Where is the "E" in MCH? The need for an evidence-based approach in safe motherhood

Advancing Survival in Nigeria: A Pre-post Evaluation of an Integrated Maternal and Neonatal Health Program

Introduction Nigeria contributes more obstetric, postpartum and neonatal deaths and stillbirths globally than any other country. The Clinton Health Access Initiative in partnership with the Nigerian Federal Ministry of Health and the state Governments of Kano, Katsina, and Kaduna implemented an integrated Maternal and Neonatal Health program from July 2014. Up to 90% women deliver at home in Northern Nigeria, where maternal mortality ratio and neonatal mortality rates (MMR and NMR) are high and severe challenges to improving survival exist. Methods Community-based leaders (“key informants”) reported monthly vital events. Pre-post comparisons of later (months 16–18) with conservative baseline (months 7–9) rates were used to assess change in MMR, NMR, perinatal mortality (PMR) and stillbirth. Two-tailed cross-tabulations and unadjusted and adjusted logistic regression analyses were conducted. Results Data on 147,455 births (144,641 livebirths and 4275 stillbirths) were analyzed. At endline (months 16–18), MMR declined 37% (OR 0.629, 95% CI 0.490–0.806, p ≤ 0.0003) vs. baseline 440/100,000 births (months 7–9). NMR declined 43% (OR 0.574, 95% CI 0.503–0.655, p < 0.0001 vs. baseline 15.2/1000 livebirths. Stillbirth rates declined 15% (OR 0.850, 95% CI 0.768–0.941, p = 0.0018) vs. baseline 21.1/1000 births. PMR declined 27% (OR 0.733, 95% CI 0.676–0.795, p < 0.0001) vs. baseline 36.0/1000 births. Adjusted results were similar. Discussion The findings are similar to the Cochrane Review effects of community-based interventions and indicate large survival improvements compared to much slower global and flat national trends. Key informant data have limitations, however, their limitations would have little effect on the results magnitude or significance.

Safer Muslim motherhood: Social conditions and maternal mortality in the Muslim world

The greatest variation in maternal mortality is among poor countries and wealthy countries that rely on emergency obstetric technology to save a woman's life during childbirth. However, substantial variation in maternal mortality ratios (MMRs) exists within and among poor countries with uneven access to advanced obstetric services. This article examines MMRs across the Muslim world and compares the impact of national wealth, female education, and skilled birth attendants on maternal mortality. Understanding how poor countries have lowered MMRs without access to expensive obstetric technologies suggests that certain social variables may act protectively to reduce the maternal risk for life-threatening obstetric complications that would require emergency obstetric care.

Travelling models and the challenge of pragmatic contexts and practical norms: the case of maternal health

As in other areas of international development, we are witnessing the proliferation of ‘traveling models’ developed by international experts and introduced in an almost identical format across numerous countries to improve some aspect of maternal health systems in low- and middle-income countries. These policies and protocols are based on ‘miracle mechanisms’ that have been taken out of their original context but are believed to be intrinsically effective in light of their operational devices.

In reality, standardised interventions are, in Africa and elsewhere, confronted with pragmatic implementation contexts that are always varied and specific, and which lead to drifts, distortions, dismemberments and bypasses. The partogram, focused antenatal care, the prevention of mother-to-child transmission of HIV or performance-based payment all illustrate these implementation gaps, often caused by the routine behaviour of health personnel who follow practical norms (and a professional culture) that are often distinct from official norms – as is the case with midwives.

Experiences in maternal and child health in Africa suggest that an alternative approach would be to start with the daily reality of social and practical norms instead of relying on models, and to promote innovations that emerge from within local health systems.

Maternal health care seeking behavior: the case of Haor (wetland) in Bangladesh

Background

The state of maternal healthcare (MHC) in Bangladesh is a grave concern especially in the remote haor areas. In this study, we aimed to determine the factors affecting the utilization of MHC services in the haor areas, to discover mothers’ knowledge of MHC, and explore their attitudes toward MHC as well as practices in seeking MHC services.

Method

In this cross-sectional survey (n = 400), we randomly selected mothers (aged 15–49 years) from haor areas of the Habiganj district of Bangladesh. The study participants’ socio demographic information as well as the extent of their knowledge about MHC, their attitudes, and practices in seeking MHC services were ascertained. The degree of association between the respondents’ socio-demographic characteristics and their health-seeking behavior (before, during, and after childbirth) was assessed by the odds ratio (OR) with 95 % confidence intervals (CI) estimated from the bivariate and multivariable logistic regression analyses.

Results

The mean age of the study participants was 27.26 years. Respondents had an average of 2.64 children, and 88.6 % had at best a primary education or less. Among the study participants, 61 % of mothers had no knowledge about the availability of MHC in the study area, and only 36 % received any antenatal care (ANC). Also, 47 % sought ANC from government healthcare institutions. Irrespective of complications and potential danger signs, 95 % of births were delivered at home with the assistance of untrained birth attendants. Only 19.75 % of mothers and 12.3 % of infants received postnatal care (PNC). Moreover, mothers who had a secondary or tertiary education level had a higher likelihood of receiving ANC (OR: 3.48, 95 % C.I: 1.49–7.63) compared to mothers with no education. Also, mothers aged 25 years or older were less likely (OR: 0.24, 95 % C.I: 0.06–0.095) to give birth in a health facility than mothers who were younger than 25. The low utilization of MHC services can be attributed to many factors such as a lack of communication, a lack of knowledge about MHC services, low income, decision making, and the lack of a companion with whom to visit health services.

Conclusion

To improve MHC utilization, to reach national targets and to save the lives of mothers and newborns, boat or ship-based special healthcare and educational programs should be implemented in the haor areas.

Agenda setting for maternal survival: the power of global health networks and norms

Nearly 300,000 women--almost all poor women in low-income countries--died from pregnancy-related complications in 2010. This represents a decline since the 1980s, when an estimated half million women died each year, but is still far higher than the aims set in the United Nations Millennium Development Goals (MDGs) at the turn of the century. The 1970s, 1980s and 1990 s witnessed a shift from near complete neglect of the issue to emergence of a network of individuals and organizations with a shared concern for reducing maternal deaths and growth in the number of organizations and governments with maternal health strategies and programmes. Maternal health experienced a marked change in agenda status in the 2000s, attracting significantly higher level attention (e.g. from world leaders) and greater resource commitments (e.g. as one issue addressed by US$40 billion in pledges to the 2010 Global Strategy for Women's and Children's Health) than ever before. Several differences between network and actor features, issue characteristics and the policy environment pre- and post-2000 help to explain the change in agenda status for global maternal mortality reduction. Significantly, a strong poverty reduction norm emerged at the turn of the century; represented by the United Nations MDGs framework, the norm set unusually strong expectations for international development actors to advance included issues. As the norm grew, it drew policy attention to the maternal health goal (MDG 5). Seeking to advance the goals agenda, world leaders launched initiatives addressing maternal and child health. New network governance and framing strategies that closely linked maternal, newborn and child health shaped the initiatives. Diverse network composition--expanding beyond a relatively narrowly focused and technically oriented group to encompass allies and leaders that brought additional resources to bear on the problem--was crucial to maternal health's rise on the agenda in the 2000s.

A Needs Assessment of Health Issues Related to Maternal Mortality Rates in Afghanistan: A Pilot Study

Maternal death rates in Afghanistan were among the highest in the world during the reign of the Taliban. Although these figures have improved, current rates are still alarming. The aim of this pilot study was to develop a needs assessment of the major health issues related to the high maternal mortality rates in Afghanistan. In-depth interviews were conducted with managerial midwives, clinical midwives, and mothers. Results of the interviews indicate that the improvement in the maternal mortality rate may be attributed to the increase in the involvement of midwives in the birthing process. However, barriers to decreasing maternal mortality still exist. These include transportation, access to care, and sociocultural factors such as the influence of the husband and mother-in-law in preventing access to midwives. Therefore, any programs to decrease maternal mortality need to address infrastructure issues (making health care more accessible) and sociocultural factors (including husbands and mother-in-laws in maternal health education). However, it should be noted that these findings are based on a small pilot study to help develop a larger scale need assessment.

Review of maternal mortality in Ethiopia: a story of the past 30 years

BACKGROUND

Ethiopia is one of the six countries which have contributed to more than 50% of all maternal deaths across the world. This country has adopted the millennium development goals (MDGs) including reducing the maternal mortality by three-quarter, and put improvement in maternal health as one of the health sector development program (HSDP) performance indicators. The purpose of this study was to review the maternal mortality ratio (MMR) in Ethiopia in the past 30 years using available literature.

METHODS

A computer based literature search in the databases of MEDLINE, PubMed, HINARI, EBASE, MEASURE DHS, The Cochrane Library, Google Search and Google Scholar was carried out. Manual search for local articles that are not available electronically in full document were also conducted. Eighteen data sources (3 nationally representative surveys, 2 secondary data analyses, 5 small scale community based studies, and 8 hospital based studies) were included in the review. The results of this review are presented in the form of line and stock graphs.

RESULTS

The national maternal mortality trend estimated by the central statistics agency of Ethiopia, The Institute for Health Metrics and Evaluation, WHO and other UN agencies showed inconsistent results. Similarly, although there were marked variations in the 95% confidence intervals among individual studies, the small scale community based and hospital based studies have shown that there has been no significant change in maternal mortality over the last three decades. A 22-year cohort analysis from Atat Hospital is the only evidence that demonstrated a very significant drop in maternal mortality among mothers who were kept in the maternity waiting area before the onset of labor.

CONCLUSION

Although the MDG and HSDP envisaged significant improvement in maternal health by this time, this review has shown that the performances are still far from the target. The multisectoral huge investment by the Ethiopian Government is a big hope to reduce the maternal mortality by three-quarters in the near future beyond 2015.

The value of building health promotion capacities within communities: evidence from a maternal health intervention in Guinea

This article presents results from a study that explored the association between community capacity for maternal health promotion and women’s use of preventive and curative maternal health services. Implemented in the Republic of Guinea, the intervention aimed to build the capacity of community-level committees to heighten awareness about maternal health risks and to promote use of professional maternal health services throughout pregnancy and childbirth. Data were collected through a population-based survey. A total of 2335 women of reproductive age were interviewed, including 878 with a live birth or stillbirth since the launch of the intervention. An index of community capacity was created to explore the effect of living in a community with strong community-level resources and support for maternal health. Other composite variables were created to measure the content of women’s antenatal counselling and their individual exposure to maternal health promotion activities at the community level. Multivariate logistic regression was used to explore the effect of community capacity and individual exposure variables on women’s use of antenatal care (ANC) (≥4 visits), institutional delivery, and care for complications. Our results show that women living in communities with a high score on the Community Capacity Index were more than twice as likely as women in communities with low score to attend at least four ANC visits, to deliver in a health facility, and to seek care for perceived complications. Building the capacity of community-level cadres to promote maternity care-seeking by women in their villages is an important complement to facility-level interventions to increase the availability, quality and utilization of essential health services.

Non-pneumatic anti-shock garment (NASG), a first-aid device to decrease maternal mortality from obstetric hemorrhage: a cluster randomized trial

Background

Obstetric hemorrhage is the leading cause of maternal mortality. Using a cluster randomized design, we investigated whether application of the Non-pneumatic Anti-Shock Garment (NASG) before transport to referral hospitals (RHs) from primary health care centers (PHCs) decreased adverse outcomes among women with hypovolemic shock. We hypothesized the NASG group would have a 50% reduction in adverse outcomes.

Methods and Findings

We randomly assigned 38 PHCs in Zambia and Zimbabwe to standard obstetric hemorrhage/shock protocols or the same protocols plus NASG prior to transport. All women received the NASG at the RH. The primary outcomes were maternal mortality; severe, end-organ failure maternal morbidity; and a composite mortality/morbidity outcome, which we labeled extreme adverse outcome (EAO). We also examined whether the NASG contributed to negative side effects and secondary outcomes. The sample size for statistical power was not reached; of a planned 2400 women, 880 were enrolled, 405 in the intervention group. The intervention was associated with a non-significant 46% reduced odds of mortality (OR 0.54, 95% CI 0.14–2.05, p = 0.37) and 54% reduction in composite EAO (OR 0.46, 95% CI 0.13–1.62, p = 0.22). Women with NASGs recovered from shock significantly faster (HR 1.25, 95% CI 1.02–1.52, p = 0.03). No differences were observed in secondary outcomes or negative effects. The main limitation was small sample size.

Conclusions

Despite a lack of statistical significance, the 54% reduced odds of EAO and the significantly faster shock recovery suggest there might be treatment benefits from earlier application of the NASG for women experiencing delays obtaining definitive treatment for hypovolemic shock. As there are no other tools for shock management outside of referral facilities, and no safety issues found, consideration of NASGs as a temporizing measure during delays may be warranted. A pragmatic study with rigorous evaluation is suggested for further research.

Trial Registration

ClinicalTrials.gov NCT00488462

Advancing maternal survival in the global context: are our strategies working?

There have been significant gains in improving maternal mortality over the last two decades. Researchers have suggested a variety of interventions and mechanisms to explain these improvements. While it is likely that much of what has been done in research and programs has contributed to this decline, the evidence regarding what works in the settings in which women deliver continues to face many challenges. We review the evidence for these improvements and suggest that there remain areas to focus on, particularly the births which currently take place in an unsupervised or substandard environments. We highlight the main areas where more evidence is needed, and end with a call to determine which of our interventions seem to have the most benefit; which do not; and where to invest future resources.

Birth preparedness and skilled attendance at birth in Nepal: implications for achieving millennium development goal 5

OBJECTIVE

to assess birth preparedness in expectant mothers and to evaluate its association with skilled attendance at birth in central Nepal.

DESIGN

a community-based prospective cohort study using structured questionnaires.

SETTING

Kaski district of Nepal.

PARTICIPANTS

a total of 701 pregnant women of more than 5 months gestation were recruited and interviewed, followed by a second interview within 45 days of delivery.

MEASUREMENTS

outcome was skilled attendance at birth. Birth preparedness was measured by five indicators: identification of delivery place, identification of transport, identification of blood donor, money saving and antenatal care check-up.

FINDINGS

level of birth preparedness was high with 65% of the women reported preparing for at least 4 of the 5 arrangements. It appears that the more arrangements made, the more likely were the women to have skilled attendance at birth (OR=1.51, p<0.001). For those pregnant women who intended to save money, identified a delivery place or identified a potential blood donor, their likelihood of actual delivery at a health facility increased by two to three fold. However, making arrangements for transportation and antenatal care check-up were not significantly associated with skilled attendance at birth.

CONCLUSIONS

intention to deliver in a health-care facility as measured by birth preparedness indicators was associated with actual skilled attendance at birth. Birth preparedness packages could increase the proportion of skilled attendance at birth in the pathway of meeting the Millennium Development Goal 5.

Maternal Health and Care in India: Why a Major Public Health Strategy Is Essential

India has large inequalities in maternal health and high maternal mortality and morbidity rates. A social model of maternal health was used as a framework for a broad review of online published literature to appraise the approaches used by India to address these issues and to examine the potential for reducing the country’s maternal health inequalities.

The review found the following:

• An apparent lack of coordinated economic, social, and health strategy and policies focused on improving maternal health

• No acknowledgment in national health policy of the limitations of the medical model of maternal health and little apparent mention of the social model

• No evident national frameworks for quality assurance in maternity care

• Lack of recognition of the importance of woman-centered care

• No evident comprehensive maternal health needs assessment to underpin coordinated multisector working

• An apparent lack of reliable national data collection for setting inequality targets and monitoring progress

• No apparent performance-focused management system for improving maternity care nationally.

Although India has made large increases in maternal health care provision over recent decades, a pragmatic review of government policies, the reports of international agencies, and the findings of published research studies indicate that major barriers exist to reducing maternal health inequalities and to achieving good quality care for disadvantaged women. The main barrier appears to be the widespread use at all levels, including government, of the medical model of maternal health, which focuses mostly on obstetric interventions and fails to address the wider economic and social determinants of maternal health or to use a woman-centered approach to maternity care.

We recommend that Indian governments adopt instead a “social model” approach to maternal health improvement and urgently employ a public health strategy led by a national multisector task force to reduce inequalities in maternal health.

Determinants of place of birth decisions in uncomplicated childbirth in Bangladesh: an empirical study

OBJECTIVE

to test the predictive value of women's self-identified criteria in place of birth decisions in the event of uncomplicated childbirth in a setting where facility based skilled birth attendants are available.

DESIGN

a retrospective, cross-sectional study was conducted in two phases. The first phase used data from in-depth interviews. The second phase used data from semi-structured questionnaires.

SETTING

the service area of Matlab, Bangladesh.

PARTICIPANTS

women 18-49 years who had an uncomplicated pregnancy and delivery resulting in a live birth.

FINDINGS

a women's intention about where to deliver during pregnancy, her perception of labour progress, the availability of transportation at the time of labour, and the close proximity of a dai to the household were independent predictors of facility-based SBA use. Marital age was also significant predictor of use.

KEY CONCLUSIONS

the availability of delivery services does not guarantee use and instead specific considerations and conditions during pregnancy and in and around the time of birth influence the preventive health seeking behaviour of women during childbirth. Our findings have implications for birth preparedness and complication readiness initiatives that aim to strengthen timely use of SBAs for all births. Demand side strategies to reduce barriers to health seeking, as part of an overall health system strengthening approach, are needed to meet the Millennium Development 5 goal.

Traditional birth attendant training for improving health behaviours and pregnancy outcomes

BACKGROUND

Between the 1970s and 1990s, the World Health Organization promoted traditional birth attendant (TBA) training as one strategy to reduce maternal and neonatal mortality. To date, evidence in support of TBA training is limited but promising for some mortality outcomes.

OBJECTIVES

To assess the effects of TBA training on health behaviours and pregnancy outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 June 2012), citation alerts from our work and reference lists of studies identified in the search.

SELECTION CRITERIA

Published and unpublished randomised controlled trials (RCT), comparing trained versus untrained TBAs, additionally trained versus trained TBAs, or women cared for/living in areas served by TBAs.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed study quality and extracted data in the original and first update review. Three authors and one external reviewer independently assessed study quality and two extracted data in this second update.

MAIN RESULTS

Six studies involving over 1345 TBAs, more than 32,000 women and approximately 57,000 births that examined the effects of TBA training for trained versus untrained TBAs (one study) and additionally trained TBA training versus trained TBAs (five studies) are included in this review. These studies consist of individual randomised trials (two studies) and cluster-randomised trials (four studies). The primary outcomes across the sample of studies were perinatal deaths, stillbirths and neonatal deaths (early, late and overall).Trained TBAs versus untrained TBAs: one cluster-randomised trial found a significantly lower perinatal death rate in the trained versus untrained TBA clusters (adjusted odds ratio (OR) 0.70, 95% confidence interval (CI) 0.59 to 0.83), lower stillbirth rate (adjusted OR 0.69, 95% CI 0.57 to 0.83) and lower neonatal death rate (adjusted OR 0.71, 95% CI 0.61 to 0.82). This study also found the maternal death rate was lower but not significant (adjusted OR 0.74, 95% CI 0.45 to 1.22).Additionally trained TBAs versus trained TBAs: three large cluster-randomised trials compared TBAs who received additional training in initial steps of resuscitation, including bag-valve-mask ventilation, with TBAs who had received basic training in safe, clean delivery and immediate newborn care. Basic training included mouth-to-mouth resuscitation (two studies) or bag-valve-mask resuscitation (one study). There was no significant difference in the perinatal death rate between the intervention and control clusters (one study, adjusted OR 0.79, 95% CI 0.61 to 1.02) and no significant difference in late neonatal death rate between intervention and control clusters (one study, adjusted risk ratio (RR) 0.47, 95% CI 0.20 to 1.11). The neonatal death rate, however, was 45% lower in intervention compared with the control clusters (one study, 22.8% versus 40.2%, adjusted RR 0.54, 95% CI 0.32 to 0.92).We conducted a meta-analysis on two outcomes: stillbirths and early neonatal death. There was no significant difference between the additionally trained TBAs versus trained TBAs for stillbirths (two studies, mean weighted adjusted RR 0.99, 95% CI 0.76 to 1.28) or early neonatal death rate (three studies, mean weighted adjusted RR 0.83, 95% CI 0.68 to 1.01). 

AUTHORS' CONCLUSIONS

The results are promising for some outcomes (perinatal death, stillbirth and neonatal death). However, most outcomes are reported in only one study. A lack of contrast in training in the intervention and control clusters may have contributed to the null result for stillbirths and an insufficient number of studies may have contributed to the failure to achieve significance for early neonatal deaths. Despite the additional studies included in this updated systematic review, there remains insufficient evidence to establish the potential of TBA training to improve peri-neonatal mortality.

Childbirth attendance strategies and their impact on maternal mortality and morbidity in low-income settings: a systematic review

OBJECTIVE

To review quantitative evidence of the effect on maternal health of different childbirth attendance strategies in low-income settings.

DESIGN

Systematic review.

METHODS

Studies using quantitative methods, referring to the period 1987-2011, written in English and reporting the impact of childbirth attendance strategies on maternal mortality or morbidity in low-income settings were included. Guidelines developed by the Cochrane collaboration and the Centre for Review and Dissemination, University of York were followed. The included articles were read and sorted by category of strategy that emerged from the reading.

RESULTS

The search criteria yielded 29 articles. The following three main categories of strategy emerged: (i) those primarily intended to improve quality of care; (ii) "centrifugal strategies," which sought to bring services to the women; and (iii) "centripetal strategies," which sought to bring the women to the services. Few of the studies had a design that provided strong evidence for the impact of the strategy concerned.

CONCLUSIONS

The evidence emerging from the studies was difficult to compare, because concepts were not defined in a consistent manner (such as "skilled birth attendance") and many studies examined the impact of a package of interventions without ferreting out the impact of individual components. Yet, some studies described individual aspects with great promise (such as cost, transport, outreach-friendly drugs or targeted training). There is a need for clearer conceptual frameworks, including some which permit assessment of packages of interventions.

Community Kangaroo Mother Care: implementation and potential for neonatal survival and health in very low-income settings

OBJECTIVE

Immediate Kangaroo Mother Care (KMC), an intervention following childbirth whereby the newborn is placed skin-to-skin (STS) on mother's chest to promote thermal regulation, breastfeeding and maternal-newborn bonding, is being taught in very low-income countries to improve newborn health and survival. Existing data are reviewed to document the association between community-based KMC (CKMC) implementation and its potential benefits.

STUDY DESIGN

New analyses of the sole randomized controlled study of CKMC in Bangladesh and others' experiences with immediate KMC are presented.

RESULT

Newborns held STS less than 7 h per day in the first 2 days of life do not experience substantially better health or survival than babies without being held STS.

CONCLUSION

Most women who were taught CKMC hold their newborns STS, but do so in a token manner unlikely to improve health or survival. Serious challenges exist to provide effective training and postpartum support to achieve adequate STS practices. These challenges must be overcome before scaling up.

Global and cultural perinatal nursing research: improving clinical practice

High-quality perinatal nursing care should be based on the best evidence including research findings, clinical expertise, and the preferences of women and their families. Principles of perinatal research initiatives are defined, with suggested research priorities designed to close current gaps in the micro and macro environments of perinatal nursing throughout the world. Nearly a decade ago, the following question was asked, "Where is the 'E' (evidence) in maternal child health?" Improving the quality and safety of perinatal nursing care for culturally diverse women globally is the primary goal of nurse researchers leading the future of perinatal healthcare.

Effectiveness of Lifesaving Skills Training and Improving Institutional Emergency Obstetric Care Readiness in Lam Dong, Vietnam

Essential obstetric care is promoted as the prime strategy to save women's lives in developing countries. We measured the effect of improving lifesaving skills (LSS) capacity in Vietnam, a country in which most women deliver in health facilities. A quasi-experimental study was implemented to assess the impact of LSS training and readiness (availability of essential obstetric equipment, supplies, and medication) on the diagnosis of life-threatening obstetric conditions and appropriate management of labor and birth. The intervention (LSS training and readiness) was provided to all clinics and hospitals from 1 of 3 demographically similar districts in southcentral Vietnam, to hospitals only in another district, with the third district serving as the comparison group. Detection of life-threatening obstetric conditions increased in both experimental clinics and hospitals, but the intervention only improved the management of these conditions in hospitals. Management of life-threatening obstetric conditions is most effective in hospitals. The intervention did not clearly benefit women delivering in clinics.

CEU: Prevention and Treatment of Postpartum Hemorrhage: New Advances for Low-Resource Settings

Postpartum hemorrhage due to uterine atony is the primary direct cause of maternal mortality globally. Management strategies in developed countries involve crystalloid fluid replacement, blood transfusions, and surgery. These definitive therapies are often not accessible in developing countries. Long transports from home or primary health care facilities, a dearth of skilled providers, and lack of intravenous fluids and/or a safe blood supply often create long delays in instituting appropriate treatment. We review the evidence for active management of third-stage labor and for the use of specific uterotonics. New strategies to prevent and manage postpartum hemorrhage in developing countries, such as community-based use of misoprostol, oxytocin in the Uniject delivery system, the non-inflatable antishock garment to stabilize and resuscitate hypovolemic shock, and the balloon condom catheter to treat intractable uterine bleeding are reviewed. New directions for clinical and operations research are suggested.

Effect of Shifting Policies on Traditional Birth Attendant Training

Traditional birth attendant (TBA) training commenced in many places in the non-Western world in the 1970s, supported by the World Health Organization and other funding bodies. By 1997, senior policy makers decided to refocus priorities on the provision of "skilled attendants" to assist birthing women. The definition of skilled attendants excluded TBAs and resulted in the subsequent withdrawal of funding for TBA training globally. A review of the health and sociological literature and international policy documents that address TBA training revealed how international policy and professional orientation are reflected in education programs designed for the TBA. Policy makers risk ignoring the important cultural and social roles TBAs fulfill in their local communities and fail to recognize the barriers to the provision of skilled care. The provision of skilled attendants for all birthing women cannot occur in isolation from TBAs who in themselves are also highly skilled. This article argues a legitimacy of alternative worldviews and acknowledges the contribution TBAs make to childbearing women across the world.

Safe Motherhood Program Evaluation: Theory and Practice

Debate on the evaluation of safe motherhood programs has mainly focused on the outcome or process measure to be used. Less attention is paid to the application of different approaches to evaluation. This article reviews current theories of evaluation and provides examples of the extent to which these theories have been applied in the actual practice of evaluation. Most evaluations use multiple methods and approaches, but the rationale and intention behind these choices are often not made explicit. Factors are identified that need to be taken into consideration when planning and conducting safe motherhood program evaluations. Safe motherhood programs are complex interventions, requiring evaluation by different theoretical approaches and multiple methods. Awareness of these approaches will allow health professionals to plan for evaluation and to use evaluation findings more effectively. If cognizant of the different approaches to evaluation, evaluation frameworks can be developed to improve assessment of the effectiveness of these programs.

Navigating the challenges of global reproductive health research

Reproductive health research in low-resource settings poses unique and complex challenges that must be addressed to ensure that global research is conducted with strict adherence to ethical principles, offers direct benefit to the research subjects, and has the potential for adoption of positive findings to the target population. This article addresses challenges to conducting reproductive health research in low-resource settings in the following areas: (1) establishment and maintenance of global collaboration, (2) community partnerships, (3) ethical issues, including informed consent and the role of incentives, (4) staff training and development, (5) data collection and management, and (6) infrastructure and logistics. Particular attention to these challenges is important to ensure that research is culturally appropriate and methodologically sound and enhances the adoption of health-promoting behaviors. Rigorous evaluation of interventions in low-resource settings may be a cost-effective and time-efficient way to identify interventions for large-scale program replication to improve women's health.

The role of a maternity waiting area (MWA) in reducing maternal mortality and stillbirths in high-risk women in rural Ethiopia

OBJECTIVE

To describe maternal mortality and stillbirth rates among women admitted via a maternity waiting area (MWA) and women admitted directly to the same hospital (non-MWA) over a 22-year period.

DESIGN

 Retrospective cohort study.

SETTING

  Hospital in rural Ethiopia, which provided comprehensive emergency obstetric care and has an established MWA.

POPULATION

  All women admitted for delivery between 1987 and 2008.

METHODS

  Data on maternal deaths, stillbirths, caesarean section and uterine rupture were abstracted from routine hospital records. Sociodemographic characteristics, antenatal care and other data were collected for 2008 only. Rates and 95% confidence intervals were calculated for maternal mortality and stillbirth.

MAIN OUTCOME MEASURES

Maternal mortality and stillbirth.

RESULTS

 There were 24, 148 deliveries over the study period, 6805 admitted via MWA and 17, 343 admitted directly. Maternal mortality was 89.9 per 100, 000 live births (95% CI, 41.1-195.2) for MWA women and 1333.1 per 100, 000 live births (95% CI, 1156.2-1536.7) for non-MWA women; stillbirth rates were 17.6 per 1000 births (95% CI, 14.8-21.0) and 191.2 per 1000 births (95% CI, 185.4-197.1), respectively; 38.5% of MWA women were delivered by caesarean section compared with 20.3% of non-MWA women, and none had uterine rupture, compared with 5.8% in the non-MWA group. For the 1714 women admitted in 2008, relatively small differences in sociodemographic characteristics, distance and antenatal care uptake were found between groups.

CONCLUSIONS

Maternal mortality and stillbirth rates were substantially lower in women admitted via MWA. It is likely that at least part of this difference is accounted for by the timely and appropriate obstetric management of women using this facility.

Threats to safe motherhood in Honduran Miskito communities: local perceptions of factors that contribute to maternal mortality

Despite global initiatives to lower rates of maternal death, barriers to safe motherhood persist, particularly in socially and economically marginalized communities. This article describes the risks that women in Honduran Miskito villages encounter during pregnancy and childbirth. Ethnographic data are used to examine emic understandings of the underlying causes of maternal death. Participant observation, four community discussions, individual interviews with 218 women and five midwives, and a maternal mortality survey were conducted during November 2004 through November 2005. Case studies are drawn from the 55 death histories collected during the survey to illustrate the factors that contribute to maternal mortality. Community members identified poverty, gender inequality, witchcraft, and sorcery as major threats to safe motherhood. All of these factors influence women's health-related behaviors; and therefore, each issue deserves attention from public health officials. Designing appropriate interventions to improve maternal health depends on understanding the forces that increase women's vulnerability during pregnancy and childbirth. Local perspectives of risk, even when they diverge from biomedical understandings, point to specific needs, issues to address, and avenues for effective intervention.

Contextual Influences on Obstetric Morbidity and Related Care Seeking Behaviour in Thailand

This study examines the association of individual and community-level characteristics with obstetric morbidity and care seeking behaviour in Thailand. Community characteristics have been recognized to shape individual health, but there have been only a few studies explaining their influence on obstetric morbidity. Multi-level logistic regression analysis among 930 women, living in 86 villages indicated that not the community social and health infrastructure but community impoverishment was associated with the likelihood of reporting the morbidity and seeking appropriate care. The findings suggest that community factors should be taken into consideration while implementing programmes to improve maternal health.

Collapsing the vertical-horizontal divide: an ethnographic study of evidence-based policymaking in maternal health

Using the international maternal health field as a case study, we draw on ethnographic research to investigate how public health researchers and policy experts are responding to tensions between vertical and horizontal approaches to health improvement. Despite nominal support for an integrative health system approach, we found that competition for funds and international recognition pushes professionals toward vertical initiatives. We also highlight how research practices contribute to the dominance of vertical strategies and limit the success of evidence-based policymaking for strengthening health systems. Rather than support disease-and subfield-specific advocacy, the public health community urgently needs to engage in open dialogue regarding the international, academic, and donor-driven forces that drive professionals toward an exclusive interest in vertical programs.

Two decades of the safe motherhood initiative: time for another wooden spoon award?

After two decades of the Safe Motherhood Initiative, meaningful reductions in maternal mortality and disability during pregnancy and childbirth in developing countries have not been realized. Herein, we present an overview of the Initiative and review the reasons for this lack of impact, focusing on the issue of strategic effectiveness. An appraisal of strategies that are currently recommended reveals a lack of strong evidence to support their effectiveness. Drawing from the Initiative's history, we propose that, among essential elements to achieve safe motherhood, recommended public health strategies should be supported by good evidence of effectiveness, through (cluster) randomized trials when feasible, before their widespread implementation.

Generation of political priority for global health initiatives: a framework and case study of maternal mortality

Why do some global health initiatives receive priority from international and national political leaders whereas others receive little attention? To analyse this question we propose a framework consisting of four categories: the strength of the actors involved in the initiative, the power of the ideas they use to portray the issue, the nature of the political contexts in which they operate, and characteristics of the issue itself. We apply this framework to the case of a global initiative to reduce maternal mortality, which was launched in 1987. We undertook archival research and interviewed people connected with the initiative, using a process-tracing method that is commonly employed in qualitative research. We report that despite two decades of effort the initiative remains in an early phase of development, hampered by difficulties in all these categories. However, the initiative's 20th year, 2007, presents opportunities to build political momentum. To generate political priority, advocates will need to address several challenges, including the creation of effective institutions to guide the initiative and the development of a public positioning of the issue to convince political leaders to act. We use the framework and case study to suggest areas for future research on the determinants of political priority for global health initiatives, which is a subject that has attracted much speculation but little scholarship.

Reflections on the knowledge base for obstetric fistula

This article presents the reflections of an experienced fistula surgeon and an epidemiologist on the current knowledge base for obstetric fistula. The incidence, prevention, and management of vesico-vaginal and recto-vaginal fistula are discussed. The authors call for more randomized controlled trials to determine the effectiveness of surgical interventions for fistula repair.

Traditional birth attendant training for improving health behaviours and pregnancy outcomes

BACKGROUND

Between the 1970s and 1990s, the World Health Organization promoted traditional birth attendant (TBA) training as one strategy to reduce maternal and neonatal mortality. To date, evidence in support of TBA training remains limited and conflicting.

OBJECTIVES

To assess effects of TBA training on health behaviours and pregnancy outcomes.

SEARCH STRATEGY

We searched the Trials Registers of the Cochrane Pregnancy and Childbirth Group and Cochrane Effective Practice and Organisation of Care Group (EPOC) (June 2006); electronic databases representing fields of education, social, and health sciences (inception to June 2006); the internet; and contacted experts.

SELECTION CRITERIA

Published and unpublished randomized controlled trials (RCT), controlled before/after and interrupted time series studies comparing trained and untrained TBAs or women cared for/living in areas served by TBAs.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed study quality and extracted data.

MAIN RESULTS

Four studies, involving over 2000 TBAs and nearly 27,000 women, are included. One cluster-randomized trial found significantly lower rates in the intervention group regarding stillbirths (adjusted OR 0.69, 95% confidence interval (CI) 0.57 to 0.83, P < 0.001), perinatal death rate (adjusted OR 0.70, 95% CI 0.59 to 0.83, P < 0.001) and neonatal death rate (adjusted OR 0.71, 95% CI 0.61 to 0.82, P < 0.001). Maternal death rate was lower but not significant (adjusted OR 0.74, 95% CI 0.45 to 1.22, P = 0.24) while referral rates were significantly higher (adjusted OR 1.50, 95% CI 1.18 to 1.90, P < 0.001). A controlled before/after study among women who were referred to a health service found perinatal deaths decreased in both intervention and control groups with no significant difference between groups (OR 1.02, 95% CI 0.59 to 1.76, P = 0.95). Similarly, the mean number of monthly referrals did not differ between groups (P = 0.321). One RCT found a significant difference in advice about introduction of complementary foods (OR 2.07, 95% CI 1.10 to 3.90, P = 0.02) but no significant difference for immediate feeding of colostrum (OR 1.37, 95% CI 0.62 to 3.03, P = 0.44). Another RCT found no significant differences in frequency of postpartum haemorrhage (OR 0.94, 95% CI 0.76 to 1.17, P = 0.60) among women cared for by trained versus TBAs.

AUTHORS' CONCLUSIONS

The potential of TBA training to reduce peri-neonatal mortality is promising when combined with improved health services. However, the number of studies meeting the inclusion criteria is insufficient to provide the evidence base needed to establish training effectiveness.

Patterns of maternal care seeking behaviours in rural Bangladesh

OBJECTIVE

Seeking care from a basic or comprehensive facility in response to obstetric complications is a key behaviour promoted in safe motherhood programmes. This study examined definitions of care seeking for maternal health complications used by families in rural Bangladesh, and the frequency and determinants of locally-defined care seeking practices.

METHODS

We conducted 24 semi-structured qualitative interviews with women who had recently given birth to characterize care seeking behaviours in response to perceived complications. Based on these findings, a quantitative household questionnaire was developed and administered to 1490 women, half of whom reported a 'serious or very serious' complication during their last pregnancy and/or delivery (n=769; 52%), and were included in the quantitative analysis.

RESULTS

Informants described three care seeking patterns in qualitative interviews: (i) sending a family member to purchase treatment to administer in the home; (ii) sending for a provider to treat the woman in the home and (iii) taking the woman outside the home to a facility or provider's office. The quantitative survey revealed that most women sought care for 'serious' complications (86%), with 42% seeking multiple sources of care. The majority of women purchased a treatment to administer at home (68%), while 20% brought a provider to the home. Thirty per cent of women were taken to a provider or facility.

CONCLUSIONS

Families generally seek care for complications, but care seeking does not correspond to definitions used by maternal health programmes. Local definitions of care seeking must be considered in intervention design so that promotion of care seeking increases for facility-based care for life-threatening emergencies rather than unintentionally increasing the use of home-based treatments of little medical value for prevention of mortality.

Ethics in public health research: minding the gaps: a reassessment of the challenges to safe motherhood

Maternal and perinatal mortality reduction has remained a priority on the international health agenda for nearly 2 decades. During this time, strategies for achieving these goals have shifted in emphasis from prevention of pregnancies to provision of care. Robust evidence is limited, particularly regarding what works best in delivering care in specific health system settings and at the population level. We describe the limited evidence base using a framework that highlights the consequences of the major gaps in measurement, evidence, and action, and we discuss existing opportunities for bridging these gaps at the policy level. Capitalizing on current global policy interests and generating demand-driven evidence is a priority for enabling documentation of progress toward reaching the United Nations Millennium Development Goals for 2015.

Strategies for reducing maternal mortality: getting on with what works

The concept of knowing what works in terms of reducing maternal mortality is complicated by a huge diversity of country contexts and of determinants of maternal health. Here we aim to show that, despite this complexity, only a few strategic choices need to be made to reduce maternal mortality. We begin by presenting the logic that informs our strategic choices. This logic suggests that implementation of an effective intrapartum-care strategy is an overwhelming priority. We also discuss the alternative configurations of such a strategy and, using the best available evidence, prioritise one strategy based on delivery in primary-level institutions (health centres), backed up by access to referral-level facilities. We then go on to discuss strategies that complement intrapartum care. We conclude by discussing the inexplicable hesitation in decision-making after nearly 20 years of safe motherhood programming: if the fifth Millennium Development Goal is to be achieved, then what needs to be prioritised is obvious. Further delays in getting on with what works begs questions about the commitment of decision-makers to this goal.

Having a "safe delivery": conflicting views from Tibet

In the Tibetan Autonomous Region (TAR) of the People's Republic of China (PRC) maternal mortality ratios remain among the highest in the world. Although traditional Tibetan medical theory, practice, and pharmacology include information on maternal and child health care, Tibet is one of the few societies in the world that does not have traditional birth attendants or midwives. Using ethnographic methods, we gathered data from individual interviews with rural Tibetan women (N=38) about their beliefs and behaviors surrounding pregnancy and childbirth. Additional data were gathered through interviews with prefecture, county, and township health care providers. These data were used to develop a culturally appropriate village birth attendant training program in rural Tibet. We describe Tibetan women's perspectives of "having a safe delivery" in relation to concepts about "safe delivery" according to evidence-based medicine in the West. Our work also provides an example of the benefits and challenges that arise when ethnographic research methods are used to design and implement health care interventions.

Kaqchikel midwives, home births, and emergency obstetric referrals in Guatemala: contextualizing the choice to stay at home

Maternal mortality is highest in those countries whose health budgets are restricted. Practical strategies employed in the International Safe Motherhood Initiative, therefore, must be both effective and economical. Investing in emergency obstetric care resources has been touted as one such strategy. This investment aims to insure significant improvements are made in regional health centers, and a chain of referral is put into place so that only problem cases are attended by the most skilled health workers. This article examines how this model of referral functions in Sololá, Guatemala, where most Kaqchikel Mayan women give birth at home with a traditional midwife, and no skilled biomedical attendant is available at the birth to make a referral. Ethnographic data is used to explore reasons why women do not go to the hospital at the first sign of difficulty. I argue that the problem frequently is not that Mayan midwives, their clients and families fail to understand the biomedical information about dangers in birth, but rather that this information fails to fit into an already existing social system of understanding birth and birth-related knowledge.

An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan

BACKGROUND

There are approximately 4 million neonatal deaths and half a million maternal deaths worldwide each year. There is limited evidence from clinical trials to guide the development of effective maternity services in developing countries.

METHODS

We performed a cluster-randomized, controlled trial involving seven subdistricts (talukas) of a rural district in Pakistan. In three talukas randomly assigned to the intervention group, traditional birth attendants were trained and issued disposable delivery kits; Lady Health Workers linked traditional birth attendants with established services and documented processes and outcomes; and obstetrical teams provided outreach clinics for antenatal care. Women in the four control talukas received usual care. The primary outcome measures were perinatal and maternal mortality.

RESULTS

Of the estimated number of eligible women in the seven talukas, 10,114 (84.3 percent) were recruited in the three intervention talukas, and 9443 (78.7 percent) in the four control talukas. In the intervention group, 9184 women (90.8 percent) received antenatal care by trained traditional birth attendants, 1634 women (16.2 percent) were seen antenatally at least once by the obstetrical teams, and 8172 safe-delivery kits were used. As compared with the control talukas, the intervention talukas had a cluster-adjusted odds ratio for perinatal death of 0.70 (95 percent confidence interval, 0.59 to 0.82) and for maternal mortality of 0.74 (95 percent confidence interval, 0.45 to 1.23).

CONCLUSIONS

Training traditional birth attendants and integrating them into an improved health care system were achievable and effective in reducing perinatal mortality. This model could result in large improvements in perinatal and maternal health in developing countries.

Use of Health Professionals for Obstetric Care in Northern Ghana

This study explores the role of access versus traditional beliefs in the decision to seek obstetric care from health professionals. Eighteen purposively sampled homogenous groups in Kassena-Nankana District of northern Ghana participated in focus-group discussions about traditional beliefs, barriers to the use of health professionals, and ways to improve obstetric care. All the groups were knowledgeable about the life-threatening signs and symptoms of complications of pregnancy and labor. Decisions about place of delivery generally were made after the onset of labor. Accessibility factors (cost, distance, transport, availability of health facilities, and nurses' attitudes) were major barriers, whereas traditional beliefs were reported as less significant. Informants made pertinent recommendations on how to improve obstetric services in the district. These findings demonstrate that even in this district, where African traditional religion is practiced by a third of the population, compared with a national average of 4 percent, lack of access was perceived as the main barrier to seeking professional obstetric care.

Examining the evidence for The International Confederation of Midwives’ essential competencies for midwifery practice

OBJECTIVE

to present the evidence for inclusion of selected midwifery tasks (skills) as essential practice competencies for midwives throughout the world. The tasks addressed are those presented to the International Confederation of Midwives (ICM) Council of Delegates in 2002 for discussion and adoption, based on the fact that during field-testing, notable variance was encountered.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

evidence-based practice should be characterised by the use of best practices derived from rigorous research, combined with and balanced by client perspectives and the expert judgement based on the critical thinking of the clinician. Much of midwifery practice is considered an art based on common sense, tradition, and woman-centred approaches to caring, as most of the women who seek midwifery care are healthy and require a health-promotion model of care that may not easily lend itself to examination by scientists or clinicians. However, when intervention is indicated to save the lives of mother, baby, or both, those interventions must be based on the best available evidence from a variety of sources leading to the most effective choices for action. The ICM Essential Competencies for Midwifery Practice (2002) are based on evidence derived from a variety of quantitative and qualitative methodologies. Expert clinical consensus may serve as to the best form of evidence at certain points in the evolution of knowledge. Every midwife needs to understand where the gaps exist in supporting traditional practices that have yet to be fully examined in a scientific manner. In summary, a multi-matrix or triangulated approach may be most appropriate to the delineation of evidence underpinning best midwifery practice.

Free Markets and Dead Mothers: The Social Ecology of Maternal Mortality in Post-Socialist Mongolia

Beginning in 1990, Mongolia, a former client state of what was then the Soviet Union, undertook liberal economic reforms. These came as a great shock to Mongolia and Mongolians, and resulted in food shortages, reports of famine, widespread unemployment, and a collapse of public health and health care. Although economic conditions have stabilized in recent years, unemployment and poverty are still at disturbingly high levels. One important consequence of the transition has been the transformation of the rural, primarily pastoral, economy. With de-collectivization, herding households have been thrown into a highly insecure subsistence mode of production, and, as a consequence, have become vulnerable to local fluctuations in rainfall and availability and quality of forage, and many now lack access to traded staples and essential commodities. Household food insecurity, malnutrition, and migration of impoverished households to provincial centers and the capital of Ulaanbaatar are one result. Reductions to investments in the health sector have also eroded the quality of services in rural areas, and restricted access to those services still functioning. Evidence suggests that women are particularly vulnerable to these political-ecological changes, and that this vulnerability is manifested in increasing rates of poor reproductive health and maternal mortality. Drawing on case-study ethnographic and epidemiological data, this article explores the links between neoliberal economic reform and maternal mortality in Mongolia.

Methodological issues in the measurement of birth preparedness in support of safe motherhood

Behavior change interventions focusing on birth preparedness for pregnant women, their husbands, and adults in the community are common components of community-oriented Safe Motherhood programs in developing countries. Few studies have examined the effectiveness of these interventions, and existing studies are flawed due to study and sample design. This article highlights methodological issues that are often overlooked when measuring indicators of birth preparedness among multiple audiences for program evaluation purposes in household-based surveys. Solutions are proposed to address each of these problems in an effort to improve future research.

What can a meta-analysis tell us about traditional birth attendant training and pregnancy outcomes?

OBJECTIVE

to summarise the available published and unpublished studies on traditional birth attendant (TBA) training effectiveness.

DESIGN

a meta-analysis.

STUDY SAMPLE

sixty studies (n=60) spanning 1971-1999 from 24 countries and three regions.

MEASUREMENTS

the effect size index, Cohen's h for each outcome; the variance-weighted mean effect size and 95% confidence interval for sub-group of outcomes; homogeneity tests on the distribution of the weighted mean effect sizes; and sensitivity analysis to detect the presence of publication bias.

FINDINGS

TBA training was associated with significant increases in attributes such as TBA 'knowledge' (90%), 'attitude' (74%), 'behaviour' (63%) and 'advice' (90%) over the untrained TBA baseline. Results for 'behaviour' and 'advice' in specific content areas related to peri-neonatal health outcome, however, reveal sources of variability and underscore the conflicting evidence on TBA training. TBA training was also associated with small but significant decreases in peri-neonatal mortality (8%) and birth asphyxia mortality (11%). Incomplete reporting limited the assessment of neonatal mortality due to tetanus and acute respiratory infection, maternal mortality, as well as assessment of the relationship between intervention characteristics and outcomes. The quality of studies included in the meta-analysis lack sufficient rigour to address the question of causality. Thus, while the data suggest that TBA training is effective in terms of the outcomes measured, we are unable to demonstrate that it is a cost-effective intervention.

IMPLICATIONS

skilled attendance at birth is a distant reality in many developing countries and effective community-based strategies are needed to help reduce high levels of mortality. Given the magnitude of peri-neonatal mortality, the associations observed between TBA training peri-neonatal and birth asphyxia mortality, and TBA attributes in content relevant to peri-neonatal survival, we suggest that these strategies may usefully include TBA training in appropriate settings. If TBAs are to be trained, however, it is imperative that their training be adequately evaluated in order to develop the strong evidence base that is lacking to-date and that is necessary for sound policy and programming.

Empowerment of women, men, families and communities: true partners for improving maternal and newborn health

Based on the Health Promotion approach, the Making Pregnancy Safer initiative has proposed a strategic framework for working with individuals, families and communities to improve maternal and newborn health. The aims are to contribute to the empowerment of women, families and communities to increase their influence and control over maternal and newborn health, as well as to increase access to and utilization of quality skilled care. The framework has identified those strategies and interventions that target the factors known to contribute to health inequalities and poor maternal and newborn health. While empowerment is an aim of the framework, it is also considered a means. Emphasis is placed on the processes and the quality of the processes rather than just on the actions themselves. The authors in this paper would like to contribute to ongoing discussions about the 'how' of working with women, men, families and communities for improved maternal and newborn health.