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McCauley M, White S, Bar-Zeev S, Godia P, Mittal P, Zafar S, van den Broek N. Physical morbidity and psychological and social comorbidities at five stages during pregnancy and after childbirth: a multicountry cross-sectional survey. BMJ Open 2022; 12:e050287. [PMID: 35470180 PMCID: PMC9039410 DOI: 10.1136/bmjopen-2021-050287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Maternal morbidity affects millions of women, the burden of which is highest in low resource settings. We sought to explore when this ill-health occurs and is most significant. SETTINGS A descriptive observational cross-sectional study at primary and secondary-level healthcare facilities in India, Pakistan, Kenya and Malawi. PARTICIPANTS Women attending for routine antenatal care, childbirth or postnatal care at the study healthcare facilities. PRIMARY AND SECONDARY OUTCOMES Physical morbidity (infectious, medical, obstetrical), psychological and social comorbidity were assessed at five stages: first half of pregnancy (≤20 weeks), second half of pregnancy (>20 weeks), at birth (within 24 hours of childbirth), early postnatal (day 1-7) and late postnatal (week 2-12). RESULTS 11 454 women were assessed: India (2099), Malawi (2923), Kenya (3145) and Pakistan (3287) with similar numbers assessed at each of the five assessment stages in each country. Infectious morbidity and anaemia are highest in the early postnatal stage (26.1% and 53.6%, respectively). For HIV, malaria and syphilis combined, prevalence was highest in the first half of pregnancy (10.0%). Hypertension, pre-eclampsia and urinary incontinence are most common in the second half of pregnancy (4.6%, 2.1% and 6.6%). Psychological (depression, thoughts of self-harm) and social morbidity (domestic violence, substance misuse) are significant at each stage but most commonly reported in the second half of pregnancy (26.4%, 17.6%, 40.3% and 5.9% respectively). Of all women assessed, maternal morbidity was highest in the second half of pregnancy (81.7%), then the early postnatal stage (80.5%). Across the four countries, maternal morbidity was highest in the second half of pregnancy in Kenya (73.8%) and Malawi (73.8%), and in the early postnatal stage in Pakistan (92.2%) and India (87.5%). CONCLUSIONS Women have significant maternal morbidity across all stages of the continuum of pregnancy and childbirth, and especially in the second half of pregnancy and after childbirth.
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Affiliation(s)
- Mary McCauley
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Department of Obstetrics, Liverpool Women's NHS Foundation Trust,Crown street, Liverpool, UK
| | - Sarah White
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sarah Bar-Zeev
- Department of Obstetrics, Centre for Maternal and Newborn Health, Lilongwe Office, Lilongwe, Malawi
| | - Pamela Godia
- Centre for Maternal and Newborn Health, Nairobi Office, Nairobi, Kenya
| | - Pratima Mittal
- Department of Obstetrics and Gynecology, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Shamsa Zafar
- Fazaia Medical College, Air University, Islamabad, Pakistan
| | - Nynke van den Broek
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Bick D, Ram U, Saravanan P, Temmerman M. New global WHO postnatal guidance is welcome but misses the long-term perspective. Lancet 2022; 399:1578-1580. [PMID: 35378078 DOI: 10.1016/s0140-6736(22)00616-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Debra Bick
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK.
| | - Uma Ram
- Seethapathy Clinic and Hospital, Chennai, Tamil Nadu, India
| | - Ponnusamy Saravanan
- Department of Populations, Evidence and Technologies, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, Medical College, Aga Khan University, Nairobi, Kenya; Department of Public Health and Family Medicine, Ghent University, Ghent, Belgium
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Musabeyezu J, Santos J, Niyigena A, Uwimana A, Hedt-Gauthier B, Boatin AA. Discharge instructions given to women following delivery by cesarean section in Sub-Saharan Africa: A scoping review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000318. [PMID: 36962191 PMCID: PMC10021225 DOI: 10.1371/journal.pgph.0000318] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 03/09/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE A scoping review of discharge instructions for women undergoing cesarean section (c-section) in sub-Saharan Africa (SSA). METHOD Studies were identified from PubMed, Globus Index Medicus, NiPAD, EMBASE, and EBSCO databases. Eligible papers included research based in a SSA country, published in English or French, and containing information on discharge instructions addressing general postnatal care, wound care, planning of future births, or postpartum depression targeted for women delivering by c-section. For analysis, we used the PRISMA guidelines for scoping reviews followed by a narrative synthesis. We assessed quality of evidence using the GRADE system. RESULTS We identified 78 eligible studies; 5 papers directly studied discharge protocols and 73 included information on discharge instructions in the context of a different study objective. 37 studies addressed wound care, with recommendations to return to a health facility for dressing changes and wound checks between 3 days to 6 weeks. 16 studies recommended antibiotic use at discharge, with 5 specifying a particular antibiotic. 19 studies provided recommendations around contraception and family planning, with 6 highlighting intrauterine device placement immediately after birth or 6-weeks postpartum and 6 studies discussing the importance of counselling services. Only 5 studies provided recommendations for the evaluation and management of postpartum depression in c-section patients; these studies screened for depression at 4-8 weeks postpartum and highlighted connections between c-section delivery and the loss of self-esteem as well as connections between emergency c-section delivery and psychiatric morbidity. CONCLUSION Few studies in SSA directly examine discharge protocols and instructions for women following c-section. Those available demonstrate wide variation in recommendations. Research is needed to develop structured evidence-based instructions with clear timelines for women. These instructions should account for financial burden, access to resources, and education of patients and communities.
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Affiliation(s)
| | - Jenna Santos
- Boston College, Boston, MA, United States of America
| | | | - Ange Uwimana
- University of Illinois College of Medicine, Chicago, IL, United States of America
| | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
| | - Adeline A. Boatin
- Harvard Medical School, Boston, MA, United States of America
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States of America
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Thiongo MN, Gichangi PB, Waithaka M, Tsui A, Zimmerman LA, Radloff S, Temmerman M, Ahmed S. Missed opportunities for family planning counselling among postpartum women in eleven counties in Kenya. BMC Public Health 2022; 22:253. [PMID: 35135514 PMCID: PMC8822701 DOI: 10.1186/s12889-022-12623-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 01/18/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Mothers may access medical facilities for their babies and miss opportunities to access family planning (FP) services. This study was undertaken to describe missed opportunities for FP among women within the extended (0-11 months) postpartum period from counties participating in Performance Monitoring and Accountability 2020 (PMA2020) surveys. DESIGN AND SETTING This study analysed cross-sectional household survey data from 11 counties in Kenya between 2014 and 2018. PMA2020 uses questions extracted from the Demographic and Health survey (DHS) and DHS definitions were used. Multivariable logistic regression was used for inferential statistics with p-value of < 0.05 considered to be significant. PARTICIPANTS Women aged 15-49 years from the households visited. PRIMARY OUTCOME MEASURE Missed opportunity for family planning/contraceptives (FP/C) counselling. RESULTS Of the 34,832 women aged 15-49 years interviewed, 10.9% (3803) and 10.8% (3746) were in the period 0-11 months and 12-23 months postpartum respectively, of whom, 38.8 and 39.6% respectively had their previous pregnancy unintended. Overall, 50.4% of women 0-23 months postpartum had missed opportunities for FP/C counselling. Among women who had contact with health care at the facility, 39.2% of women 0-11 months and 44.7% of women 12-23 months had missed opportunities for FP/C counselling. Less than half of the women 0-11 months postpartum (46.5%) and 64.5% of women 12 - 23 months postpartum were using highly efficacious methods. About 27 and 18% of the women 0-11 months and 12 - 23 months postpartum respectively had unmet need for FP/C. Multivariable analysis showed that being low parity and being from the low wealth quintile significantly increased the odds of missed opportunities for FP/C counselling among women in the extended postpartum period, p < 0.05. CONCLUSIONS A large proportion of women have missed opportunities for FP/C counselling within 2 years postpartum. Programs should address these missed opportunities.
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Affiliation(s)
- Mary N Thiongo
- International Centre for Reproductive Health, Mombasa, Kenya
| | | | | | - Amy Tsui
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg school of Public Health, Baltimore, MD, USA
| | - Linnea A Zimmerman
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg school of Public Health, Baltimore, MD, USA
| | - Scott Radloff
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg school of Public Health, Baltimore, MD, USA
| | | | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg school of Public Health, Baltimore, MD, USA
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Sharma B, Christensson K, Bäck L, Karlström A, Lindgren H, Mudokwenyu-Rawdon C, Maimbolwa MC, Laisser RM, Omoni G, Chimwaza A, Mwebaza E, Kiruja J, Hildingsson I. African midwifery students' self-assessed confidence in postnatal and newborn care: A multi-country survey. Midwifery 2021; 101:103051. [PMID: 34153740 DOI: 10.1016/j.midw.2021.103051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 04/08/2021] [Accepted: 05/20/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Majority of maternal and new-born deaths occur within 28 hours and one week after birth. These can be prevented by well-educated midwives. Confidence in postnatal and newborn care skills depend on the quality of midwifery education. OBJECTIVE To assess confidence and its associated factors for basic postnatal and new-born care skills of final year midwifery students , from seven African countries. METHODS A multi-country cross-sectional study where final year midwifery students answered a questionnaire consisting of basic skills of postnatal and newborn care listed by the International Confederation of Midwives. The postnatal care area had 16 and newborn care area had 19 skill statements. The 16 skills of postnatal care were grouped into three domains through principle component analysis (PCA); Basic postnatal care; postnatal complications and educating parents and documentation. The 19 skills under the newborn care area were grouped into three domains; Basic care and care for newborn complications; Support parents for newborn care; and Care for newborns of HIV positive mothers and documentation. RESULTS In total 1408 midwifery students from seven Sub-Saharan countries participated in the study namely; Kenya, Malawi, Tanzania, Uganda, Zambia, Zimbabwe, and Somaliland Overall high confidence for all domains under Post Natal Care ranged from 30%-50% and for Newborn care from 39-55%. High confidence for postnatal skills was not found to be associated with any background variables (Age, sex, type and level of educational programme). High confidence for newborn care was associated with being female students, those aged 26-35 years, students from the direct entry programmes and those enrolled in diploma programmes. CONCLUSIONS Almost half of the study participants expressed lack of confidence for skills under postnatal and newborn care. No association was found between high confidence for domains of postnatal care and background variables. High confidence was associated with being a female, between 26-35 years of age, from direct entry or diploma programmes for newborn care area. The results of the study indicate gaps in midwifery education. Countries could use the ICM list of competencies to develop country specific standards for midwifery education. However, actual competence remains to be measured.
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Affiliation(s)
- Bharati Sharma
- Indian Institute of Public Health Gandhinagar, India; Department of Women's and Children's health, Karolinska Institutet, Stockholm, Sweden.
| | - Kyllike Christensson
- Department of Women's and Children's health, Karolinska Institutet, Stockholm, Sweden
| | - Lena Bäck
- Department of Nursing, Mid Sweden University, Sundsvall, Sweden
| | | | - Helena Lindgren
- Department of Women's and Children's health, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | - Grace Omoni
- School of Nursing Science, University of Nairobi, Kenya
| | | | - Enid Mwebaza
- Jhpiego Johns Hopkins University, Kampala, Uganda
| | - Jonah Kiruja
- Hargeisa University, Somaliland, Africa; Dalarna University, Falun, Sweden
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McCauley M, Zafar S, van den Broek N. Maternal multimorbidity during pregnancy and after childbirth in women in low- and middle-income countries: a systematic literature review. BMC Pregnancy Childbirth 2020; 20:637. [PMID: 33081734 PMCID: PMC7574312 DOI: 10.1186/s12884-020-03303-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 09/30/2020] [Indexed: 01/21/2023] Open
Abstract
Background For every maternal death, 20 to 30 women are estimated to have morbidities related to pregnancy or childbirth. Much of this burden of disease is in women in low- and middle-income countries. Maternal multimorbidity can include physical, psychological and social ill-health. Limited data exist about the associations between these morbidities. In order to address all health needs that women may have when attending for maternity care, it is important to be able to identify all types of morbidities and understand how each morbidity influences other aspects of women’s health and wellbeing during pregnancy and after childbirth. Methods We systematically reviewed published literature in English, describing measurement of two or more types of maternal morbidity and/or associations between morbidities during pregnancy or after childbirth for women in low- and middle-income countries. CINAHL plus, Global Health, Medline and Web of Science databases were searched from 2007 to 2018. Outcomes were descriptions, occurrence of all maternal morbidities and associations between these morbidities. Narrative analysis was conducted. Results Included were 38 papers reporting about 36 studies (71,229 women; 60,911 during pregnancy and 10,318 after childbirth in 17 countries). Most studies (26/36) were cross-sectional surveys. Self-reported physical ill-health was documented in 26 studies, but no standardised data collection tools were used. In total, physical morbidities were included in 28 studies, psychological morbidities in 32 studies and social morbidities in 27 studies with three studies assessing associations between all three types of morbidity and 30 studies assessing associations between two types of morbidity. In four studies, clinical examination and/or basic laboratory investigations were also conducted. Associations between physical and psychological morbidities were reported in four studies and between psychological and social morbidities in six. Domestic violence increased risks of physical ill-health in two studies. Conclusions There is a lack of standardised, comprehensive and routine measurements and tools to assess the burden of maternal multimorbidity in women during pregnancy and after childbirth. Emerging data suggest significant associations between the different types of morbidity. Systematic review registration number PROSPERO CRD42018079526.
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Affiliation(s)
- Mary McCauley
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Shamsa Zafar
- Fazaia Medical College, Air University, Islamabad, Pakistan
| | - Nynke van den Broek
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
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Masha SC, Wahome E, Vaneechoutte M, Cools P, Crucitti T, Sanders EJ. High prevalence of curable sexually transmitted infections among pregnant women in a rural county hospital in Kilifi, Kenya. PLoS One 2017; 12:e0175166. [PMID: 28362869 PMCID: PMC5375155 DOI: 10.1371/journal.pone.0175166] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/21/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Women attending antenatal care (ANC) in resource-limited countries are frequently screened for syphilis and HIV, but rarely for other sexually transmitted infections (STIs). We assessed the prevalence of curable STIs, defined as infection with either Chlamydia trachomatis or Neisseria gonorrhoeae or Trichomonas vaginalis, from July to September 2015. METHODS In a cross-sectional study, women attending ANC at the Kilifi County Hospital, Kenya, had a urine sample tested for C. trachomatis/N. gonorrhoeae by GeneXpert® and a vaginal swab for T. vaginalis by culture. Bacterial vaginosis (BV) was defined as a Nugent score of 7-10 of the Gram stain of a vaginal smear in combination with self-reported vaginal discharge. Genital ulcers were observed during collection of vaginal swabs. All women responded to questions on socio-demographics and sexual health and clinical symptoms of STIs. Predictors for curable STIs were assessed in multivariable logistic regression. RESULTS A total of 42/202 (20.8%, 95% confidence interval (CI):15.4-27.0) women had a curable STI. The prevalence was 14.9% for C. trachomatis (95% CI:10.2-20.5), 1.0% for N. gonorrhoeae (95% CI: 0.1-3.5), 7.4% for T. vaginalis (95% CI:4.2-12.0), 19.3% for BV (95% CI: 14.1-25.4) and 2.5% for genital ulcers (95% CI: 0.8-5.7). Predictors for infection with curable STIs included women with a genital ulcer (adjusted odds ratio (AOR) = 35.0, 95% CI: 2.7-461.6) compared to women without a genital ulcer, women who used water for cleaning after visiting the toilet compared to those who used toilet paper or other solid means (AOR = 4.1, 95% CI:1.5-11.3), women who reported having sexual debut ≤ 17 years compared to women having sexual debut ≥18 years (AOR = 2.7, 95% CI:1.1-6.6), and BV-positive women (AOR = 2.7, 95% CI:1.1-6.6) compared to BV-negative women. CONCLUSION One in five women attending ANC had a curable STI. These infections were associated with genital ulcers, hygiene practices, early sexual debut and bacterial vaginosis.
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Affiliation(s)
- Simon Chengo Masha
- Centre for Geographic Medicine Research–Coast, Kenya Medical Research Institute (KEMRI), Kilifi, Kenya
- Laboratory Bacteriology Research, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Pwani University, Faculty of Pure and Applied Sciences, Department of Biological Sciences, Kilifi, Kenya
| | - Elizabeth Wahome
- Centre for Geographic Medicine Research–Coast, Kenya Medical Research Institute (KEMRI), Kilifi, Kenya
| | - Mario Vaneechoutte
- Laboratory Bacteriology Research, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Piet Cools
- Laboratory Bacteriology Research, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Tania Crucitti
- HIV/STI Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Eduard J. Sanders
- Centre for Geographic Medicine Research–Coast, Kenya Medical Research Institute (KEMRI), Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Headington, United Kingdom
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Zafar S, Jean-Baptiste R, Rahman A, Neilson JP, van den Broek NR. Non-Life Threatening Maternal Morbidity: Cross Sectional Surveys from Malawi and Pakistan. PLoS One 2015; 10:e0138026. [PMID: 26390124 PMCID: PMC4577127 DOI: 10.1371/journal.pone.0138026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 08/24/2015] [Indexed: 12/02/2022] Open
Abstract
Background For more accurate estimation of the global burden of pregnancy associated disease, clarity is needed on definition and assessment of non-severe maternal morbidity. Our study aimed to define maternal morbidity with clear criteria for identification at primary care level and estimate the distribution of and evaluate associations between physical (infective and non-infective) and psychological morbidities in two different low-income countries. Methods Cross sectional study with assessment of morbidity in early pregnancy (34%), late pregnancy (35%) and the postnatal period (31%) among 3459 women from two rural communities in Pakistan (1727) and Malawi (1732). Trained health care providers at primary care level used semi-structured questionnaires documenting signs and symptoms, clinical examination and laboratory tests which were bundled to reflect infectious, non-infectious and psychological morbidity. Results One in 10 women in Malawi and 1 in 5 in Pakistan reported a previous pregnancy complication with 1 in 10 overall reporting a previous neonatal death or stillbirth. In the index pregnancy, 50.1% of women in Malawi and 53% in Pakistan were assessed to have at least one morbidity (infective or non-infective). Both infective (Pakistan) and non-infective morbidity (Pakistan and Malawi) was lower in the postnatal period than during pregnancy. Multiple morbidities were uncommon (<10%). There were marked differences in psychological morbidity: 26.9% of women in Pakistan 2.6% in Malawi had an Edinburgh Postnatal Depression Score (EPDS) > 9. Complications during a previous pregnancy, infective morbidity (p <0.001), intra or postpartum haemorrhage (p <0.02) were associated with psychological morbidity in both settings. Conclusions Our findings highlight the need to strengthen the availability and quality of antenatal and postnatal care packages. We propose to adapt and improve the framework and criteria used in this study, ensuring a basic set of diagnostic tests is available, to ensure more robust assessment of non-severe maternal morbidity.
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Affiliation(s)
| | | | - Atif Rahman
- Department of Mental Health and Well-Being, University of Liverpool, Liverpool, United Kingdom
| | - James P. Neilson
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Nynke R. van den Broek
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
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Duysburgh E, Kerstens B, Kouanda S, Kaboré CP, Belemsaga Yugbare D, Gichangi P, Masache G, Crahay B, Gondola Sitefane G, Bique Osman N, Foia S, Barros H, Castro Lopes S, Mann S, Nambiar B, Colbourn T, Temmerman M. Opportunities to improve postpartum care for mothers and infants: design of context-specific packages of postpartum interventions in rural districts in four sub-Saharan African countries. BMC Pregnancy Childbirth 2015; 15:131. [PMID: 26038100 PMCID: PMC4453099 DOI: 10.1186/s12884-015-0562-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 05/18/2015] [Indexed: 12/04/2022] Open
Abstract
Background Postpartum maternal and infant mortality is high in sub-Saharan Africa and improving postpartum care as a strategy to enhance maternal and infant health has been neglected. We describe the design and selection of suitable, context-specific interventions that have the potential to improve postpartum care. Methods The study is implemented in rural districts in Burkina Faso, Kenya, Malawi and Mozambique. We used the four steps ‘systems thinking’ approach to design and select interventions: 1) we conducted a stakeholder analysis to identify and convene stakeholders; 2) we organised stakeholders causal analysis workshops in which the local postpartum situation and challenges and possible interventions were discussed; 3) based on comprehensive needs assessment findings, inputs from the stakeholders and existing knowledge regarding good postpartum care, a list of potential interventions was designed, and; 4) the stakeholders selected and agreed upon final context-specific intervention packages to be implemented to improve postpartum care. Results Needs assessment findings showed that in all study countries maternal, newborn and child health is a national priority but specific policies for postpartum care are weak and there is very little evidence of effective postpartum care implementation. In the study districts few women received postpartum care during the first week after childbirth (25 % in Burkina Faso, 33 % in Kenya, 41 % in Malawi, 40 % in Mozambique). Based on these findings the interventions selected by stakeholders mainly focused on increasing the availability and provision of postpartum services and improving the quality of postpartum care through strengthening postpartum services and care at facility and community level. This includes the introduction of postpartum home visits, strengthening postpartum outreach services, integration of postpartum services for the mother in child immunisation clinics, distribution of postpartum care guidelines among health workers and upgrading postpartum care knowledge and skills through training. Conclusion There are extensive gaps in availability and provision of postpartum care for mothers and infants. Acknowledging these gaps and involving relevant stakeholders are important to design and select sustainable, context-specific packages of interventions to improve postpartum care.
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Affiliation(s)
- Els Duysburgh
- International Centre for Reproductive Health, Department of uro-gynaecology, Ghent University, De Pintelaan 185 P3, 9000, Ghent, Belgium.
| | - Birgit Kerstens
- International Centre for Reproductive Health, Department of uro-gynaecology, Ghent University, De Pintelaan 185 P3, 9000, Ghent, Belgium.
| | - Seni Kouanda
- Institut de Recherche en Sciences et de la Santé, P.O. Box 7192, Ouagadougou, 03, Burkina Faso.
| | - Charles Paulin Kaboré
- Institut de Recherche en Sciences et de la Santé, P.O. Box 7192, Ouagadougou, 03, Burkina Faso.
| | | | - Peter Gichangi
- International Centre of Reproductive Health Kenya, Obote Avenue - Tudor Estate, P.O. Box 91109, 80103, Mombasa, Kenya.
| | - Gibson Masache
- Parent and Child Health Initiative Trust, P.O. Box 31686, Lilongwe, 3, Malawi.
| | - Beatrice Crahay
- International Centre of Reproductive Health Mozambique, Av. Maquiguana, Praceta 1607, Prédio 100, 1 Andar, Maputo, Mozambique.
| | - Gilda Gondola Sitefane
- International Centre of Reproductive Health Mozambique, Av. Maquiguana, Praceta 1607, Prédio 100, 1 Andar, Maputo, Mozambique.
| | - Nafissa Bique Osman
- Eduardo Mondlane University, Faculdade de Medicina, Av. Salvador Allende 702, Maputo, Mozambique.
| | - Severiano Foia
- Eduardo Mondlane University, Faculdade de Medicina, Av. Salvador Allende 702, Maputo, Mozambique.
| | - Henrique Barros
- Department of Hygiene and Epidemiology, Faculdade de Medicina da Universidade do Porto, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal.
| | - Sofia Castro Lopes
- Department of Hygiene and Epidemiology, Faculdade de Medicina da Universidade do Porto, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal.
| | - Susan Mann
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Bejoy Nambiar
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Tim Colbourn
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Marleen Temmerman
- International Centre for Reproductive Health, Department of uro-gynaecology, Ghent University, De Pintelaan 185 P3, 9000, Ghent, Belgium. .,Department of Reproductive Health and Research, World Health Organisation, Avenue Appia 20, 1211, Geneva, 27, Switzerland.
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Vanderkruik RC, Tunçalp Ö, Chou D, Say L. Framing maternal morbidity: WHO scoping exercise. BMC Pregnancy Childbirth 2013; 13:213. [PMID: 24252359 PMCID: PMC3840647 DOI: 10.1186/1471-2393-13-213] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 11/13/2013] [Indexed: 11/23/2022] Open
Abstract
Background Maternal morbidity estimations are not based on well-documented methodologies and thus have limited validity for informing efforts to address the issue and improve maternal health. To fill this gap, maternal morbidity needs to be clearly defined, driving the development of tools and indicators to measure and monitor maternal health. This article describes the scoping exercise conducted by the World Health Organization’s Department of Reproductive of Health and Research (WHO/RHR), as an essential first step in this process. Methods A literature review was conducted to identify the range of definitions and conditions included in various studies of maternal morbidity with a special focus on the similarities and discrepancies of the definitions used across the studies. Furthermore a questionnaire was developed which included sections on key areas identified during the review and was sent out electronically to 130 international experts in the field of maternal health. Results Maternal morbidities have been categorized in a variety of ways based on the causes, types of complications, and/or timeline. Issues regarding the time frame, severity, identification and classification and demographics were identified as key areas in the literature that require further investigation to achieve consensus on a maternal morbidity definition. Fifty-five (N = 55) individuals responded with completed questionnaires. Respondents’ views on the time frame for the postpartum period varied from 6 weeks to beyond one year postpartum, it was noted that time frame depended on the type of complication. The majority of respondents said maternal morbidity should comprise a continuum of severity, whereas the identification of the cases should use a mixed criteria employing multiple methods. Conclusions Significant discrepancy in literature and expert opinion exists concerning elements of a maternal morbidity definition. There is a clear need for a concrete definition that would allow for consistent measurement and monitoring of maternal morbidity across settings and time.
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Affiliation(s)
- Rachel C Vanderkruik
- Department of Applied Research and Evaluation, National Initiative for Children's Healthcare Quality (NICHQ), Boston, MA, USA.
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Sartorius BKD, Chersich MF, Mwaura M, Meda N, Temmerman M, Newell ML, Farley TMM, Luchters S. Maternal anaemia and duration of zidovudine in antiretroviral regimens for preventing mother-to-child transmission: a randomized trial in three African countries. BMC Infect Dis 2013; 13:522. [PMID: 24192332 PMCID: PMC3829097 DOI: 10.1186/1471-2334-13-522] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 10/22/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although substantiated by little evidence, concerns about zidovudine-related anaemia in pregnancy have influenced antiretroviral (ARV) regimen choice for preventing mother-to-child transmission of HIV-1, especially in settings where anaemia is common. METHODS Eligible HIV-infected pregnant women in Burkina Faso, Kenya and South Africa were followed from 28 weeks of pregnancy until 12-24 months after delivery (n = 1070). Women with a CD4 count of 200-500 cells/mm(3) and gestational age 28-36 weeks were randomly assigned to zidovudine-containing triple-ARV prophylaxis continued during breastfeeding up to 6-months, or to zidovudine during pregnancy plus single-dose nevirapine (sd-NVP) at labour. Additionally, two cohorts were established, women with CD4 counts: <200 cells/mm(3) initiated antiretroviral therapy, and >500 cells/mm(3) received zidovudine during pregnancy plus sd-NVP at labour. Mild (haemoglobin 8.0-10.9 g/dl) and severe anaemia (haemoglobin < 8.0 g/dl) occurrence were assessed across study arms, using Kaplan-Meier and multivariable Cox proportional hazards models. RESULTS At enrolment (corresponded to a median 32 weeks gestation), median haemoglobin was 10.3 g/dl (IQR = 9.2-11.1). Severe anaemia occurred subsequently in 194 (18.1%) women, mostly in those with low baseline haemoglobin, lowest socio-economic category, advanced HIV disease, prolonged breastfeeding (≥ 6 months) and shorter ARV exposure. Severe anaemia incidence was similar in the randomized arms (equivalence P-value = 0.32). After 1-2 months of ARV's, severe anaemia was significantly reduced in all groups, though remained highest in the low CD4 cohort. CONCLUSIONS Severe anaemia occurs at a similar rate in women receiving longer triple zidovudine-containing regimens or shorter prophylaxis. Pregnant women with pre-existing anaemia and advanced HIV disease require close monitoring. TRIAL REGISTRATION NUMBER ISRCTN71468401.
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Affiliation(s)
| | | | | | | | | | | | | | - Stanley Luchters
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Poverty and postnatal depression: a systematic mapping of the evidence from low and lower middle income countries. Health Place 2012; 18:1188-97. [DOI: 10.1016/j.healthplace.2012.05.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 02/10/2012] [Accepted: 05/19/2012] [Indexed: 02/07/2023]
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13
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Storeng KT, Drabo S, Ganaba R, Sundby J, Calvert C, Filippi V. Mortality after near-miss obstetric complications in Burkina Faso: medical, social and health-care factors. Bull World Health Organ 2012; 90:418-425B. [PMID: 22690031 PMCID: PMC3370364 DOI: 10.2471/blt.11.094011] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 11/18/2011] [Accepted: 01/23/2012] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To investigate mortality in women in Burkina Faso in the 4 years following a life-threatening near-miss obstetric complication and to identify the medical, social and health-care-related causes of death. METHODS In total, 1014 women were recruited after hospital discharge and followed for up to 4 years: 337 had near-miss complications and 677 had uncomplicated pregnancies. Significant differences in mortality between the groups were assessed using Fisher's exact test. The medical causes of death were identified from medical records and verbal autopsy data; social and health-care-related factors associated with death were identified from interviews with the deceased women's relatives. FINDINGS In the 4 years, 15 (5.3%) women died in the near-miss group and 5 (0.9%) died after uncomplicated pregnancies (P < 0.001). More than half the deaths after a near miss, but none after an uncomplicated delivery, were pregnancy-related. Indirect factors contributed to many of these deaths, particularly human immunodeficiency virus infection. Relatives' accounts suggested that the high cost and poor quality of health care, a lack of follow-up care and an unmet need for contraception contributed to the excess mortality in the near-miss group. CONCLUSION Women in Burkina Faso who initially survived a near-miss obstetric complication had an increased risk of all-cause and pregnancy-related death in the ensuing 4 years. The likelihood of survival over the longer term could be increased by offering a continuum of care that addresses the indirect and social causes of death and supplements the emergency intrapartum obstetric care provided by current safe motherhood programmes.
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Affiliation(s)
- Katerini T Storeng
- Centre for Development and the Environment, University of Oslo, PB 1116 Blindern, Oslo 0317, Norway.
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Changes in sexual behaviour among HIV-infected women in west and east Africa in the first 24 months after delivery. AIDS 2012; 26:997-1007. [PMID: 22343965 DOI: 10.1097/qad.0b013e3283524ca1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Describe changes in sexual behaviour and determinants of unsafe sex among HIV-infected women in the 24 months after delivery. DESIGN Cohort analysis nested within a prevention of mother-to-child transmission trial in Burkina Faso (n = 339) and Kenya (n = 432). METHODS Women were followed during pregnancy and until 12-24 months after delivery. At each visit, structured questionnaires were administered about sexual activity and condom use, and risk-reduction counselling and condoms were provided. RESULTS At study entry, a median 2 months after HIV testing (interquartile range =1-4), 411/770 (53.4%) of women reported partner disclosure, increasing to 284/392 (71.9%) at the final visit. Although most partners were supportive following disclosure, between 5 and 10% of disclosed women experienced hostile or unsupportive partner responses during follow-up visits. At each visit, about a third of sexually active women reported unsafe sex (unprotected sex with HIV-uninfected or unknown status partner). In multivariable logistic regression, unsafe sex was 1.70-fold more likely in Kenyan than in Burkinabe women [95% confidence interval (95% CI) = 1.14-2.54], and in those with less advanced HIV disease or aged 16-24 years. Compared with women who disclosed their status to partners and others, unsafe sex was over six-fold higher in nondisclosers (95% CI = 3.31-12.11), the effect size reducing with increasing disclosure. CONCLUSION HIV-infected women who recently delivered have a high potential for further HIV transmission, especially as HIV discordance is common in Africa. Longitudinal care for women, including positive-prevention interventions, is needed within new services providing antiretroviral prophylaxis during breastfeeding - this repeated interface with services could focus on reducing unsafe sex. Much remains unknown about how to facilitate beneficial disclosure.
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Tsui AO, McDonald-Mosley R, Burke AE. Family planning and the burden of unintended pregnancies. Epidemiol Rev 2010; 32:152-74. [PMID: 20570955 PMCID: PMC3115338 DOI: 10.1093/epirev/mxq012] [Citation(s) in RCA: 241] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2010] [Indexed: 01/09/2023] Open
Abstract
Family planning is hailed as one of the great public health achievements of the last century, and worldwide acceptance has risen to three-fifths of exposed couples. In many countries, however, uptake of modern contraception is constrained by limited access and weak service delivery, and the burden of unintended pregnancy is still large. This review focuses on family planning's efficacy in preventing unintended pregnancies and their health burden. The authors first describe an epidemiologic framework for reproductive behavior and pregnancy intendedness and use it to guide the review of 21 recent, individual-level studies of pregnancy intentions, health outcomes, and contraception. They then review population-level studies of family planning's relation to reproductive, maternal, and newborn health benefits. Family planning is documented to prevent mother-child transmission of human immunodeficiency virus, contribute to birth spacing, lower infant mortality risk, and reduce the number of abortions, especially unsafe ones. It is also shown to significantly lower maternal mortality and maternal morbidity associated with unintended pregnancy. Still, a new generation of research is needed to investigate the modest correlation between unintended pregnancy and contraceptive use rates to derive the full health benefits of a proven and cost-effective reproductive technology.
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Affiliation(s)
- Amy O Tsui
- Population, Family and Reproductive Health Department, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, W4041, Baltimore, MD 21205, USA.
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