbirth occurs at home and is not assisted by skilled birth attendants. On the other hand having a birth attendant with midwifery skills during child birth is one of the most important interventions in reducing maternal morbidity and mortality. The objective of this study was to make an in-depth assessment of reasons why mothers do not use health facilities for child delivery.

METHODS

Focus Group Discussions were used to gather information on use of health facilities for delivery in Butajira districts of South Central Ethiopia. The study was conducted from January to February 2012. Information was collected from four groups of women who had delivered in the past two years and four groups of men whose wives/partners have delivered in the same period. Data was coded and categorized using open code, qualitative data management software and analyzed based on thematic analysis.

RESULTS

A total of eight FGD sessions, four with women and four with men groups were conducted involving 81 residents of the Butajira district. FGD participants answered that a large majority of women in the district gave birth at home. Two major themes, client related factors and facility/staff factors, emerged. Factors that emerged within major themes of client factors were decision making on place of delivery, reliance on Traditional Birth Attendants (TBAs), misconception about services provided at health facility, inability of family members to be present at time of labor and delivery, lack of privacy, traditional and/or spiritual factors, economic factors and accessibility to health care facilities. Within major themes of facility/staff factors subthemes that emerged were poor reception, refusal of admission, lack of privacy, information gap, poor competence and shortage of staff and materials at health facilities.

CONCLUSION

Women in the study areas do not deliver in health facilities because of reasons that can be attributed to health care system and client related factors. These need to be addressed by considering the specific factors related to the health system and community perspectives.

Exploring women's perspectives of access to care during pregnancy and childbirth: a qualitative study from rural Papua New Guinea

OBJECTIVES

to explore women's perceptions and experiences of pregnancy and childbirth in a rural community in PNG.

DESIGN

a qualitative, descriptive study comprising focus group discussions (FGDs) and in depth interviews.

SETTING

this study took place in a rural community in Eastern Highlands Province, PNG.

PARTICIPANTS

51 women participated in seven focus group discussions. In depth interviews were undertaken with 21 women, including women recruited at the antenatal clinic, women purposively selected in the community and three key informants in the community.

FINDINGS

the majority of women mentioned the benefits of receiving antenatal care at the health facility and the importance of a supervised, facility birth. Women faced numerous challenges with regards to accessing these services, including geographical, financial and language barriers. Cultural and customary beliefs surrounding childbirth and lack of decision making powers also impacted on whether women had a supervised birth.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

distance, terrain and transport as well as decision making processes and customary beliefs influenced whether a woman did or did not reach a health facility to give birth. While the wider issue of availability and location of health services and health system strengthening is addressed shorter term, community based interventions could be of benefit. These interventions should include safe motherhood and birth preparedness messages disseminated to women, men and key family and community members.

Disadvantaged populations in maternal health in China who and why?

BACKGROUND

China has made impressive progress towards the Millennium Development Goal (MDG) for maternal and reproductive health, but ensuring that progress reaches all segments of the population remains a challenge for policy makers. The aim of this review is to map disadvantaged populations in terms of maternal health in China, and to explain the causes of these inequities to promote policy action.

METHODS

We searched PUBMED, Popline, Proquest and WanFang and included primary studies conducted in mainland China. Experts were also contacted to identify additional studies. Disadvantaged populations in terms of MDG 5 and the reasons for this disadvantage explored by authors were identified and coded based on the conceptual framework developed by the WHO Commission on the Social Determinants of Health.

RESULTS

In China, differences in maternal health service utilization and the maternal mortality ratio among different income groups, and among regions with different socio-economic development still exist, although these differences are narrowing. Groups with low levels of education and ethnic minorities utilize maternal health care less frequently and experience higher maternal mortality, although we could not determine whether these differences have changed in the last decade. Rural-to-urban migrants use maternal health care and contraception to a lower extent than permanent residents of cities, and differential maternal mortality shows a widening trend among these groups. Gender inequity also contributes to the disadvantaged position of women. Intermediary factors that explain these inequities include material circumstances such as long distances to health facilities for women living in remote areas, behavioral factors such as traditional beliefs that result in reduced care seeking among ethnic minorities, and health system determinants such as out-of-pocket payments posing financial barriers for the poor.

CONCLUSIONS

Inequity in maternal health continues to be an issue worthy of greater programmatic and monitoring efforts in China.

Why some women fail to give birth at health facilities: a qualitative study of women's perceptions of perinatal care from rural Southern Malawi

BACKGROUND

Despite Malawi government's policy to support women to deliver in health facilities with the assistance of skilled attendants, some women do not access this care.

OBJECTIVE

The study explores the reasons why women delivered at home without skilled attendance despite receiving antenatal care at a health centre and their perceptions of perinatal care.

METHODS

A descriptive study design with qualitative data collection and analysis methods. Data were collected through face-to-face in-depth interviews using a semi- structured interview guide that collected information on women's perception on perinatal care. A total of 12 in- depth interviews were conducted with women that had delivered at home in the period December 2010 to March 2011. The women were asked how they perceived the care they received from health workers before, during, and after delivery. Data were manually analyzed using thematic analysis.

RESULTS

Onset of labor at night, rainy season, rapid labor, socio-cultural factors and health workers' attitudes were related to the women delivering at home. The participants were assisted in the delivery by traditional birth attendants, relatives or neighbors. Two women delivered alone. Most women went to the health facility the same day after delivery.

CONCLUSIONS

This study reveals beliefs about labor and delivery that need to be addressed through provision of appropriate perinatal information to raise community awareness. Even though, it is not easy to change cultural beliefs to convince women to use health facilities for deliveries. There is a need for further exploration of barriers that prevent women from accessing health care for better understanding and subsequently identification of optimal solutions with involvement of the communities themselves.

Why do women prefer home births in Ethiopia?

Background

Skilled attendants during labor, delivery, and in the early postpartum period, can prevent up to 75% or more of maternal death. However, in many developing countries, very few mothers make at least one antenatal visit and even less receive delivery care from skilled professionals. The present study reports findings from a region where key challenges related to transportation and availability of obstetric services were addressed by an ongoing project, giving a unique opportunity to understand why women might continue to prefer home delivery even when facility based delivery is available at minimal cost.

Methods

The study took place in Ethiopia using a mixed study design employing a cross sectional household survey among 15–49 year old women combined with in-depth interviews and focus group discussions.

Results

Seventy one percent of mothers received antenatal care from a health professional (doctor, health officer, nurse, or midwife) for their most recent birth in the one year preceding the survey. Overall only 16% of deliveries were assisted by health professionals, while a significant majority (78%) was attended by traditional birth attendants. The most important reasons for not seeking institutional delivery were the belief that it is not necessary (42%) and not customary (36%), followed by high cost (22%) and distance or lack of transportation (8%). The group discussions and interviews identified several reasons for the preference of traditional birth attendants over health facilities. Traditional birth attendants were seen as culturally acceptable and competent health workers. Women reported poor quality of care and previous negative experiences with health facilities. In addition, women’s low awareness on the advantages of skilled attendance at delivery, little role in making decisions (even when they want), and economic constraints during referral contribute to the low level of service utilization.

Conclusions

The study indicated the crucial role of proper health care provider-client communication and providing a more client centered and culturally sensitive care if utilization of existing health facilities is to be maximized. Implications of findings for maternal health programs and further research are discussed.

Do Malawian women critically assess the quality of care? A qualitative study on women's perceptions of perinatal care at a district hospital in Malawi

Background

Malawi has a high perinatal mortality rate of 40 deaths per 1,000 births. To promote neonatal health, the Government of Malawi has identified essential health care packages for improving maternal and neonatal health in health care facilities. However, regardless of the availability of health services, women’s perceptions of the care is important as it influences whether the women will or will not use the services. In Malawi 95% of pregnant women receive antenatal care from skilled attendants, but the number is reduced to 71% deliveries being conducted by skilled attendants. The objective of this study was to describe women’s perceptions on perinatal care among the women delivered at a district hospital.

Methods

A descriptive study design with qualitative data collection and analysis methods. Data were collected through face-to-face in-depth interviews using semi-structured interview guides collecting information on women’s perceptions on perinatal care. A total of 14 in depth interviews were conducted with women delivering at Chiradzulu District Hospital from February to March 2011. The women were asked how they perceived the care they received from health workers during antepartum, intrapartum and postpartum. They were also asked about the information they received during provision of care. Data were manually analyzed using thematic analysis.

Results

Two themes from the study were good care and unsatisfactory care. Subthemes under good care were: respect, confidentiality, privacy and normal delivery. Providers’ attitude, delay in providing care, inadequate care, and unavailability of delivery attendants were subthemes under unsatisfactory care.

Conclusions

Although the results show that women wanted to be well received at health facilities, respected, treated with kindness, dignity and not shouted at, they were not critical of the care they received. The women did not know the quality of care to expect because they were not well informed. The women were not critical of the care they received because they were not aware of the standard of care. Instead they had low expectations. Health workers have a responsibility to inform women and their families about the care that women should expect. There is also a need for standardization of the antenatal information that is provided.

Women's perspective of maternity care in Cambodia

BACKGROUND

Consideration of the needs of pregnant women and their ability and willingness to attend maternal services and pay for them is central to the provision of accessible and acceptable maternal care. Women's satisfaction with maternal services is poorly understood in many developing countries, including Cambodia in South East Asia. The objective of this study was to investigate women's perceptions and experiences of private and public skilled birth attendants, including midwives, during childbirth in Cambodia.

METHODS

A qualitative design using a naturalistic inquiry approach was undertaken to seek sensitive personal issue. Thirty individual in-depth interviews were conducted with women who had recently given birth at private and public health facilities in one province in Cambodia. Data were analysed using a thematic approach.

FINDINGS

Women's choice of health facility was influenced by their perceptions of safety and staff attitudes. Reported barriers to the effective utilisation of public maternity services were costs associated with the birth, staff attitudes and a lack of supportive care during labour and in the postpartum period. Although private health care is more expensive than public health care, some women reported a preference for private birth attendants as they perceived them to provide safer and more supportive care in labour.

CONCLUSION

Women expect, but do not always receive humane, professional, supportive and respectful treatment from public skilled birth attendants. While the removal of unexpected costs and geographical barriers are important to increasing public maternity care and service utilisation, improvements in maternity services should focus on addressing provider attitudes and enhancing communication skills during labour, birth and the immediate postpartum period.

Utilization of antenatal ultrasound scan and implications for caesarean section: a cross-sectional study in rural Eastern China

Background

Antenatal ultrasound scan is a widely accepted component of antenatal care. Studies have looked at the relationship between ultrasound scanning and caesarean section (CS) in certain groups of women in China. However, there are limited data on the utilization of antenatal ultrasound scanning in the general population, including its association with CS. The purpose of this study is to describe the utilization of antenatal ultrasound screening in rural Eastern China and to explore the association between antenatal ultrasound scan and uptake of CS.

Methods

Based on a cluster randomized sample, a total of 2326 women with childbirth participated in the study. A household survey was conducted to collect socio-economic information, obstetric history and utilization of maternal health services.

Results

Coverage of antenatal care was 96.8% (2251/2326). During antenatal care, 96.1% (2164/2251) women received ultrasound screening and the reported average number was 2.55. 46.8% women received at least 3 ultrasound scans and the maximum number reached 11. The CS rate was found to be 54.8% (1275/2326). After adjusting for socio-demographic and clinical variables, it showed a statistically significant association between antenatal ultrasound scans and uptake of CS by multivariate logistic regression model. High husband education level, high maternal age, having previous adverse pregnant outcome and pregnancy complications during the index pregnancy were also found to be risk factors of choosing a CS.

Conclusions

A high use of antenatal ultrasound scan in rural Eastern China is found and is influenced by socio-demographic and clinical factors. Evidence-based guidelines for antenatal ultrasound scans need to be developed and disseminated to clinicians including physicians, nurses and sonographers. Guidance about the appropriate use of ultrasound scans should also be shared with women in order to discourage unreasonable expectations and demands. It is important to monitor the use of antenatal ultrasound scan as well as the indications for caesarean section in rural China.

Traditional Birth Attendants in Samoa: Integration With the Formal Health System

A traditional birth attendant (TBA) is a person who assists the mother during childbirth and who initially acquired her skills by delivering babies herself or through apprenticeship to other TBAs. In many parts of the world, TBAs continue to provide a significant proportion of maternity care during pregnancy, birth, and the postpartum period. In Samoa, TBAs are recognized part of both the formal and informal health care system. The aim of this research was to examine the contribution that TBAs made in the provision of maternity care in Samoa. A descriptive study was undertaken, and 100 TBAs who had attended more than 400 births a year were interviewed as part of a broader Safe Motherhood Needs Assessment.

The findings highlighted that although TBAs can work in collaboration with individual health providers or facilities or be integrated into the health system, TBAs were often practicing autonomously within their communities, independent of collaborative links. This study showed that formal recognition and registration of TBAs would improve the recording of births and augment their partnership to the formal health care system. This formal registration process has since been implemented to improve monitoring and evaluation and assist future research with this important group.

Unintended Consequences of Policy Decisions to Reduce Maternal Mortality in the Asia Pacific

OBJECTIVES:To describe the role of midwives and maternity care in three low resource settings and to challenge some policy options introduced to reduce maternal mortality for women residing in rural and remote areas.

APPROACH:A series of retrospective analyses were undertaken drawing on work the authors have conducted in rural and remote China, Timor-Leste, and Samoa over the past 5–20 years. Sources include our own empirical research, grey literature, as well as published secondary sources.

FINDINGS:In China, hospital birthing is promoted as a major strategy in reducing maternal mortality. This has greatly increased financial burdens for women and their families. In Samoa, traditional birth attendants (TBAs) are integrated into Samoa’s health system alongside midwives and other health professionals, and they play a critical role in providing support for pregnant and birthing women. In Timor-Leste, the government has moved away from training TBAs and has shifted the focus from skilled attendance to facility-based delivery. Evaluation of a national maternity waiting home strategy, designed to improve access to facility-based delivery, did not improve access for women in remote areas.

CONCLUSIONS:Low-income countries need to be cautious when adopting global solutions, such as facility-based delivery, to tackle maternal deaths. Women-centered and cost-effective care should be provided locally. Culturally compatible maternity care can be achieved in concert with safety and emergency obstetric care. Midwives can create the bridges between social and professional systems that allow this to happen.

China's facility-based birth strategy and neonatal mortality: a population-based epidemiological study

BACKGROUND

China's success in improving the quality of and access to obstetric care in hospitals offers an opportunity to examine the effect of a large-scale facility-based strategy on neonatal mortality. We aimed to establish this effect by assessing how the institutional strategy of intrapartum care has affected neonatal mortality and its regional inequalities.

METHODS

We did a population-based epidemiological study of China's National Maternal and Child Mortality Surveillance System from 1996 to 2008. We used data from 116 surveillance sites in China (37 urban districts and 79 rural counties) to examine neonatal mortality by cause, socioeconomic region, and place of birth, with Poisson regression to calculate relative risks. Rural counties were categorised into types 1-4, with type 4 being the least developed. We report attributable risks and preventable fractions for hospital births versus home births.

FINDINGS

Neonatal mortality decreased by 62% between 1996 and 2008. The rate of neonatal mortality was much lower for hospital births than for home births in all regions, with relative risks (RR) ranging from 0·30 (95% CI 0·22-0·40) in type 2 rural counties, to 0·52 (0·33-0·83) in type 4 counties (p<0·0001). The proportion of neonatal deaths prevented by hospital birth ranged from 70% (95% CI 59·7-77·8) to 48% (16·9-67·3). Babies born in urban hospitals had a low rate of neonatal mortality (5·7 per 1000 livebirths); but those born in hospitals in type 4 rural counties were almost four times more likely to die than were children born in urban hospitals (RR 3·80, 2·53-5·72).

INTERPRETATION

Other countries can learn from China's substantial progress in reducing neonatal mortality. The major effect of China's facility-based strategy on neonatal mortality is much greater than that reported for community-based interventions. Our findings will provide a great impetus for countries to increase demand for and quality of facility-based intrapartum care.

FUNDING

China Medical Board, UNICEF China.