Coverage, associated factors, and impact of companionship during labor: A large-scale observational study in six hospitals in Nepal

Does mistreatment during institutional childbirth increase the likelihood of experiencing postpartum depressive symptoms? A prospective cohort study in Nepal

BACKGROUND

Postpartum depression is associated with low socioeconomic status, adverse birthing processes, and life stress. Increasing evidence of mistreatment during childbirth, negative birth experiences, and poor quality of maternal care is of global concern.

OBJECTIVE

To assess the risk of experiencing depressive symptoms among postpartum women exposed to mistreatment during institutional birthing in Nepal.

METHOD

We conducted a prospective cohort study from 29 March to 19 August 2022. Of 1629 women who gave birth in a hospital in Nepal, 1222 were assessed for mistreatment during childbirth and depressive symptoms using the Edinburgh Postnatal Depression Scale. We used binomial generalized linear mixed model to examine the risk ratio of postpartum depressive symptoms in women exposed to mistreatment during childbirth.

RESULTS

The prevalence of postpartum depressive symptoms was 4.4%. Women exposed to mistreatment during childbirth were almost fifty percent more likely to have postpartum depressive symptoms (cRR 1.47; 95% CI 1.14, 1.89; p = 0.003) compared with the unexposed group. Furthermore, adolescent mothers exposed to mistreatment during childbirth had a seventy percent increased risk of depressive symptoms (aRR 1.72; 95% CI 1.23, 2.41; p = 0.002). Similarly, women who gave birth to female infants were thirty percent more likely to experience postpartum depressive symptoms (aRR 1.32; 95% CI 1.01-1.74; p = 0.039).

CONCLUSION

We observed an association between postpartum depressive symptoms and mistreatment during institutional births in Nepal. The implementation of appropriate respectful maternity care during childbirth and also routine screening for depressive symptoms is critical to improving perinatal mental health and well-being.

From global recommendations to (in)action: A scoping review of the coverage of companion of choice for women during labour and birth

Women greatly value and benefit from the presence of someone they trust to support them throughout labour and childbirth ('labour companion of choice'). Labour companionship improves maternal and perinatal outcomes, including enhancing physiological labour and birth experiences. Despite clear benefits, implementation is slow. We conducted a scoping review to assess coverage and models of labour companionship, including quantitative studies reporting coverage of labour companionship in any level health facility globally. We searched MEDLINE, CINAHL, and Global Health from 1 January 2010-14 December 2021. We extracted data on study design, labour companionship coverage, timing and type of companions allowed, and recoded data into categories for comparison across studies. We included data from a maternal health sentinel network of hospitals in Latin America, using descriptive statistics to assess coverage among 120,581 women giving birth in these sites from April 2018-April 2022. In the scoping review, we included 77 studies from 27 countries. There was wide variation in the coverage of labour companionship: almost one-third of studies reported coverage less than 40%, and one-third of studies reported coverage between 40-80%. Husbands or partners were the most frequent companion (37.7%, 29/77), followed by family member or friend (gender not specified) (32.5%, 25/77), family member or friend (female-only) (13.0%, 10/77). Across nine sentinel hospitals in five Latin American countries, there was variation in coverage, with no companion at any time ranging from 14.9%-93.8%. Despite the well-known benefits and factors affecting implementation of labour companionship, more work is needed to improve equitable coverage. Concerted efforts are needed to engage with communities, health workers, health managers, and policy-makers to establish policies, address implementation barriers, and integrate data on coverage into perinatal records and quality processes to ensure that all women have access. Harmonized reporting of labour companionship would greatly enhance understanding at global level.

Mistreatment during childbirth and postnatal period reported by women in Nepal -a multicentric prevalence study

INTRODUCTION

Trust of women and families toward health institutions has led to increased use of their services for childbirth. Whilst unpleasant experience of care during childbirth will halt this achievement and have adverse consequences. We examined the experience of women regarding the care received during childbirth in health institutions in Nepal.

METHOD

A prospective cohort study conducted in 11 hospitals in Nepal for a period of 18 months. Using a semi-structured questionnaire based on the typology of mistreatment during childbirth, information on childbirth experience was gathered from women (n = 62,926) at the time of discharge. Using those variables, principal component analysis was conducted to create a single mistreatment index. Bivariate and multivariate linear regression analyses were conducted to assess the association of the mistreatment index with sociodemographic, obstetric and newborn characteristics.

RESULT

A total of 62,926 women were consented and enrolled in the study. Of those women, 84.3% had no opportunity to discuss any concerns, 80.4% were not adequately informed before providing care, and 1.5% of them were refused for care due to inability to pay. According to multivariate regression analysis, women 35 years or older (β, - 0.3587; p-value, 0.000) or 30-34 years old (β,- 0.38013; p-value, 0.000) were less likely to be mistreated compared to women aged 18 years or younger. Women from a relatively disadvantaged (Dalit) ethnic group were more likely to be mistreated (β, 0.29596; p-value, 0.000) compared to a relatively advantaged (Chettri) ethnic group. Newborns who were born preterm (β, - 0.05988; p-value, 0.000) were less likely to be mistreated than those born at term.

CONCLUSION

The study reports high rate of some categories of mistreatment of women during childbirth. Women from disadvantaged ethnic group, young women, and term newborns are at higher risk of mistreatment. Strengthening health system and improving health workers' readiness and response will be key in experience respectful care during childbirth.

Desire for Birth Companionship Among Pregnant Women Attending Antenatal Care in Debremarkos City, Northwest Ethiopia: Magnitude and Associated Factors

Background

Birth companionship is one of the components of the respectful maternity continuum of care recommended by the World Health Organization (WHO). Women's desire for birth companionship needs to be given attention during the antenatal care period to make them ready during labor and delivery. There is a dearth of study about the status of women's desire for birth companionship and associated factors.

Objective

This study aimed to assess the prevalence of desire for birth companionship and associated factors among pregnant women in Debremarkos city, northwest Ethiopia.

Methods

Institution-based cross-sectional study was conducted from February 1, 2021 to March 30, 2021 in Debremarkos city, northwest Ethiopia. A total of 423 participants were accessed by systematic random sampling. A face-to-face interviewer-administered questionnaire was employed. The data were entered into Epi data version 4.6 and transformed to SPSS version 25. Binary logistic regression analysis was done, and variables with a p-value ≤ 0.2 on bivariable analysis were taken for multivariable analysis. Adjusted odds ratio with a 95% confidence interval was used to detect the association, and a p-value of <0.05 in the multivariable analysis was used to declare statistical significance.

Results

The prevalence of desire for birth companionship was 57.45% (52.6–62.2%). Women who were the primary decision-maker for maternal health care services [adjusted odds ratio (AOR) =3.0; 95% CI 1.7–5.6], women with planned pregnancy (AOR = 2.0; 95% CI 1.0–3.9), women who have no bad obstetric history (AOR = 2.3; 95% CI 1.2–4.4), and women whose 1st antenatal care visit starts within the second trimester (AOR = 2.6; 1.6–4.4) were statistically significant with desire on birth companionship.

Conclusions

Desire of pregnant women for birth companionship was high in this study. Improving women's decision-making power, emphasis on the type of pregnancy, obstetrical history, and early initiation of antenatal care visit were the suggested areas to increase the desire of women for birth companionship.

Partnership-defined quality approach to companionship during labour and birth in East New Britain, Papua New Guinea: A mixed-methods study

Companionship during labour and birth is a critical component of quality maternal and newborn care, resulting in improved care experiences and better birth outcomes. Little is known about the preferences and experiences of companionship in Papua New Guinea (PNG), and how it can be implemented in a culturally appropriate way. The aim of this study was to describe perspectives and experiences of women, their partners and health providers regarding labour and birth companionship, identify enablers and barriers and develop a framework for implementing this intervention in PNG health facilities. A mixed methods study was conducted with five facilities in East New Britain, PNG. Data included 5 facility audits, 30 labour observations and 29 in-depth interviews with women who had recently given birth, partners and maternity care providers. A conceptual framework was developed drawing on existing quality care implementation frameworks. Women and partners wanted companions to be present, whilst health providers had mixed views. Participants described benefits of companionship including encouragement and physical support for women, better communication and advocacy, improved labour outcomes and assistance with workforce issues. Adequate privacy and space constraints were highlighted as key barriers to address. Of the women observed, only 30% of women had a companion present during labour, and 10% had a companion at birth. A conceptual framework was used to highlight the interconnected inputs required at community, facility and provincial health system levels to improve the quality of care. Key elements to address included attitudes towards companionship, the need for education and training and restrictive hospital policies. Supporting women to have their companion of choice present during labour and birth is critical to improving women's experiences of care and improving the quality of maternal and newborn care. In order to provide companionship during labour and birth in PNG, a complex, intersecting, multi-faceted approach is required.

Factors associated with poor adherence to intrapartum fetal heart monitoring in relationship to intrapartum related death: A prospective cohort study

BACKGROUND

Poor quality of intrapartum care remains a global health challenge for reducing stillbirth and early neonatal mortality. Despite fetal heart rate monitoring (FHRM) being key to identify fetus at risk during labor, sub-optimal care prevails in low-income settings. The study aims to assess the predictors of suboptimal fetal heart rate monitoring and assess the association of sub-optimal FHRM and intrapartum related deaths.

METHOD

A prospective cohort study was conducted in 12 hospitals between April 2017 to October 2018. Pregnant women with fetal heart sound present during admission were included. Inferential statistics were used to assess proportion of sub-optimal FHRM. Multi-level logistic regression was used to detect association between sub-optimal FHRM and intrapartum related death.

RESULT

The study cohort included 83,709 deliveries, in which in more than half of women received suboptimal FHRM (56%). The sub-optimal FHRM was higher among women with obstetric complication than those with no complication (68.8% vs 55.5%, p-value<0.001). The sub-optimal FHRM was higher if partograph was not used than for whom partograph was completely filled (70.8% vs 15.9%, p-value<0.001). The sub-optimal FHRM was higher if the women had no companion during labor than those who had companion during labor (57.5% vs 49.6%, p-value<0.001). After adjusting for background characteristics and intra-partum factors, the odds of intrapartum related death was higher if FHRM was done sub-optimally in reference to women who had FHRM monitored as per protocol (aOR, 1.47; 95% CI; 1.13, 1.92).

CONCLUSION

Adherence to FHRM as per clinical standards was inadequate in these hospitals of Nepal. Furthermore, there was an increased odds of intra-partum death if FHRM had not been carried out as per clinical standards. FHRM provided as per protocol is key to identify fetuses at risk, and efforts are needed to improve the adherence of quality of care to prevent death.

Establishing the practice of birth companion in labour ward of a tertiary care centre in India-a quality improvement initiative

BACKGROUND

Birth companion is a key component for providing respectful maternity care and has been recommended by WHO and Government of India. It is a low-cost beneficial intervention that is vital in improving quality of care during labour and delivery.

LOCAL PROBLEM

Despite the available evidence on benefits of birth companion, there was no policy on allowing birth companion at our hospital in the past.

METHODS AND INTERVENTIONS

We aimed to establish the practice of allowing birth companions in all eligible women in labour ward from existing 0% to 50% in 6 weeks' duration. This study was conducted in the Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi. A quality improvement (QI) team was formed, and after obtaining the baseline data, problems were analysed using fish bone chart. A new policy of allowing birth companion was made and efforts made to sensitise and train the doctors and nurses posted in labour ward. Changed ideas were executed in multiple plan-do-study-act (PDSA) cycles. Simple interventions such as dress code for birth companions, curtains for ensuring privacy, display of posters and frequent reminders on WhatsApp groups were planned .

RESULTS

The median value of women accompanied by birth companion marginally increased to 25% after the first PDSA cycle. Implementation of further changed ideas led to increase in median, which reached 66.6%. Thereafter, there was a decline, but by the end of 6 months, it was possible to attain the goal and sustain it.

CONCLUSIONS

Simple steps of QI methodology can be used to address the prevalent problems in our healthcare. Implementation of any new practice comes with major challenges, but we could achieve our goal because of a motivated team working together on multiple changed ideas applied sequentially in PDSA cycles.

Respectful maternal and newborn care: measurement in one EN-BIRTH study hospital in Nepal

BACKGROUND

Respectful maternal and newborn care (RMNC) is an important component of high-quality care but progress is impeded by critical measurement gaps for women and newborns. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study was an observational study with mixed methods assessing measurement validity for coverage and quality of maternal and newborn indicators. This paper reports results regarding the measurement of respectful care for women and newborns.

METHODS

At one EN-BIRTH study site in Pokhara, Nepal, we included additional questions during exit-survey interviews with women about their experiences (July 2017-July 2018). The questionnaire was based on seven mistreatment typologies: Physical; Sexual; or Verbal abuse; Stigma/discrimination; Failure to meet professional standards of care; Poor rapport between women and providers; and Health care denied due to inability to pay. We calculated associations between these typologies and potential determinants of health - ethnicity, age, sex, mode of birth - as possible predictors for reporting poor care.

RESULTS

Among 4296 women interviewed, none reported physical, sexual, or verbal abuse. 15.7% of women were dissatisfied with privacy, and 13.0% of women reported their birth experience did not meet their religious and cultural needs. In descriptive analysis, adjusted odds ratios and multivariate analysis showed primiparous women were less likely to report respectful care (β = 0.23, p-value < 0.0001). Women from Madeshi (a disadvantaged ethnic group) were more likely to report poor care (β = - 0.34; p-value 0.037) than women identifying as Chettri/Brahmin. Women who had caesarean section were less likely to report poor care during childbirth (β = - 0.42; p-value < 0.0001) than women with a vaginal birth. However, babies born by caesarean had a 98% decrease in the odds (aOR = 0.02, 95% CI, 0.01-0.05) of receiving skin-to-skin contact than those with vaginal births.

CONCLUSIONS

Measurement of respectful care at exit interview after hospital birth is challenging, and women generally reported 100% respectful care for themselves and their baby. Specific questions, with stratification by mode of birth, women's age and ethnicity, are important to identify those mistreated during care and to prioritise action. More research is needed to develop evidence-based measures to track experience of care, including zero separation for the mother-newborn pair, and to improve monitoring.