The right to remain silent: a qualitative study of the medical and social ramifications of pregnancy disclosure for Gambian women

Concealed pregnancy as an act of care? A qualitative analysis of motivations for concealing and non-disclosure of early pregnancy in The Gambia

BACKGROUND

A barrier to achieving first trimester antenatal care (ANC) attendance in many countries has been the widespread cultural practice of not discussing pregnancies in the early stages. Motivations for concealing pregnancy bear further study, as the interventions necessary to encourage early ANC attendance may be more complicated than targeting infrastructural barriers to ANC attendance such as transportation, time, and cost.

METHODS

Five focus groups with a total of 30 married, pregnant women were conducted to assess the feasibility of conducting a randomised controlled trial to evaluate the effectiveness of early initiation of physical activity and/or yoghurt consumption in reducing Gestational Diabetes Mellitus in pregnant women in The Gambia. Focus group transcripts were coded through a thematic analysis approach, assessing themes as they arose in relation to failure to attend early ANC.

RESULTS

Two reasons for the concealment of pregnancies in the first trimester or ahead of a pregnancy's obvious visibility to others were given by focus group participants. These were 'pregnancy outside of marriage' and 'evil spirits and miscarriage.' Concealment on both grounds was motivated through specific worries and fears. In the case of a pregnancy outside of marriage, this was worry over social stigma and shame. Evil spirits were widely considered to be a cause of early miscarriage, and as such, women may choose to conceal their pregnancies in the early stages as a form of protection.

CONCLUSION

Women's lived experiences of evil spirits have been under-explored in qualitative health research as they relate specifically to women's access to early antenatal care. Better understanding of how such sprits are experienced and why some women perceive themselves as vulnerable to related spiritual attacks may help healthcare workers or community health workers to identify in a timely manner the women most likely to fear such situations and spirits and subsequently conceal their pregnancies.

The role of informational support from women's social networks on antenatal care initiation: qualitative evidence from pregnant women in Uganda

BACKGROUND

Early and appropriate use of antenatal care services is critical for reducing maternal and neonatal mortality and morbidity. Yet most women in sub-Saharan Africa, including Uganda, do not seek antenatal care until later during pregnancy. This qualitative study explored pregnant women's reliance on social ties for information about initiation of antenatal care.

METHODS

We conducted semi-structured, in-depth interviews with 30 pregnant women seeking their first antenatal care visit at Kawempe Referral Hospital in Kampala, Uganda. Recruitment was done purposively to obtain variation by parity and whether women currently had a male partner. Study recruitment occurred from August 25^th 2020 - October 26^th, 2020. We used thematic analysis following a two-stage coding process, with both deductive and inductive codes. Deductive codes followed the key domains of social network and social support theory.

RESULTS

We found that the most important source of information about antenatal care initiation was these women's mothers. Other sources included their mothers-in-law, female elders including grandmothers, and male partners. Sisters and female friends were less influential information sources about antenatal initiation. One of the primary reasons for relying on their own mothers, mothers-in-law, and elder women was due to these women's lived experience with pregnancy and childbirth. Trust in the relationship was also an important factor. Some pregnant women were less likely to rely on their sisters or female friends, either due to lack of trust or these women's lack of experience with pregnancy and childbirth. The advice that pregnant women received from their mothers and others on the ideal timing for antenatal care initiation varied significantly, including examples of misinformation about when to initiate antenatal care. Pregnant women seemed less likely to delay care when more than one social tie encouraged early antenatal care.

CONCLUSIONS

Educating women's social networks, especially their mothers, mothers-in-law, and community elders, about the importance of early antenatal care initiation is a promising avenue for encouraging pregnant women to seek care earlier in pregnancy.

How Do Women Learn They Are Pregnant? The Introduction of Clinics and Pregnancy Awareness in Nepal

The earlier a woman learns about her pregnancy status, the sooner she can make decisions about her own and infant's health. This paper examines how women learn about their pregnancy status and measures how access to pregnancy tests affects earlier pregnancy knowledge. Using 10 years of individual-level monthly panel data in Nepal, we find that, on average, women learn they are pregnant in their 4.6th month of pregnancy. Living approximately a mile further from a clinic offering pregnancy tests increases the time a woman knows she is pregnant by one week (5 percent increase) and decreases the likelihood of knowing in the first trimester by 4.5 percentage points (16 percent decrease). Women with prior pregnancies experience the most substantial effects of distance within the first two trimesters, while, for women experiencing their first pregnancy, distance does not affect knowledge. These results suggest that, while access to clinics can increase pregnancy awareness for women who recognize pregnancy symptoms, other complementary policies are needed to increase pregnancy awareness of women in their first pregnancy.

"My husband is my family." The culture of pregnancy disclosure and its implications on early pregnancy registration in a child nutrition intervention in rural Maharashtra, India

Less than seventeen percent pregnant women in rural India had full antenatal check-ups. Early uptake to maternal and child healthcare services is strongly associated with cultural beliefs and practices around pregnancy and childbirth. This study aims to assess the cultural elements that influence women's behaviours of disclosure of their pregnancy in rural setting in Maharashtra state of India. We conducted 25 In-depth semi structured interviews with pregnant women and two focus groups with Community Health Workers in villages around Nagpur and Bhandara districts. The pregnant women were selected purposively with preference given to those who had a previous pregnancy. The audio recorded interviews were transcribed verbatim and translated into English. An inductive thematic approach was applied for data analysis. According to most respondents, they would only directly disclose their pregnancy to their husband and close relatives. Although, most pregnant women were hesitant towards nonrelatives discovering their pregnancy before completion of three months. The reasons behind delayed disclosure of pregnancy were fear of losing baby due to black magic, and casting of evil eyes by jealous neighbours and people with bad intentions. The Community Health Workers seconded these believes and mentioned that if pregnancy disclosed earlier, the foetus would remain incomplete (adhura). These superstitions prevented the women from availing benefits from the health facility at the earliest. The study identified several local beliefs and perceptions that hinders health care utilization of the women. Interventions that are tailored to the local cultural context can address these obstacles to increase the uptake of antenatal check-up early in pregnancy.

Changes in attitudes and behaviors supportive of maternal and newborn health in Ethiopia: an evaluative case study

Background

Ethiopia’s high neonatal mortality rate led to the government’s 2013 introduction of Community-Based Newborn Care (CBNC) to bring critical prevention and treatment interventions closer to communities in need. However, complex behaviors that are deeply embedded in social and cultural norms continue to prevent women and newborns from getting the care they need. A demand creation strategy was designed to create an enabling environment to support appropriate maternal, newborn, and child health (MNCH) behaviors and CBNC. We explored the extent to which attitudes and behaviors during the prenatal and perinatal periods varied by the implementation strength of the Demand Creation Strategy for MNCH-CBNC.

Methods

Using an embedded, multiple case study design, we purposively selected four kebeles (villages) from two districts with different levels of implementation strength of demand creation activities. We collected information from a total of 150 key stakeholders across kebeles using multiple qualitative methods including in-depth interviews, focus group discussions, and illness narratives; sessions were transcribed into English and coded using NVivo 10.0. We developed case reports for each kebele and a final cross-case report to compare results from high and low implementation strength kebeles.

Results

We found that five MNCH attitudes and behaviors varied by implementation strength. In high implementation strength kebeles women felt more comfortable disclosing their pregnancy early, women sought antenatal care (ANC) in the first trimester, families did not have fatalistic ideas about newborn survival, mothers sought care for sick newborns in a timely manner, and newborns received care at the health facility in less than an hour. We also found changes across all kebeles that did not vary by implementation strength, including male engagement during pregnancy and a preference for giving birth at a health facility.

Conclusions

Findings suggest that a demand creation approach—combining participatory approaches with community empowering strategies—can promote shifts in behaviors and attitudes to support the health of mothers and newborns, including use of MNCH services. Future studies need to consider the most efficient level of intervention intensity to make the greatest impact on MNCH attitudes and behaviors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03865-8.

Barriers and enablers to reporting pregnancy and adverse pregnancy outcomes in population-based surveys: EN-INDEPTH study

BACKGROUND

Risks of neonatal death, stillbirth and miscarriage are highest in low- and middle-income countries (LMICs), where data has most gaps and estimates rely on household surveys, dependent on women reporting these events. Underreporting of pregnancy and adverse pregnancy outcomes (APOs) is common, but few studies have investigated barriers to reporting these in LMICs. The EN-INDEPTH multi-country study applied qualitative approaches to explore barriers and enablers to reporting pregnancy and APOs in surveys, including individual, community, cultural and interview level factors.

METHODS

The study was conducted in five Health and Demographic Surveillance System sites in Guinea-Bissau, Ethiopia, Uganda, Bangladesh and Ghana. Using an interpretative paradigm and phenomenology methodology, 28 focus group discussions were conducted with 82 EN-INDEPTH survey interviewers and supervisors and 172 women between February and August 2018. Thematic analysis was guided by an a priori codebook.

RESULTS

Survey interview processes influenced reporting of pregnancy and APOs. Women found questions about APOs intrusive and of unclear relevance. Across all sites, sociocultural and spiritual beliefs were major barriers to women reporting pregnancy, due to fear that harm would come to their baby. We identified several factors affecting reporting of APOs including reluctance to speak about sad memories and variation in recognition of the baby's value, especially for APOs at earlier gestation. Overlaps in local understanding and terminology for APOs may also contribute to misreporting, for example between miscarriages and stillbirths. Interviewers' skills and training were the keys to enabling respondents to open up, as was privacy during interviews.

CONCLUSION

Sociocultural beliefs and psycho-social impacts of APOs play a large part in underreporting these events. Interviewers' skills, careful tool development and translation are the keys to obtaining accurate information. Reporting could be improved with clearer explanations of survey purpose and benefits to respondents and enhanced interviewer training on probing, building rapport and empathy.

Ruling out early trimester pregnancy when implementing community-based deworming programs

BACKGROUND

Large-scale deworming programs have, to date, mostly targeted preschool- and school-age children. As community-based deworming programs become more common, deworming will be offered to women of reproductive age. The World Health Organization recommends preventive chemotherapy be administered to pregnant women only after the first trimester. It is therefore important for deworming programs to be able to identify women in early pregnancy. Our objective was to validate a short questionnaire which could be used by deworming program managers to identify and screen out women in early pregnancy.

METHODOLOGY/PRINCIPAL FINDINGS

In May and June 2018, interviewers administered a questionnaire, followed by a pregnancy test, to 1,203 adult women living in the Peruvian Amazon. Regression analyses were performed to identify questions with high predictive properties (using the pregnancy test as the gold standard). Test parameters were computed at different decision tree nodes (where nodes represented questions). With 106 women confirmed to be pregnant, the positive predictive value of asking the single question 'Are you pregnant?' was 100%, at a 'cost' of a false negative rate of 1.9% (i.e. 21 women were incorrectly identified as not pregnant when they were truly pregnant). Additional questions reduced the false negative rate, but increased the false positive rate. Rates were dependent on both the combination and the order of questions.

CONCLUSIONS/SIGNIFICANCE

To identify women in early pregnancy when deworming programs are community-based, both the number and order of questions are important. The local context and cultural acceptability of different questions should inform this decision. When numbers are manageable and resources are available, pregnancy tests can be considered at different decision tree nodes to confirm pregnancy status. Trade-offs in terms of efficiency and misclassification rates will need to be considered to optimize deworming coverage in women of reproductive age.

Using Participatory Workshops to Assess Alignment or Tension in the Community for Minimally Invasive Tissue Sampling Prior to Start of Child Mortality Surveillance: Lessons From 5 Sites Across the CHAMPS Network

The Child Health and Mortality Prevention Surveillance (CHAMPS) program is a 7-country network (as of December 2018) established by the Bill & Melinda Gates Foundation to identify the causes of death in children in communities with high rates of under-5 mortality. The program carries out both mortality and pregnancy surveillance, and mortality surveillance employs minimally invasive tissue sampling (MITS) to gather small samples of body fluids and tissue from the bodies of children who have died. While this method will lead to greater knowledge of the specific causes of childhood mortality, the procedure is in tension with cultural and religious norms in many of the countries where CHAMPS works-Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa. Participatory Inquiry Into Community Knowledge of Child Health and Mortality Prevention (PICK-CHAMP) is a community entry activity designed to introduce CHAMPS to communities and gather initial perspectives on alignments and tensions between CHAMPS activities and community perceptions and priorities. Participants' responses revealed medium levels of overall alignment in all sites (with the exception of South Africa, where alignment was high) and medium levels of tension (with the exception of Ethiopia, where tension was high). Alignment was high and tension was low for pregnancy surveillance across all sites, whereas Ethiopia reflected low alignment and high tension for MITS. Participants across all sites indicated that support for MITS was possible only if the procedure did not interfere with burial practices and rituals.

Provision and uptake of routine antenatal services: a qualitative evidence synthesis

BACKGROUND

Antenatal care (ANC) is a core component of maternity care. However, both quality of care provision and rates of attendance vary widely between and within countries. Qualitative research can assess factors underlying variation, including acceptability, feasibility, and the values and beliefs that frame provision and uptake of ANC programmes.This synthesis links to the Cochrane Reviews of the effectiveness of different antenatal models of care. It was designed to inform the World Health Organization guidelines for a positive pregnancy experience and to provide insights for the design and implementation of improved antenatal care in the future.

OBJECTIVES

To identify, appraise, and synthesise qualitative studies exploring:· Women's views and experiences of attending ANC; and factors influencing the uptake of ANC arising from women's accounts;· Healthcare providers' views and experiences of providing ANC; and factors influencing the provision of ANC arising from the accounts of healthcare providers.

SEARCH METHODS

To find primary studies we searched MEDLINE, Ovid; Embase, Ovid; CINAHL, EbscoHost; PsycINFO, EbscoHost; AMED, EbscoHost; LILACS, VHL; and African Journals Online (AJOL) from January 2000 to February 2019. We handsearched reference lists of included papers and checked the contents pages of 50 relevant journals through Zetoc alerts received during the searching phase.

SELECTION CRITERIA

We included studies that used qualitative methodology and that met our quality threshold; that explored the views and experiences of routine ANC among healthy, pregnant and postnatal women or among healthcare providers offering this care, including doctors, midwives, nurses, lay health workers and traditional birth attendants; and that took place in any setting where ANC was provided.We excluded studies of ANC programmes designed for women with specific complications. We also excluded studies of programmes that focused solely on antenatal education.

DATA COLLECTION AND ANALYSIS

Two authors undertook data extraction, logged study characteristics, and assessed study quality. We used meta-ethnographic and Framework techniques to code and categorise study data. We developed findings from the data and presented these in a 'Summary of Qualitative Findings' (SoQF) table. We assessed confidence in each finding using GRADE-CERQual. We used these findings to generate higher-level explanatory thematic domains. We then developed two lines of argument syntheses, one from service user data, and one from healthcare provider data. In addition, we mapped the findings to relevant Cochrane effectiveness reviews to assess how far review authors had taken account of behavioural and organisational factors in the design and implementation of the interventions they tested. We also translated the findings into logic models to explain full, partial and no uptake of ANC, using the theory of planned behaviour.

MAIN RESULTS

We include 85 studies in our synthesis. Forty-six studies explored the views and experiences of healthy pregnant or postnatal women, 17 studies explored the views and experiences of healthcare providers and 22 studies incorporated the views of both women and healthcare providers. The studies took place in 41 countries, including eight high-income countries, 18 middle-income countries and 15 low-income countries, in rural, urban and semi-urban locations. We developed 52 findings in total and organised these into three thematic domains: socio-cultural context (11 findings, five moderate- or high-confidence); service design and provision (24 findings, 15 moderate- or high-confidence); and what matters to women and staff (17 findings, 11 moderate- or high-confidence) The third domain was sub-divided into two conceptual areas; personalised supportive care, and information and safety. We also developed two lines of argument, using high- or moderate-confidence findings:For women, initial or continued use of ANC depends on a perception that doing so will be a positive experience. This is a result of the provision of good-quality local services that are not dependent on the payment of informal fees and that include continuity of care that is authentically personalised, kind, caring, supportive, culturally sensitive, flexible, and respectful of women's need for privacy, and that allow staff to take the time needed to provide relevant support, information and clinical safety for the woman and the baby, as and when they need it. Women's perceptions of the value of ANC depend on their general beliefs about pregnancy as a healthy or a risky state, and on their reaction to being pregnant, as well as on local socio-cultural norms relating to the advantages or otherwise of antenatal care for healthy pregnancies, and for those with complications. Whether they continue to use ANC or not depends on their experience of ANC design and provision when they access it for the first time.The capacity of healthcare providers to deliver the kind of high-quality, relationship-based, locally accessible ANC that is likely to facilitate access by women depends on the provision of sufficient resources and staffing as well as the time to provide flexible personalised, private appointments that are not overloaded with organisational tasks. Such provision also depends on organisational norms and values that overtly value kind, caring staff who make effective, culturally-appropriate links with local communities, who respect women's belief that pregnancy is usually a normal life event, but who can recognise and respond to complications when they arise. Healthcare providers also require sufficient training and education to do their job well, as well as an adequate salary, so that they do not need to demand extra informal funds from women and families, to supplement their income, or to fund essential supplies.

AUTHORS' CONCLUSIONS

This review has identified key barriers and facilitators to the uptake (or not) of ANC services by pregnant women, and in the provision (or not) of good-quality ANC by healthcare providers. It complements existing effectiveness reviews of models of ANC provision and adds essential insights into why a particular type of ANC provided in specific local contexts may or may not be acceptable, accessible, or valued by some pregnant women and their families/communities. Those providing and funding services should consider the three thematic domains identified by the review as a basis for service development and improvement. Such developments should include pregnant and postnatal women, community members and other relevant stakeholders.

High report of miscarriage among women living with HIV who want to conceive in Uganda

Objective

Data on early miscarriage incidence is limited due to various social and methodological barriers. We report on 24-month pregnancy outcomes of 299 female Ugandan HIV clients in committed relationships with an intention to conceive. Miscarriage data are reported as auxiliary findings to a larger study (5R01HD072633).

Results

127 (42%) participants reported a pregnancy during the study; among the remaining 172, 82 indicated they stopped trying to conceive, and 16 dropped out prior to month 24. Of the 127 pregnancies, 55 (43%) resulted in live births, 67 (53%) in spontaneous miscarriage, 1 (< 1%) in stillbirth, 1 (< 1%) in abortion, and 3 (2%) in unknown outcomes. Three-quarters (75%) of miscarriages for which time until miscarriage was available were reported to occur in the first trimester (mean = 11.3 weeks gestation). The 67 participants who reported a miscarriage tended to be older (mean 33 vs. 30 years), but the significance of age did not persist after adjusting for multiple tests. We observed relatively low rates of pregnancy and high rates of miscarriage among this cohort of HIV-positive women wanting to conceive. Rigorously designed studies are needed to better understand the observed high rate of early miscarriage among HIV-infected women.

Weekly miscarriage rates in a community-based prospective cohort study in rural western Kenya

OBJECTIVE

Information on adverse pregnancy outcomes is important to monitor the impact of public health interventions. Miscarriage is a challenging end point to ascertain and there is scarce information on its rate in low-income countries. The objective was to estimate the background rate and cumulative probability of miscarriage in rural western Kenya.

DESIGN

This was a population-based prospective cohort.

PARTICIPANTS AND SETTING

Women of childbearing age were followed prospectively to identify pregnancies and ascertain their outcomes in Siaya County, western Kenya. The cohort study was carried out in 33 adjacent villages under health and demographic surveillance.

OUTCOME MEASURE

Miscarriage.

RESULTS

Between 2011 and 2013, among 5536 women of childbearing age, 1453 pregnancies were detected and 1134 were included in the analysis. The cumulative probability was 18.9%. The weekly miscarriage rate declined steadily with increasing gestation until approximately 20 weeks. Known risk factors for miscarriage such as maternal age, gravidity, occupation, household wealth and HIV infection were confirmed.

CONCLUSIONS

This is the first report of weekly miscarriage rates in a rural African setting in the context of high HIV and malaria prevalence. Future studies should consider the involvement of community health workers to identify the pregnancy cohort of early gestation for better data on the actual number of pregnancies and the assessment of miscarriage.

'Some anti-malarials are too strong for your body, they will harm you.' Socio-cultural factors influencing pregnant women's adherence to anti-malarial treatment in rural Gambia

Background

Despite declining prevalence of malaria in The Gambia, non-adherence to anti-malarial treatment still remains a challenge to control efforts. There is limited evidence on the socio-cultural factors that influence adherence to anti-malarial treatment in pregnancy. This study explored perceptions of malaria in pregnancy and their influence on adherence to anti-malarial treatment in a rural area of The Gambia.

Methods

An exploratory ethnographic study was conducted ancillary to a cluster-randomized trial on scheduled screening and treatment of malaria in pregnancy at village level in the Upper River Region of The Gambia from June to August 2014. Qualitative data were collected through interviewing and participant observation. Analysis was concurrent to data collection and carried out using NVivo 10.

Results

Although women had good bio-medical knowledge of malaria in pregnancy, adherence to anti-malarial treatment was generally perceived to be low. Pregnant women were perceived to discontinue the provided anti-malarial treatment after one or 2 days mainly due to non-recognition of symptoms, perceived ineffectiveness of the anti-malarial treatment, the perceived risks of medication and advice received from mothers-in-law.

Conclusion

Improving women’s knowledge of malaria in pregnancy is not sufficient to assure adherence to anti-malarial treatment. Addressing structural barriers such as unclear health workers’ messages about medication dosage, illness recognition, side effects of the medication and the integration of relatives, especially the mothers-in-law, in community-based programmes are additionally required.

Perspectives on the design and methodology of periconceptional nutrient supplementation trials

Periconceptional supplementation could extend the period over which maternal and fetal nutrition is improved, but there are many challenges facing early-life intervention studies. Periconceptional trials differ from pregnancy supplementation trials, not only because of the very early or pre-gestational timing of nutrient exposure but also because they generate subsidiary information on participants who remain non-pregnant. The methodological challenges are more complex although, if well designed, they provide opportunities to evaluate concurrent hypotheses related to the health of non-pregnant women, especially nulliparous adolescents. This review examines the framework of published and ongoing randomised trial designs. Four cohorts typically arise from the periconceptional trial design--two of which are non-pregnant and two are pregnant--and this structure provides assessment options related to pre-pregnant, maternal, pregnancy and fetal outcomes. Conceptually the initial decision for single or micronutrient intervention is central--as is the choice of dosage and content--in order to establish a comparative framework across trials, improve standardisation, and facilitate interpretation of mechanistic hypotheses. Other trial features considered in the review include: measurement options for baseline and outcome assessments; adherence to long-term supplementation; sample size considerations in relation to duration of nutrient supplementation; cohort size for non-pregnant and pregnant cohorts as the latter is influenced by parity selection; integrating qualitative studies and data management issues. Emphasis is given to low resource settings where high infection rates and the possibility of nutrient-infection interactions may require appropriate safety monitoring. The focus is on pragmatic issues that may help investigators planning a periconceptional trial.

What matters to women: a systematic scoping review to identify the processes and outcomes of antenatal care provision that are important to healthy pregnant women

BACKGROUND

Global uptake of antenatal care (ANC) varies widely and is influenced by the value women place on the service they receive. Identifying outcomes that matter to pregnant women could inform service design and improve uptake and effectiveness.

OBJECTIVES

To undertake a systematic scoping review of what women want, need and value in pregnancy.

SEARCH STRATEGY

Eight databases were searched (1994-2015) with no language restriction. Relevant journal contents were tracked via Zetoc.

DATA COLLECTION AND ANALYSIS

An initial analytic framework was constructed with findings from 21 papers, using data-mining techniques, and then developed using meta-ethnographic approaches. The final framework was tested with 17 more papers.

MAIN RESULTS

All continents except Australia were represented. A total of 1264 women were included. The final meta-theme was: Women want and need a positive pregnancy experience, including four subthemes: maintaining physical and sociocultural normality; maintaining a healthy pregnancy for mother and baby (including preventing and treating risks, illness and death); effective transition to positive labour and birth; and achieving positive motherhood (including maternal self-esteem, competence, autonomy). Findings informed a framework for future ANC provision, comprising three equally important domains: clinical practices (interventions and tests); relevant and timely information; and pyschosocial and emotional support; each provided by practitioners with good clinical and interpersonal skills within a high quality health system.

CONCLUSIONS

A positive pregnancy experience matters across all cultural and sociodemographic contexts. ANC guidelines and services should be designed to deliver it, and those providing ANC services should be aware of it at each encounter with pregnant women.

TWEETABLE ABSTRACT

Women around the world want ANC staff and services to help them achieve a positive pregnancy experience.

Periconceptional multiple-micronutrient supplementation and placental function in rural Gambian women: a double-blind, randomized, placebo-controlled trial

BACKGROUND

Maternal micronutrient deficiencies are commonly associated with clinical indicators of placental dysfunction.

OBJECTIVE

We tested the hypothesis that periconceptional multiple-micronutrient supplementation (MMS) affects placental function.

DESIGN

We conducted a double-blind, randomized, placebo-controlled trial of MMS in 17- to 45-y-old Gambian women who were menstruating regularly and within the previous 3 mo. Eligible subjects were pre-randomly assigned to supplementation with the UNICEF/WHO/United Nations University multiple micronutrient preparation (UNIMMAP) or placebo on recruitment and until they reached their first antenatal check-up or for 1 y if they failed to conceive. Primary outcome measures were midgestational indexes of utero-placental vascular-endothelial function [ratio of plasminogen-activator inhibitor (PAI) 1 to PAI-2 and mean uterine-artery resistance index (UtARI)] and placental active transport capacity at delivery [fetal to maternal measles antibody (MMA) ratio].

RESULTS

We recruited 1156 women who yielded 415 pregnancies, of which 376 met all of the inclusion criteria. With adjustment for gestational age at sampling, there were no differences in PAI-1 to PAI-2 or MMA ratios between trial arms, but there was a 0.02-unit reduction in UtARI between 18 and 32 wk of gestation (95% CI: -0.03, -0.00; P = 0.040) in women taking UNIMMAP.

CONCLUSIONS

Placental vascular function was modifiable by periconceptional micronutrient supplementation. However, the effect was small and supplementation did not further affect other variables of placental function. This trial was registered at www.controlled-trials.com as ISRCTN 13687662.

Factors affecting attendance at and timing of formal antenatal care: results from a qualitative study in Madang, Papua New Guinea

BACKGROUND

Appropriate antenatal care (ANC) is key for the health of mother and child. However, in Papua New Guinea (PNG), only a third of women receive any ANC during pregnancy. Drawing on qualitative research, this paper explores the influences on ANC attendance and timing of first visit in the Madang region of Papua New Guinea.

METHODS

Data were collected in three sites utilizing several qualitative methods: free-listing and sorting of terms and definitions, focus group discussions, in-depth interviews, observation in health care facilities and case studies of pregnant women. Respondents included pregnant women, their relatives, biomedical and traditional health providers, opinion leaders and community members.

RESULTS

Although generally reported to be important, respondents' understanding of the procedures involved in ANC was limited. Factors influencing attendance fell into three main categories: accessibility, attitudes to ANC, and interpersonal issues. Although women saw accessibility (distance and cost) as a barrier, those who lived close to health facilities and could easily afford ANC also demonstrated poor attendance. Attitudes were shaped by previous experiences of ANC, such as waiting times, quality of care, and perceptions of preventative care and medical interventions during pregnancy. Interpersonal factors included relationships with healthcare providers, pregnancy disclosure, and family conflict. A desire to avoid repeat clinic visits, ideas about the strength of the fetus and parity were particularly relevant to the timing of first ANC visit.

CONCLUSIONS

This long-term in-depth study (the first of its kind in Madang, PNG) shows how socio-cultural and economic factors influence ANC attendance. These factors must be addressed to encourage timely ANC visits: interventions could focus on ANC delivery in health facilities, for example, by addressing healthcare staff's attitudes towards pregnant women.

Exploring risk perception and attitudes to miscarriage and congenital anomaly in rural Western Kenya

Background

Understanding the socio-cultural context and perceptions of adverse pregnancy outcomes is important for informing the best approaches for public health programs. This article describes the perceptions, beliefs and health-seeking behaviours of women from rural western Kenya regarding congenital anomalies and miscarriages.

Methods

Ten focus group discussions (FGDs) were undertaken in a rural district in western Kenya in September 2010. The FGDs included separate groups consisting of adult women of childbearing age, adolescent girls, recently pregnant women, traditional birth attendants and mothers of children with a birth defect. Participants were selected purposively. A deductive thematic framework approach using the questions from the FGD guides was used to analyse the transcripts.

Results

There was substantial overlap between perceived causes of miscarriages and congenital anomalies and these were broadly categorized into two groups: biomedical and cultural. The biomedical causes included medications, illnesses, physical and emotional stresses, as well as hereditary causes. Cultural beliefs mostly related to the breaking of a taboo or not following cultural norms. Mothers were often stigmatised and blamed following miscarriage, or the birth of a child with a congenital anomaly. Often, women did not seek care following miscarriage unless there was a complication. Most reported that children with a congenital anomaly were neglected either because of lack of knowledge of where care could be sought or because these children brought shame to the family and were hidden from society.

Conclusion

The local explanatory model of miscarriage and congenital anomalies covered many perceived causes within biomedical and cultural beliefs. Some of these fuelled stigmatisation and blame of the mother. Understanding of these beliefs, improving access to information about the possible causes of adverse outcomes, and greater collaboration between traditional healers and healthcare providers may help to reduce stigma and increase access to formal healthcare providers.

Why do women not use antenatal services in low- and middle-income countries? A meta-synthesis of qualitative studies

BACKGROUND

Almost 50% of women in low- and middle-income countries (LMICs) don't receive adequate antenatal care. Women's views can offer important insights into this problem. Qualitative studies exploring inadequate use of antenatal services have been undertaken in a range of countries, but the findings are not easily transferable. We aimed to inform the development of future antenatal care programmes through a synthesis of findings in all relevant qualitative studies.

METHODS AND FINDINGS

Using a predetermined search strategy, we identified robust qualitative studies reporting on the views and experiences of women in LMICs who received inadequate antenatal care. We used meta-ethnographic techniques to generate themes and a line-of-argument synthesis. We derived policy-relevant hypotheses from the findings. We included 21 papers representing the views of more than 1,230 women from 15 countries. Three key themes were identified: "pregnancy as socially risky and physiologically healthy", "resource use and survival in conditions of extreme poverty", and "not getting it right the first time". The line-of-argument synthesis describes a dissonance between programme design and cultural contexts that may restrict access and discourage return visits. We hypothesize that centralised, risk-focused antenatal care programmes may be at odds with the resources, beliefs, and experiences of pregnant women who underuse antenatal services.

CONCLUSIONS

Our findings suggest that there may be a misalignment between current antenatal care provision and the social and cultural context of some women in LMICs. Antenatal care provision that is theoretically and contextually at odds with local contextual beliefs and experiences is likely to be underused, especially when attendance generates increased personal risks of lost family resources or physical danger during travel, when the promised care is not delivered because of resource constraints, and when women experience covert or overt abuse in care settings.

Factors affecting antenatal care attendance: results from qualitative studies in Ghana, Kenya and Malawi

BACKGROUND

Antenatal care (ANC) is a key strategy to improve maternal and infant health. However, survey data from sub-Saharan Africa indicate that women often only initiate ANC after the first trimester and do not achieve the recommended number of ANC visits. Drawing on qualitative data, this article comparatively explores the factors that influence ANC attendance across four sub-Saharan African sites in three countries (Ghana, Kenya and Malawi) with varying levels of ANC attendance.

METHODS

Data were collected as part of a programme of qualitative research investigating the social and cultural context of malaria in pregnancy. A range of methods was employed interviews, focus groups with diverse respondents and observations in local communities and health facilities.

RESULTS

Across the sites, women attended ANC at least once. However, their descriptions of ANC were often vague. General ideas about pregnancy care - checking the foetus' position or monitoring its progress - motivated women to attend ANC; as did, especially in Kenya, obtaining the ANC card to avoid reprimands from health workers. Women's timing of ANC initiation was influenced by reproductive concerns and pregnancy uncertainties, particularly during the first trimester, and how ANC services responded to this uncertainty; age, parity and the associated implications for pregnancy disclosure; interactions with healthcare workers, particularly messages about timing of ANC; and the cost of ANC, including charges levied for ANC procedures - in spite of policies of free ANC - combined with ideas about the compulsory nature of follow-up appointments.

CONCLUSION

In these socially and culturally diverse sites, the findings suggest that 'supply' side factors have an important influence on ANC attendance: the design of ANC and particularly how ANC deals with the needs and concerns of women during the first trimester has implications for timing of initiation.

Social and cultural factors affecting uptake of interventions for malaria in pregnancy in Africa: a systematic review of the qualitative research

Background

Malaria during pregnancy (MiP) results in adverse birth outcomes and poor maternal health. MiP-related morbidity and mortality is most pronounced in sub-Saharan Africa, where recommended MiP interventions include intermittent preventive treatment, insecticide-treated bednets and appropriate case management. Besides their clinical efficacy, the effectiveness of these interventions depends on the attitudes and behaviours of pregnant women and the wider community, which are shaped by social and cultural factors. Although these factors have been studied largely using quantitative methods, qualitative research also offers important insights. This article provides a comprehensive overview of qualitative research on social and cultural factors relevant to uptake of MiP interventions in sub-Saharan Africa.

Methods and Findings

A systematic search strategy was employed: literature searches were undertaken in several databases (OVID SP, IS Web of Knowledge, MiP Consortium library). MiP-related original research, on social/cultural factors relevant to MiP interventions, in Africa, with findings derived from qualitative methods was included. Non-English language articles were excluded. A meta-ethnographic approach was taken to analysing and synthesizing findings. Thirty-seven studies were identified. Fourteen concentrated on MiP. Others focused on malaria treatment and prevention, antenatal care (ANC), anaemia during pregnancy or reproductive loss. Themes identified included concepts of malaria and risk in pregnancy, attitudes towards interventions, structural factors affecting delivery and uptake, and perceptions of ANC.

Conclusions

Although malaria risk is associated with pregnancy, women's vulnerability is often considered less disease-specific and MiP interpreted in locally defined categories. Furthermore, local discourses and health workers' ideas and comments influence concerns about MiP interventions. Understandings of ANC, health worker-client interactions, household decision-making, gender relations, cost and distance to health facilities affect pregnant women's access to MiP interventions and lack of healthcare infrastructure limits provision of interventions. Further qualitative research is however required: many studies were principally descriptive and an in-depth comparative approach is recommended.

Stillbirths: why they matter

In this first paper of The Lancet's Stillbirths Series we explore the present status of stillbirths in the world-from global health policy to a survey of community perceptions in 135 countries. Our findings highlight the need for a strong call for action. In times of global focus on motherhood, the mother's own aspiration of a liveborn baby is not recognised on the world's health agenda. Millions of deaths are not counted; stillbirths are not in the Global Burden of Disease, nor in disability-adjusted life-years lost, and they are not part of the UN Millennium Development Goals. The grief of mothers might be aggravated by social stigma, blame, and marginalisation in regions where most deaths occur. Most stillborn babies are disposed of without any recognition or ritual, such as naming, funeral rites, or the mother holding or dressing the baby. Beliefs in the mother's sins and evil spirits as causes of stillbirth are rife, and stillbirth is widely believed to be a natural selection of babies never meant to live. Stillbirth prevention is closely linked with prevention of maternal and neonatal deaths. Knowledge of causes and feasible solutions for prevention is key to health professionals' priorities, to which this Stillbirths Series paper aims to contribute.

The external Ballard examination does not accurately assess the gestational age of infants born at home in a rural community of The Gambia

Background

Accurate assessment of gestational age at birth is critical to the identification of neonates at high risk. In resource‐poor settings, postnatal techniques are commonly used but may be difficult to apply and have not been well validated against ultrasound in community studies. The aim of this study was to evaluate postnatal assessment of gestational age in rural Africa using the external criteria of the Ballard examination against 1st/early 2nd‐trimester ultrasound and date of last menstrual period.

Method

In a sample of women from Kiang West, The Gambia (n = 80), the precision of gestational age estimates using the external Ballard examination was compared with those derived from 1st and early 2nd‐trimester ultrasound examination and date of last menstrual period.

Results

The incidence of preterm delivery was low at 2.5%. The external Ballard examination tended to underestimate gestational age by a mean (SD) of 15.6 (10.9) days compared with that derived from ultrasound and to underestimate by 15.4 (23.1) days compared with that derived from date of last menstrual period. The differences between the methods varied with gestation.

Conclusion

In this rural, community‐born population of infants, postnatal assessment of gestational age by external Ballard examination performed poorly compared with ultrasound and last menstrual period. No reliable gestational age could be derived from its estimate and it failed to detect a significant proportion of high‐risk infants. The development of an accurate but simple method of postnatally assessing gestational age specifically for use by health workers in rural Africa is required.

Bottlenecks for high coverage of intermittent preventive treatment in pregnancy: the case of adolescent pregnancies in rural Burkina Faso

BACKGROUND

While IPTp-SP is currently being scaled up in sub-Saharan Africa (SSA), the coverage with the required>or=2 doses of SP remains considerably short of the Roll Back Malaria (RBM) goal of 80%, not to mention of the recently advocated universal coverage.

METHODS

The study triangulates quantitative data from a health center randomized community-based trial on IPTp-SP effectiveness and the additional benefit of a promotional campaign with qualitative data from focused ethnography.

FINDINGS

In rural Burkina Faso, despite the significantly higher risk of malaria infection among adolescent primigravidae (PG) (OR 2.44 95%CI 1.81-3.28, p<0.001), making them primary target beneficiaries of IPTp-SP, adolescents adhered to the required three or more ANC visits significantly less (PG: 46.6%; SG 43.7%) than adults (PG: 61.9%; SG 54.9%) and had lower SP uptake during the malaria transmission season, further showing the difficulty of reaching this age group. Adolescents' structural constraints (such as their social position and household labor requirements) and needs (such as anonymity in the health encounter) leave them highly vulnerable during their pregnancies and, especially, during the high malaria transmission season.

CONCLUSION

Our study shows that adolescents need to be targeted specifically, prior to their first pregnancy and with measures adapted to their social context, addressing their structural constraints and needs and going beyond standard health promotion campaigns. Unless such specific measures are taken, adolescents' social vulnerability will present a serious bottleneck for the effectiveness of IPTi-SP.

Between life and death: exploring the sociocultural context of antenatal mental distress in rural Ethiopia

The high prevalence of antenatal common mental disorders in sub-Saharan Africa compared to high-income countries is poorly understood. This qualitative study explored the sociocultural context of antenatal mental distress in a rural Ethiopian community. Five focus group discussions and 25 in-depth interviews were conducted with purposively sampled community stakeholders. Inductive analysis was used to develop final themes. Worry about forthcoming delivery and fears for the woman's survival were prominent concerns of all participants, but only rarely perceived to be pathological in intensity. Sociocultural practices such as continuing physical labour, dietary restriction, prayer and rituals to protect against supernatural attack were geared towards safe delivery and managing vulnerability. Despite strong cultural norms to celebrate pregnancy, participants emphasised that many pregnancies were unwanted and an additional burden on top of pre-existing economic and marital difficulties. Short birth interval and pregnancy out of wedlock were both seen as shameful and potent sources of mental distress. The notion that pregnancy in traditional societies is uniformly a time of joy and happiness is misplaced. Although antenatal mental distress may be self-limiting for many women, in those with enduring life difficulties, including poverty and abusive relationships, poor maternal mental health may persist.

Making stillbirths count, making numbers talk - issues in data collection for stillbirths

BACKGROUND

Stillbirths need to count. They constitute the majority of the world's perinatal deaths and yet, they are largely invisible. Simply counting stillbirths is only the first step in analysis and prevention. From a public health perspective, there is a need for information on timing and circumstances of death, associated conditions and underlying causes, and availability and quality of care. This information will guide efforts to prevent stillbirths and improve quality of care.

DISCUSSION

In this report, we assess how different definitions and limits in registration affect data capture, and we discuss the specific challenges of stillbirth registration, with emphasis on implementation. We identify what data need to be captured, we suggest a dataset to cover core needs in registration and analysis of the different categories of stillbirths with causes and quality indicators, and we illustrate the experience in stillbirth registration from different cultural settings. Finally, we point out gaps that need attention in the International Classification of Diseases and review the qualities of alternative systems that have been tested in low- and middle-income settings.

SUMMARY

Obtaining high-quality data will require consistent definitions for stillbirths, systematic population-based registration, better tools for surveys and verbal autopsies, capacity building and training in procedures to identify causes of death, locally adapted quality indicators, improved classification systems, and effective registration and reporting systems.

Rural Gambian women's reliance on health workers to deliver sulphadoxine-pyrimethamine as recommended intermittent preventive treatment for malaria in pregnancy

Background

The use of most anti-malarial medications is restricted during pregnancy, but two doses of sulphadoxine-pyrimethamine are recommended after the first trimester as intermittent preventive treatment in pregnancy (IPTp). In The Gambia, only 32% of women receive two doses and very little research has been conducted on women's awareness of drug safety during pregnancy. The objective of this paper was to assess whether rural Gambian women were aware of the importance of the timing of the two-dose IPT dose schedule and its relevance to drug safety.

Methods

This was a qualitative study in which 41 interviews and 16 focus group discussions with women, adolescents, men and traditional birth attendants were conducted. A generic qualitative approach was used to generate a theory as to why women might not participate in IPTp as recommended.

Results

Although most women used calendar months to count their stage of pregnancy, these months did not correlate with their concept of foetal development. Foetal growth was described following Islamic tradition as water, clot, piece of meat and human being, although there was little consensus about the order or timing in which these stages occurred. Common signs and conditions of malaria were known. Women were anxious about miscarriage and recognized that some medicines should not be taken in the first trimester, but were urged by men and traditional birth attendants to attend for antenatal care in the first trimester to "start treatment." General knowledge about the purpose of pregnancy medications and when they should be taken was poor among both men and women. One important result was that women relied entirely on health workers to provide safe drugs, at the correct time.

Conclusion

Women did not have relevant information to judge the safety and appropriate timing of pregnancy drugs, which made them over-reliant on health workers. They should be encouraged to date their own pregnancies in culturally relevant terms and to anticipate when and which medications they should receive.

Community-based distribution of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy improved coverage but reduced antenatal attendance in southern Malawi

OBJECTIVE

To evaluate the impact of a 2-year programme for community-based delivery of sulfadoxine-pyrimethamine (SP) on intermittent preventive treatment during pregnancy coverage, antenatal clinic attendance and pregnancy outcome.

METHODS

Fourteen intervention and 12 control villages in the catchment areas of Chikwawa and Ngabu Government Hospitals, southern Malawi, were selected. Village-based community health workers were trained in information, education and counselling on malaria control in pregnancy and the importance of attending antenatal clinics and promoted these messages to pregnant women. In the intervention group community health workers also distributed SP to pregnant women.

RESULTS

In the control area, coverage of intermittent preventive treatment during pregnancy (>2 doses) was low before (44.1%) and during the intervention (46.1%). In the intervention area, coverage increased from 41.5% to 82.9% (P < 0.01). Antenatal clinic attendance (>2 visits) was maintained in control villages at above 90%, but fell in intervention villages from 87.3% to 51.5% (P < 0.01). Post-natal malaria parasitaemia prevalence fell in women from both study areas during the intervention phase (P < 0.05). Increasing the coverage of intermittent preventive treatment during pregnancy to >40% did not significantly improve maternal haemoglobin or reduce low birthweight prevalence.

CONCLUSIONS

Better coverage of community-based intermittent preventive treatment during pregnancy can lower attendance at antenatal clinics; thus its effect on pregnancy outcome and antenatal attendance need to be monitored.

Monitoring and evaluation of malaria in pregnancy - developing a rational basis for control

Monitoring and evaluation of malaria control in pregnancy is essential for assessing the efficacy and effectiveness of health interventions aimed at reducing the major burden of this disease on women living in endemic areas. Yet there is no currently integrated strategic approach on how this should be achieved. Malaria control in pregnancy is formulated in relation to epidemiological patterns of exposure. Current emphasis is on intermittent preventive treatment (IPTp) during pregnancy with sulphadoxine-pyrimethamine in higher transmission areas, combined with insecticide treated bed nets (ITNs) and case management. Emphasis in lower transmission areas is primarily on case management. This paper discusses a rational basis for monitoring and evaluation based on: assessments of therapeutic and prophylactic drug efficacy; proportional reductions in parasite prevalence; seasonal effects; rapid assessment methodologies; birthweight and/or anaemia nomograms; case-coverage methods; maternal mortality indices; operational and programmatic indicators; and safety and pharmacovigilance of antimalarials in pregnancy. These approaches should be incorporated more effectively within National Programmes in order to facilitate surveillance and improve identification of high-risk women. Systems for utilizing routinely collected data should be strengthened, with greater attention to safety and pharmacovigilance with the advent of artemisinin combination therapies, and prospects of inadvertent exposures to artemisinins in the first trimester. Integrating monitoring activities within malaria control, reproductive health and adolescent-friendly services will be critical for implementation. Large-scale operational research is required to further evaluate the validity of currently proposed indicators, and in order to clarify the breadth and scale of implementation to be deployed.