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Mehay A, Motta GD, Hunter L, Rayment J, Wiggins M, Haora P, McCourt C, Harden A. What are the mechanisms of effect of group antenatal care? A systematic realist review and synthesis of the literature. BMC Pregnancy Childbirth 2024; 24:625. [PMID: 39354405 PMCID: PMC11446066 DOI: 10.1186/s12884-024-06792-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 08/28/2024] [Indexed: 10/03/2024] Open
Abstract
BACKGROUND There is growing interest in the benefits of group models of antenatal care. Although clinical reviews exist, there have been few reviews that focus on the mechanisms of effect of this model. METHODS We conducted a realist review using a systematic approach incorporating all data types (including non-research and audiovisual media), with synthesis along Context-Intervention-Mechanism-Outcome (CIMO) configurations. RESULTS A wide range of sources were identified, yielding 100 relevant sources in total (89 written and 11 audiovisual). Overall, there was no clear pattern of 'what works for whom, in what circumstances' although some studies have identified clinical benefits for those with more vulnerability or who are typically underserved by standard care. Findings revealed six interlinking mechanisms, including: social support, peer learning, active participation in health, health education and satisfaction or engagement with care. A further, relatively under-developed theory related to impact on professional practice. An overarching mechanism of empowerment featured across most studies but there was variation in how this was collectively or individually conceptualised and applied. CONCLUSIONS Mechanisms of effect are amplified in contexts where inequalities in access and delivery of care exist, but poor reporting of populations and contexts limited fuller exploration. We recommend future studies provide detailed descriptions of the population groups involved and that they give full consideration to theoretical underpinnings and contextual factors. REGISTRATION The protocol for this realist review was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42016036768).
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Affiliation(s)
- Anita Mehay
- School of Health and Psychological Sciences, City, University of London, Myddelton Street, London, EC1R 1UW, UK.
| | - Giordana Da Motta
- School of Health and Psychological Sciences, City, University of London, Myddelton Street, London, EC1R 1UW, UK
| | | | - Juliet Rayment
- School of Health and Psychological Sciences, City, University of London, Myddelton Street, London, EC1R 1UW, UK
| | | | - Penny Haora
- University of Queensland, Brisbane, Australia
| | - Christine McCourt
- School of Health and Psychological Sciences, City, University of London, Myddelton Street, London, EC1R 1UW, UK
| | - Angela Harden
- School of Health and Psychological Sciences, City, University of London, Myddelton Street, London, EC1R 1UW, UK
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Kukula VA, Awini E, Ghosh B, Apetorgbor V, Zielinski R, Amankwah G, Ofosu WK, James K, Williams JEO, Lori JR, Moyer CA. Effect of group antenatal care versus individualized antenatal care on birth preparedness and complication readiness: a cluster randomized controlled study among pregnant women in Eastern Region of Ghana. BMC Pregnancy Childbirth 2024; 24:546. [PMID: 39152408 PMCID: PMC11328422 DOI: 10.1186/s12884-024-06743-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 08/07/2024] [Indexed: 08/19/2024] Open
Abstract
BACKGROUND As utilization of individual antenatal care (I-ANC) has increased throughout sub-Saharan Africa, questions have arisen about whether individual versus group-based care might yield better outcomes. We implemented a trial of group-based antenatal care (G-ANC) to determine its impact on birth preparedness and complication readiness (BPCR) among pregnant women in Ghana. METHODS We conducted a cluster randomized controlled trial comparing G-ANC to routine antenatal care in 14 health facilities in the Eastern Region of Ghana. We recruited women in their first trimester to participate in eight two-hour interactive group sessions throughout their pregnancies. Meetings were facilitated by midwives trained in G-ANC methods, and clinical assessments were conducted in addition to group discussions and activities. Data were collected at five timepoints, and results are presented comparing baseline (T0) to 34 weeks' gestation to 3 weeks post-delivery (T1) for danger sign recognition, an 11-point additive scale of BPCR, as well as individual items comprising the scale. RESULTS 1285 participants completed T0 and T1 assessments (N = 668 I-ANC, N = 617, G-ANC). At T1, G-ANC participants were able to identify significantly more pregnancy danger signs than I-ANC participants (mean increase from 1.8 to 3.4 in G-ANC vs. 1.7 to 2.2 in I-ANC, p < 0.0001). Overall BPCR scores were significantly greater in the G-ANC group than the I-ANC group. The elements of BPCR that showed the greatest increases included arranging for emergency transport (I-ANC increased from 1.5 to 11.5% vs. G-ANC increasing from 2 to 41% (p < 0.0001)) and saving money for transportation (19-32% in the I-ANC group vs. 19-73% in the G-ANC group (p < 0.0001)). Identifying someone to accompany the woman to the facility rose from 1 to 3% in the I-ANC group vs. 2-20% in the G-ANC group (p < 0.001). CONCLUSIONS G-ANC significantly increased BPCR among women in rural Eastern Region of Ghana when compared to routine antenatal care. Given the success of this intervention, future efforts that prioritize the implementation of G-ANC are warranted. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04033003 (25/07/2019). PROTOCOL AVAILABLE Protocol Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9508671/ .
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Affiliation(s)
- Vida A Kukula
- Dodowa Health Research Center, Ghana Health Service, Dodowa, Ghana
| | - Elizabeth Awini
- Dodowa Health Research Center, Ghana Health Service, Dodowa, Ghana
| | - Bidisha Ghosh
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | | | - Ruth Zielinski
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | | | - Winfred K Ofosu
- Regional Health Directorate, Ghana Health Service, Koforidua, Eastern Region, Ghana
| | - Katherine James
- Regional Health Directorate, Ghana Health Service, Koforidua, Eastern Region, Ghana
| | | | - Jody R Lori
- Dodowa Health Research Center, Ghana Health Service, Dodowa, Ghana
| | - Cheryl A Moyer
- University of Michigan Medical School, Ann Arbor, MI, USA.
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Zielinski R, Abdelnabi S, Amankwah G, Kukula VA, Apetorgbor V, Awini E, Williams J, Moyer C, Ghosh B, Lori JR. Knowledge, Acceptance, and Uptake of Family Planning: A Cluster Randomized Controlled Trial of Group Antenatal Care in Ghana. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:1025. [PMID: 39200636 PMCID: PMC11355032 DOI: 10.3390/ijerph21081025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/29/2024] [Accepted: 07/31/2024] [Indexed: 09/02/2024]
Abstract
The use of family planning (FP) methods significantly contributes to improved outcomes for mothers and their offspring. However, the use of FP remains low, particularly in low- and middle-income countries. A cluster randomized controlled clinical trial was implemented in Ghana, comparing group antenatal care (ANC) with routine care. The group ANC intervention included eight meetings where the seventh group meeting incorporated information and discussion regarding methods of FP. Data collection occurred at five time points: baseline (T0), 34 weeks' gestation (T1), 6-12 weeks post birth (T2), 5-8 months post birth, and 11-14 months post birth (T4). At T1, there was a significantly greater increase in the knowledge of FP methods as well as the intention to use FP after the birth among the intervention group. The uptake of FP was significantly higher in the intervention group for all post-birth timepoints except for T4 where the control group had significantly higher rates. The reasons for the diminishing effect are unclear. An increasing uptake of FP methods requires a multifaceted approach that includes increasing accessibility, knowledge, and acceptability as well as addressing societal and cultural norms.
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Affiliation(s)
- Ruth Zielinski
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, 400 North Ingalls, Ann Arbor, MI 48109, USA; (S.A.); (B.G.); (J.R.L.)
| | - Samia Abdelnabi
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, 400 North Ingalls, Ann Arbor, MI 48109, USA; (S.A.); (B.G.); (J.R.L.)
| | - Georgina Amankwah
- Dodowa Health Research Center, Ghana Health Service, Dodowa P.O. Box DD1, Greater Accra Region, Ghana; (G.A.); (V.A.K.); (V.A.); (E.A.); (J.W.)
| | - Vida A. Kukula
- Dodowa Health Research Center, Ghana Health Service, Dodowa P.O. Box DD1, Greater Accra Region, Ghana; (G.A.); (V.A.K.); (V.A.); (E.A.); (J.W.)
| | - Veronica Apetorgbor
- Dodowa Health Research Center, Ghana Health Service, Dodowa P.O. Box DD1, Greater Accra Region, Ghana; (G.A.); (V.A.K.); (V.A.); (E.A.); (J.W.)
| | - Elizabeth Awini
- Dodowa Health Research Center, Ghana Health Service, Dodowa P.O. Box DD1, Greater Accra Region, Ghana; (G.A.); (V.A.K.); (V.A.); (E.A.); (J.W.)
| | - John Williams
- Dodowa Health Research Center, Ghana Health Service, Dodowa P.O. Box DD1, Greater Accra Region, Ghana; (G.A.); (V.A.K.); (V.A.); (E.A.); (J.W.)
| | - Cheryl Moyer
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
| | - Bidisha Ghosh
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, 400 North Ingalls, Ann Arbor, MI 48109, USA; (S.A.); (B.G.); (J.R.L.)
| | - Jody R. Lori
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, 400 North Ingalls, Ann Arbor, MI 48109, USA; (S.A.); (B.G.); (J.R.L.)
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Casella Jean-Baptiste M, Julmisse M, Adeyemo OO, Vital Julmiste TM, Illuzzi JL. Integrated group antenatal and pediatric care in Haiti: A comprehensive care accompaniment model. PLoS One 2024; 19:e0300908. [PMID: 38995942 PMCID: PMC11244772 DOI: 10.1371/journal.pone.0300908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 06/17/2024] [Indexed: 07/14/2024] Open
Abstract
INTRODUCTION The J9 Plus (J9) maternal-child accompaniment program is based on four pillars: group antenatal care (GANC), group pediatric care, psychosocial support, and community-based care. We aimed to evaluate the impact of the J9 model of care on perinatal outcomes. METHODOLOGY We conducted a convergent mixed methods study of maternal-newborn dyads born in 2019 at Hôpital Universitaire de Mirebalais. Quantitative data was collected retrospectively to compare dyads receiving J9 care to usual care. A secondary analysis of qualitative data described patient perspectives of J9 care. RESULTS Antenatal care attendance was significantly higher among women in J9 (n = 524) compared to usual care (n = 523), with 490(93%) and 189(36%) having >4 visits, respectively; p <0.001, as was post-partum visit attendance [271(52%) compared to 84(16%), p<0.001] and use of post-partum family planning methods [98(19%) compared to 47(9%), p = 0.003]. Incidence of pre-eclampsia with severe features was significantly lower in the J9 group [44(9%)] compared to the usual care group [73(14%)], p <0.001. Maternal and neonatal mortality and low birth weight did not differ across groups. Cesarean delivery [103(20%) and 82(16%), p<0.001] and preterm birth [118 (24%)] and 80 (17%), p <0.001] were higher in the J9 group compared to usual care, respectively. In the qualitative analysis, ease of access to high-quality care, meaningful social support, and maternal empowerment through education were identified as key contributors to these outcomes. CONCLUSION Compared to usual care, the J9 Plus maternal-child accompaniment model of care is associated with increased engagement in antenatal and postpartum care, increased utilization of post-partum family planning, and lower incidence of pre-eclampsia with severe features, which remains a leading cause of maternal mortality in Haiti. The J9 accompaniment approach to care is an empowering model that has the potential to be replicated in similar settings to improve quality of care and outcomes globally.
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Affiliation(s)
| | - Marc Julmisse
- Executive Direction, Zanmi Lasante/ Partners In Health, Mirebalais, Haiti
| | - Oluwatosin O. Adeyemo
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, United States of America
| | | | - Jessica L. Illuzzi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, United States of America
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Casella Jean-Baptiste M, Vital Julmiste TM, Ball E. Health Information System Strengthening During Antenatal Care in Haiti: Continuous Quality Improvement Study. JMIR Form Res 2024; 8:e55000. [PMID: 38875702 PMCID: PMC11214024 DOI: 10.2196/55000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 04/02/2024] [Accepted: 05/03/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND Journey to 9 Plus (J9) is an integrated reproductive, maternal, neonatal, and child health approach to care that has at its core the goal of decreasing the rate of maternal and neonatal morbidity and mortality in rural Haiti. For the maximum effectiveness of this program, it is necessary that the data system be of the highest quality. OpenMRS, an electronic medical record (EMR) system, has been in place since 2013 throughout a tertiary referral hospital, the Hôpital Universitaire de Mirebalais, in Haiti and has been expanded for J9 data collection and reporting. The J9 program monthly reports showed that staff had limited time and capacity to perform double charting, which contributed to incomplete and inconsistent reports. Initial evaluation of the quality of EMR data entry showed that only 18% (58/325) of the J9 antenatal visits were being documented electronically at the start of this quality improvement project. OBJECTIVE This study aimed to improve the electronic documentation of outpatient antenatal care from 18% (58/325) to 85% in the EMR by J9 staff from November 2020 to September 2021. The experiences that this quality improvement project team encountered could help others improve electronic data collection as well as the transition from paper to electronic documentation within a burgeoning health care system. METHODS A continuous quality improvement strategy was undertaken as the best approach to improve the EMR data collection at Hôpital Universitaire de Mirebalais. The team used several continuous quality improvement tools to conduct this project: (1) a root cause analysis using Ishikawa and Pareto diagrams, (2) baseline evaluation measurements, and (3) Plan-Do-Study-Act improvement cycles to document incremental changes and the results of each change. RESULTS At the beginning of the quality improvement project in November 2020, the baseline data entry for antenatal visits was 18% (58/325). Ten months of improvement strategies resulted in an average of 89% (272/304) of antenatal visits documented in the EMR at point of care every month. CONCLUSIONS The experiences that this quality improvement project team encountered can contribute to the transition from paper to electronic documentation within burgeoning health care systems. Essential to success was having a strong and dedicated nursing leadership to transition from paper to electronic data and motivated nursing staff to perform data collection to improve the quality of data and thus, the reports on patient outcomes. Engaging the nursing team closely in the design and implementation of EMR and quality improvement processes ensures long-term success while centering nurses as key change agents in patient care systems.
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Affiliation(s)
| | | | - Ellen Ball
- Partners In Health, Boston, MA, United States
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Forster DA, Matthews R, Hyde R, Fox D, Dyson K, Ryan T. Exploring the feasibility of conducting a randomised controlled trial of group-based pregnancy care and education: a pilot randomised controlled trial in Melbourne, Australia. Pilot Feasibility Stud 2024; 10:81. [PMID: 38769553 PMCID: PMC11103971 DOI: 10.1186/s40814-024-01501-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 04/30/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND In group-based pregnancy models, antenatal care and childbirth/parenting education are provided in groups of eight to 10 women, usually with two midwives, and six to eight sessions. Current evidence is inconclusive regarding potential benefit or harm. We aimed to explore the feasibility of implementing an adequately powered randomised controlled trial (RCT). METHODS A two-arm pilot RCT was conducted in a tertiary maternity hospital in Melbourne, Australia. Women were randomly allocated to either the intervention to receive group-based antenatal care and education (group care) or to usual care, which included hospital-based midwife, caseload midwifery, team midwifery, or GP shared care. Participants were English-speaking, primiparous, low risk, and < 24 weeks gestation at booking. DATA COLLECTION feasibility measures throughout pilot, baseline questionnaire at recruitment, clinical outcome data from the medical record, and a telephone-administered questionnaire 6 weeks postpartum. A focus group explored midwives' views. RESULTS Seventy-four women were recruited from May to June 2017 (group care = 40, usual care = 34). Study uptake was 35%. Women allocated to group care rated their overall pregnancy care more highly (88% good/very good vs 77% in usual care). There was no evidence of harm related to group care. Overarching themes from the midwives were that group care helped 'build connections' and 'empower women'. All midwives would work in the model again and believed it should be expanded. CONCLUSION Group care was acceptable to both women and midwives with no evidence of harm. The pilot demonstrated the feasibility of undertaking a large adequately powered RCT, important given the inconclusive evidence on clinical outcomes regarding the model, and its current relatively widespread implementation. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12623000858695.
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Affiliation(s)
- Della A Forster
- Judith Lumley Centre, La Trobe University, Bundoora, VIC, 3086, Australia.
- The Royal Women's Hospital, Locked Bag 300, Cnr Grattan St and Flemington Rd, Parkville, VIC, 3052, Australia.
| | - Robyn Matthews
- Judith Lumley Centre, La Trobe University, Bundoora, VIC, 3086, Australia
- The Royal Women's Hospital, Locked Bag 300, Cnr Grattan St and Flemington Rd, Parkville, VIC, 3052, Australia
| | - Rebecca Hyde
- Judith Lumley Centre, La Trobe University, Bundoora, VIC, 3086, Australia
- School of Nursing & Midwifery, La Trobe University, Bundoora, VIC, 3086, Australia
- The Royal Women's Hospital, Locked Bag 300, Cnr Grattan St and Flemington Rd, Parkville, VIC, 3052, Australia
| | - Deborah Fox
- Centre for Midwifery, Child and Family Health, University of Technology Sydney, Ultimo, NSW, 2007, Australia
| | - Kaye Dyson
- The Royal Women's Hospital, Locked Bag 300, Cnr Grattan St and Flemington Rd, Parkville, VIC, 3052, Australia
| | - Trish Ryan
- The Royal Women's Hospital, Locked Bag 300, Cnr Grattan St and Flemington Rd, Parkville, VIC, 3052, Australia
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Balasooriyan A, van der Veen MH, Bonifácio CC, Dedding C. Understanding parental perspectives on young children's oral health (≤ 4 years) growing up in a disadvantaged neighbourhood of Amsterdam, the Netherlands: an exploratory study. BMC Public Health 2024; 24:627. [PMID: 38413935 PMCID: PMC10900557 DOI: 10.1186/s12889-024-18073-0] [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: 09/12/2023] [Accepted: 02/12/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Families' understanding towards oral health problems among young children is poorly studied. More insight into parents' experiences, especially of those living in disadvantaged neighbourhoods, is needed to address persistent oral health inequalities. This qualitative study aims to explore parental perspectives on children's oral health (≤ 4 years) and the opportunities they see to improve children's oral health. METHODS Forty-seven mothers and five fathers with different migration backgrounds from a disadvantaged neighbourhood in Amsterdam, the Netherlands, participated in our study. Semi-structured interviews (n = 27), participant observations (n = 7) and one focus group discussion were conducted. A thematic data analysis was used. RESULTS Parents describe their daily life with young children as busy, hectic and unpredictable. Parents seem to be most concerned about parenting. Mothers, in particular, feel fully responsible for raising their children and managing daily complexities. While most parents value their children's oral health, they all experience challenges. Parents find it hard to limit daily candy intake and to handle unwilling children during tooth brushing. They feel limited support for these issues from their household, social network and professionals. CONCLUSION Parental struggles in children's oral health are complex and interrelated as they occur across family, societal, community and professional levels. Given the complex daily reality of families with young children, establishing and maintaining healthy oral health habits seems not at the top of parents' minds. They ask for advice in the upbringing of their children backed up by social support, increased attention to children's oral health within the community and professional assistance. Collaborating with parents as knowledgeable partners might be the first step in acting upon the endeavour to address oral health inequality among young children.
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Affiliation(s)
- Awani Balasooriyan
- Department of Preventive Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU Amsterdam, Amsterdam, The Netherlands.
| | - Monique H van der Veen
- Department of Preventive Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU Amsterdam, Amsterdam, The Netherlands
- Department of Paediatric Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU Amsterdam, Amsterdam, The Netherlands
| | - Clarissa Calil Bonifácio
- Department of Paediatric Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU Amsterdam, Amsterdam, The Netherlands
| | - Christine Dedding
- Department of Ethics, Law and Humanities, Amsterdam University Medical Centre (UMC), Amsterdam, The Netherlands
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Lori JR, Kukula VA, Liu L, Apetorgbor VEA, Ghosh B, Awini E, Lockhart N, Amankwah G, Zielinski R, Moyer CA, Williams J. Improving health literacy through group antenatal care: results from a cluster randomized controlled trial in Ghana. BMC Pregnancy Childbirth 2024; 24:37. [PMID: 38182969 PMCID: PMC10768124 DOI: 10.1186/s12884-023-06224-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/22/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Although the majority of Ghanaian women receive antenatal care (ANC), many exhibit low health literacy by misinterpreting and incorrectly operationalizing ANC messages, leading to poor maternal and newborn health outcomes. Prior research in low-resource settings has found group antenatal care (G-ANC) feasible for women and providers. This study aims to determine the effect of G-ANC on increasing maternal health literacy. We hypothesized that pregnant women randomized into G-ANC would exhibit a greater increase in maternal health literacy than women in routine, individual ANC. METHODS A 5-year cluster randomized controlled trial was conducted in 14 rural and peri-urban health facilities in the Eastern Region of Ghana. Facilities were paired based on patient volume and average gestational age at ANC enrollment and then randomized into intervention (G-ANC) vs. control (routine, individual ANC); 1761 pregnant women were recruited. Data collection occurred at baseline (T0) and post-birth (T2) using the Maternal Health Literacy scale, a 12-item composite scale to assess maternal health literacy. Logistic regression compared changes in health literacy from T0 to T2. RESULTS Overall, women in both the intervention and control groups improved their health literacy scores over time (p < 0.0001). Women in the intervention group scored significantly higher on 3 individual items and on overall composite scores (p < 0.0001) and were more likely to attend 8 or more ANC visits. CONCLUSION While health literacy scores improved for all women attending ANC, women randomized into G-ANC exhibited greater improvement in overall health literacy post-birth compared to those receiving routine individual care. Life-saving information provided during ANC must be presented in an understandable format to prevent women and newborns from dying of preventable causes. TRIAL REGISTRY Ethical approval for the study was obtained from the Institutional Review Boards of the University of Michigan (HUM#00161464) and the Ghana Health Service (GHS-ERC: 016/04/19).
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Affiliation(s)
- Jody R Lori
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, 400 N. Ingalls Bldg, Ann Arbor, MI, United States of America.
| | - Vida Ami Kukula
- Dodowa Health Research Centre, Ghana Health Service, P.O.Box DD1, Dodowa, Ghana
| | - Liya Liu
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, 400 N. Ingalls Bldg, Ann Arbor, MI, United States of America
| | | | - Bidisha Ghosh
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, 400 N. Ingalls Bldg, Ann Arbor, MI, United States of America
| | - Elizabeth Awini
- Dodowa Health Research Centre, Ghana Health Service, P.O.Box DD1, Dodowa, Ghana
| | - Nancy Lockhart
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, 400 N. Ingalls Bldg, Ann Arbor, MI, United States of America
| | - Georgina Amankwah
- Dodowa Health Research Centre, Ghana Health Service, P.O.Box DD1, Dodowa, Ghana
| | - Ruth Zielinski
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, 400 N. Ingalls Bldg, Ann Arbor, MI, United States of America
| | - Cheryl A Moyer
- Department of Learning Health Sciences, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, United States of America
| | - John Williams
- Dodowa Health Research Centre, Ghana Health Service, P.O.Box DD1, Dodowa, Ghana
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Lanyo TN, Zielinski R, Kukula VA, Apetorgbor VEA, Ghosh B, Lockhart NA, Lori JR. Improving respectful maternity care through group antenatal care: findings from a cluster randomized controlled trial. RESEARCH SQUARE 2023:rs.3.rs-3682833. [PMID: 38196651 PMCID: PMC10775374 DOI: 10.21203/rs.3.rs-3682833/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Background Disrespect and patient mistreatment are identified as barriers to care-seeking and low uptake of facility-based deliveries. These mitigating factors have led to slow progress in the achievement of maternal and child health targets, especially in Ghana. Group antenatal care, as an alternative to individual antenatal was implemented to explore the impact on outcomes, including mothers' perception of respectful care. Methods A cluster randomized controlled trial was conducted in 14 health facilities across four districts in the Easter Region of Ghana. These facilities were randomized to intervention or control using a matched pair. Data was collected at several timepoints: enrollment (Time 0), 34 weeks gestation to 3 weeks post-delivery (Time 1), 6 to 12 weeks post-delivery (Time 2), 5 to 8 months post-delivery (Time 3), and 11 to 14 months post-delivery (Time 4). Questions related to respectful care were asked at Time 2, while a focus group discussion (FGDs) was conducted as part of a process evaluation to examine participants' experiences about respectful maternity care. Results The findings from the intervention group indicate that participants perceived higher levels of respect in comparison to the control group. Privacy and con dentiality were maintained. They believed they had been provided with adequate information, education, and counseling, empowering them to make informed decisions. Participants perceived a shortened waiting time and reduced discrimination in care provision. Generally, there were higher levels of satisfaction with antenatal care. Conclusion The provision of respectful maternity care, which is essential to increasing healthcare utilization, has been demonstrated to correlate positively with group antenatal care.
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Stanikzai MH, Tawfiq E, Jafari M, Wasiq AW, Seddiq MK, Currie S, Sayam H, Baray AH, Saeedzai SA. Contents of antenatal care services in Afghanistan: findings from the national health survey 2018. BMC Public Health 2023; 23:2469. [PMID: 38082286 PMCID: PMC10712111 DOI: 10.1186/s12889-023-17411-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/05/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Maternal and newborn mortality is a public health concern in low- and middle-income countries (LMICs), including Afghanistan, where the evolving socio-political circumstances have added new complexities to healthcare service delivery. Birth outcomes for both pregnant women and their newborns are improved if women receive benefits of quality antenatal care (ANC). OBJECTIVES This study aimed to assess the contents of ANC services and identify predictors of utilization of services by pregnant women during ANC visits to health facilities in Afghanistan. METHODS In this cross-sectional study, we used data from the Afghanistan Health Survey 2018 (AHS2018). We included a total of 6,627 ever-married women, aged 14-49 years, who had given birth in the past 2 years or were pregnant at the time of survey and had consulted a health worker for ANC services in a health facility. The outcome was defined as 1-4 services and 5-8 services that a pregnant woman received during an ANC visit. The services were (i) taking a pregnant woman's blood pressure, (ii) weighing her, (iii) testing her blood, (iv) testing her urine, (v) providing advice on nutrition, (vi) advising about complicated pregnancy, (vii) advising about the availability of health services, and (viii) giving her at least one dose of Tetanus Toxoid (TT) vaccine. The binary outcome (1-4 services versus 5-8 services) was used in a multivariable logistic regression model. RESULTS Of all 6,627 women, 31.4% (2,083) received 5-8 services during ANC visits. Only 1.3% (86) received all 8 services, with 98.7% (6,541) receiving between 1 and 7 services, and 71.6% (4,745) women had their blood pressure measured during ANC visits. The likelihood (adOR = Adjusted Odds Ratio) of receiving 5-8 services was higher in women who could read and write (adOR = 1.33: 1.15-1.54), in women whose husbands could read and write (adOR = 1.14: 1.00-1.28), in primipara women (adOR = 1.42: 1.02-1.98), in women who knew one danger sign (adOR = 5.38: 4.50-6.45), those who knew 2 danger signs (adOR = 8.51: 7.12-10.19) and those who knew ≥ 3 danger signs (adOR = 13.19: 10.67-16.29) of complicated pregnancy, and in women who had almost daily access to TV (adOR = 1.16: 1.01-1.33). However, the likelihood of receiving 5-8 services was lower in women who used private clinics (adOR = 0.64: 0.55-0.74) and who received services from nurses (adOR = 0.27 (0.08-0.88). CONCLUSION Our findings have the potential to influence the design and implementation of ANC services of health interventions to improve the delivery of services to pregnant women during ANC visits.
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Affiliation(s)
- Muhammad Haroon Stanikzai
- Department of Public Health, Faculty of Medicine, Kandahar University, District # 10, Kandahar, 3801, Afghanistan.
| | - Essa Tawfiq
- The Kirby Institute, UNSW Sydney, Sydney, Australia
| | | | - Abdul Wahed Wasiq
- Department of Internal Medicine, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan
| | | | - Sheena Currie
- Jhpiego, 1615 Thames Street, Baltimore, MD, 21231, USA
| | - Hadia Sayam
- Department of Para-clinic, Faculty of Medicine, Malalay Institute of Higher Education, Kandahar, Afghanistan
| | - Ahmad Haroon Baray
- Department of Public Health, Faculty of Medicine, Kandahar University, District # 10, Kandahar, 3801, Afghanistan
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Girotra S, Malik M, Roy S, Basu S. Utilization and determinants of adequate quality antenatal care services in India: evidence from the National Family Health Survey (NFHS-5) (2019-21). BMC Pregnancy Childbirth 2023; 23:800. [PMID: 37978458 PMCID: PMC10657001 DOI: 10.1186/s12884-023-06117-z] [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: 04/05/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Pregnancy-related complications and insufficiencies in antenatal care services are leading causes of maternal and infant morbidity and mortality in low-resource settings. However, there has been an undue focus on achieving a minimum number of Antenatal Care (ANC) visits without adequate focus on the factors affecting ANC service utilization. This secondary data analysis from the fifth round of the National Family Health Survey (NFHS-5, 2019-21) was conducted to estimate the coverage of adequate quality ANC service and its determinants in India. METHODS The study sample included 176,877 women aged 15-49 years who had experienced a pregnancy in the last 5 years. The primary outcome variable was the utilization of ANC services by women during their last pregnancy assessed by the frequency of ANC visits and the quality of ANC services. Quality of ANC service utilisation was categorised as adequate quality, inadequate quality and ≥ 4 ANC visits and, inadequate quality and < 4 ANC visits. We performed multinomial logistic regression and reported relative risk ratio (RRR) along with 95% confidence intervals. We adjusted for sampling weight, clustering, and stratification in the sampling design. RESULTS The median (IQR) number of ANC visits attended by a woman during her previous pregnancy was 4 (IQR 3-7). A majority (59.25%) of the women reported availing of ≥ 4 antenatal care (ANC) visits during their previous pregnancy while 6.12% of women reported availing no ANC visits in their last pregnancy. Women aged ≥ 30 years were significantly less likely (aRRR 0.73 95% CI 0.66, 0.80) to receive ANC services of inadequate quality, and < 4 ANC visits. Additionally, any exposure to mass media (aRRR 0.69 95% CI 0.66, 0.73), and having health insurance (aRRR 0.71 95% CI 0.68, 0.75) decreased their risk of receiving inadequate quality ANC services and < 4 ANC visits. Women belonging to the richest wealth quintile (aRRR 0.52 95% CI 0.47,0.58) and those with an intended pregnancy (aRRR 0.62 95% CI 0.58 ,0.66) were at significantly lower risk of utilizing inadequate quality ANC services and < 4 ANC visits. CONCLUSION Although nearly 3 in 5 women in India utilized a minimum mandated ≥ 4 ANC visits during their last pregnancy, only one in five of those received adequate quality of ANC services indicating suboptimal content. However, only one in five women utilized the WHO-mandated ≥ 8 ANC visits for a positive pregnancy experience. Furthermore, 14.3% of the women received ANC services of inadequate quality despite attending ≥ 4 ANC visits in their previous pregnancy. Our study emphasized the importance of the quality of ANC services utilised irrespective of number of ANC visits availed. Efforts should be undertaken to enhance the utilization of antenatal care (ANC) services by implementing media initiatives that aim to raise awareness, particularly among women belonging to disadvantaged population groups.
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Affiliation(s)
- Siaa Girotra
- Indian Institute of Public Health, Public Health Foundation of India, New Delhi, India
| | - Mansi Malik
- Indian Institute of Public Health, Public Health Foundation of India, New Delhi, India
| | - Shubhanjali Roy
- Indian Institute of Public Health, Public Health Foundation of India, New Delhi, India
| | - Saurav Basu
- Indian Institute of Public Health, Public Health Foundation of India, New Delhi, India.
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Martens N, Hindori-Mohangoo AD, Hindori MP, Damme AV, Beeckman K, Reis R, Crone MR, van der Kleij RR. Anticipated benefits and challenges of implementing group care in Suriname's maternity and child care sector: a contextual analysis. BMC Pregnancy Childbirth 2023; 23:592. [PMID: 37596532 PMCID: PMC10436662 DOI: 10.1186/s12884-023-05904-y] [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: 04/11/2023] [Accepted: 08/07/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Suriname is a uppermiddle-income country with a relatively high prevalence of preventable pregnancy complications. Access to and usage of high-quality maternity care services are lacking. The implementation of group care (GC) may yield maternal and child health improvements. However, before introducing a complex intervention it is pivotal to develop an understanding of the local context to inform the implementation process. METHODS A context analysis was conducted to identify local needs toward maternity and postnatal care services, and to assess contextual factor relevant to implementability of GC. During a Rapid Qualitative Inquiry, 63 online and face-to-face semi-structured interviews were held with parents, community members, on-and off-site healthcare professionals, policy makers, and one focus group with parents was conducted. Audio recordings were transcribed in verbatim and analysed using thematic analysis and Framework Method. The Consolidated Framework for Implementation Research served as a base for the coding tree, which was complemented with inductively derived codes. RESULTS Ten themes related to implementability, one theme related to sustainability, and seven themes related to reaching and participation of the target population in GC were identified. Factors related to health care professionals (e.g., workload, compatibility, ownership, role clarity), to GC, to recipients and to planning impact the implementability of GC, while sustainability is in particular hampered by sparse financial and human resources. Reach affects both implementability and sustainability. Yet, outer setting and attitudinal barriers of health professionals will likely affect reach. CONCLUSIONS Multi-layered contextual factors impact not only implementability and sustainability of GC, but also reach of parents. We advise future researchers and implementors of GC to investigate not only determinants for implementability and sustainability, but also those factors that may hamper, or facilitate up-take. Practical, attitudinal and cultural barriers to GC participation need to be examined. Themes identified in this study will inspire the development of adaptations and implementation strategies at a later stage.
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Affiliation(s)
- Nele Martens
- Leiden University Medical Center, Leiden, the Netherlands.
| | | | - Manodj P Hindori
- Foundation for Perinatal Interventions and Research in Suriname (Perisur), Paramaribo, Suriname
| | - Astrid Van Damme
- Department of Public Health, Vrije Universiteit Brussel (VUB), Jette, Belgium
- Department of Nursing and Midwifery Research Group (NUMID), Universitair Ziekenhuis Brussel (UZ Brussel), Jette, Belgium
| | - Katrien Beeckman
- Department of Public Health, Vrije Universiteit Brussel (VUB), Jette, Belgium
- Department of Nursing and Midwifery Research Group (NUMID), Universitair Ziekenhuis Brussel (UZ Brussel), Jette, Belgium
- Centre for Research and Innovation in Care, Universiteit Antwerpen, Antwerp, Belgium
| | - Ria Reis
- Leiden University Medical Centre, Leiden, Netherlands
- Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, Netherlands
- University of Cape Town, Cape Town, South Africa
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Koivu AM, Näsänen-Gilmore PK, Hunter PJ, Muthiani Y, Isojärvi J, Heimonen O, Bastola K, Csonka L, Ashorn P, Ashorn U. Antenatal interventions to address harmful behaviors and psychosocial risk factors in the prevention of low birth weight. Am J Clin Nutr 2023; 117 Suppl 2:S148-S159. [PMID: 37331761 DOI: 10.1016/j.ajcnut.2022.11.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/11/2022] [Accepted: 11/08/2022] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Risk factors related to the harmful behaviors, psychosocial wellbeing, and socio-economic circumstances in the lives of pregnant women can lead to adverse birth outcomes, including low birth weight (LBW). OBJECTIVE This systematic search and review aims to provide a comparative evidence synthesis on the effect of eleven antenatal interventions targeted to address psychosocial risk factors on adverse birth outcomes. METHODS We searched MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials and CINAHL Complete between March 2020 and May 2020. We included randomized controlled trials (RCTs) and reviews of RCTs of eleven antenatal interventions for pregnant females reporting LBW, preterm birth (PTB), small-for-gestational-age or stillbirth as outcomes. For interventions where randomization was either not feasible or unethical, we accepted non-randomized controlled studies. RESULTS Seven records contributed data to the quantitative estimates of the effect sizes and 23 contributed to narrative analysis. Psychosocial interventions for reducing smoking in pregnancy likely reduced the risk of LBW, and professionally provided psychosocial support for at-risk women possibly reduced the risk of PTB. Financial incentives or nicotine replacement therapy as smoking cessation aids, or virtually delivered psychosocial support did not appear to reduce the risk of adverse birth outcomes. The available evidence on these interventions was primarily from high-income countries. For other reviewed interventions (psychosocial interventions to reduce alcohol use, group based psychosocial support programs, intimate partner violence prevention interventions, antidepressant medication, and cash transfers) there was little evidence in any direction regarding the efficacy or the data was conflicting. CONCLUSIONS Professionally provided psychosocial support during pregnancy in general and specifically as a means to reduce smoking can potentially contribute to improved newborn health. The gaps in the investments for research and implementation of psychosocial interventions should be addressed to better meet the global targets in LBW reduction.
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Affiliation(s)
- Annariina M Koivu
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
| | - Pieta K Näsänen-Gilmore
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Finnish Institute for Health and Welfare, FI-00271, Helsinki, Finland
| | | | - Yvonne Muthiani
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jaana Isojärvi
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Otto Heimonen
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kalpana Bastola
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Leon Csonka
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Mohiddin A, Semrau KEA, Simon J, Langlois EV, Shiffman J, Nabwera H, Hofmeyr GJ, Lawn JE, Black RE, Askari S, Klein N, Ashorn U, Ashorn P, Temmerman M. The ethical, economic, and developmental imperative to prevent small vulnerable newborns and stillbirths: essential actions to improve the country and global response. Lancet 2023; 401:1636-1638. [PMID: 37167987 DOI: 10.1016/s0140-6736(23)00721-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/02/2023] [Indexed: 05/13/2023]
Affiliation(s)
- Abdu Mohiddin
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya.
| | | | | | - Etienne V Langlois
- Partnership for Maternal, Newborn & Child Health (PMNCH), WHO, Geneva, Switzerland
| | - Jeremy Shiffman
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Paul H Nitze School of Advanced International Studies, Johns Hopkins University, Baltimore, MD, USA
| | - Helen Nabwera
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya; Liverpool School of Tropical Medicine, Liverpool, UK
| | - G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, University of Botswana, Botswana, Africa; Effective Care Research Unit, University of the Witwatersrand, South Africa
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Robert E Black
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Nigel Klein
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Ulla Ashorn
- Center for Child, Adolescent, and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere University Hospital, Tampere, Finland
| | - Per Ashorn
- Center for Child, Adolescent, and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere University Hospital, Tampere, Finland
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
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Thakkar N, Alam P, Saxena D. Factors associated with underutilization of antenatal care in India: Results from 2019-2021 National Family Health Survey. PLoS One 2023; 18:e0285454. [PMID: 37155665 PMCID: PMC10166529 DOI: 10.1371/journal.pone.0285454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/24/2023] [Indexed: 05/10/2023] Open
Abstract
INTRODUCTION Despite progress in recent years, full antenatal care utilization in India continues to be relatively low and inequitable, particularly between states and districts. In 2015-2016, for example, only 51% of women aged 15-49 in India attended antenatal care at least four times during pregnancy. Using data from the fifth iteration of India's National Family Health Survey, our study aims to explore factors related to the underutilization of antenatal care in India. MATERIALS AND METHODS Data from the most recent live birth in the past five years among women aged 15-49 years were included in our analysis (n = 172,702). Our outcome variable was "adequate antenatal care visits", defined as four or more antenatal visits. Utilizing Andersen's behavioral model, 14 factors were identified as possible explanatory variables. We used univariate and multivariate binary logistic regression models to analyze the association between explanatory variables and adequate visits. Associations were considered statistically significant if p<0.05. RESULTS Of the 172,702 women in our sample, 40.75% (95% CI: 40.31-41.18%) had an inadequate number of antenatal care visits. In multivariate analysis, women with less formal education, from poorer households and more rural areas had higher odds of inadequate visits. Regionally, women from Northeastern and Central states had higher odds of inadequate antenatal care utilization compared to those from Southern states. Caste, birth order, and pregnancy intention were also among the variables associated with utilization of antenatal care. DISCUSSION Despite improvements in antenatal care utilization, there is cause for concern. Notably, the percentage of Indian women receiving adequate antenatal care visits is still below the global average. Our analysis also reveals a continuity in the groups of women at highest risk for inadequate visits, which may be due to structural drivers of inequality in healthcare access. To improve maternal health and access to antenatal care services, interventions aimed at poverty alleviation, infrastructure development, and education should be pursued.
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Affiliation(s)
- Nandan Thakkar
- Office of Graduate Education, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Prima Alam
- Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Deepak Saxena
- Indian Institute of Public Health-Gandhinagar, Gandhinagar, Gujarat, India
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Wang X, Zhu Y, Liu J, Ma Y, Birch S. Equity in maternal and child health care utilization in Guangdong province of China 2009-2019: A retrospective analysis. Front Public Health 2022; 10:963344. [PMID: 36176519 PMCID: PMC9513387 DOI: 10.3389/fpubh.2022.963344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/18/2022] [Indexed: 01/24/2023] Open
Abstract
Background Equity is the principal challenge of maternal and child health care (MCH) across the world, especially in China. Existing researches focused on equity in MCH resources and outcomes. There is an evidence gap regarding equity of MCH services utilization, revealing the black box between equity in MCH resources and MCH outcomes. In the study, we evaluate the changes of equity in integrated MCH service utilization in Guangdong province of China during 2009-2019. Methods Data used in this study are from the Guangdong Maternal and Child Health Routine Reporting System and the Guangdong Health Statistical Yearbook (2009-2019). The Gini coefficient (G) and Theil index (T) were employed to assess equity and source of inequity in four geographic regions of Guangdong province. Results Generally, among the integrated MCH care, coverage of pre-pregnancy care (<50%) is lower than in other stages. In the past decade, inequity of MCH care in the Equalization of Essential Public Health Service (EEPHS) program has gradually reduced to G < 0.1. Screening of genetic metabolic disease and of hearing showed largest reductions of inequity (G reducing from 0.3-0.4 to 0.03-0.04). Inequity in reproductive health tests for brides-to-be, psychological assessment and consultation, education classes for mother-to-be and health management of children under 3 were mainly contributed by intra-region disparities in 2019. Conclusion Equity has gradually improved in the last decade in Guangdong. The national EEPHS program and the Integrated Prevention of Mother-to-Child Transmission of HIV, Syphilis and HBV of Guangdong have played important roles in reducing inequity in MCH service utilization. Further strategies, targeting pre-pregnancy reproductive healthcare, psychological assessments and consultations for the pregnant and education classes for mothers-to-be, should be taken to promote coverage and equity.
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Affiliation(s)
- Xin Wang
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Yingxian Zhu
- Guangdong Women and Children Hospital, Guangzhou, China
| | - Jia Liu
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Yuanzhu Ma
- Guangdong Women and Children Hospital, Guangzhou, China,*Correspondence: Yuanzhu Ma
| | - Stephen Birch
- Centre for the Business and Economics of Health, University of Queensland, Brisbane, QLD, Australia
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Somji A, Ramsey K, Dryer S, Makokha F, Ambasa C, Aryeh B, Booth K, Xueref S, Moore S, Mwenesi R, Rashid S. "Taking care of your pregnancy": a mixed-methods study of group antenatal care in Kakamega County, Kenya. BMC Health Serv Res 2022; 22:969. [PMID: 35906642 PMCID: PMC9336107 DOI: 10.1186/s12913-022-08200-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 06/15/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Traditional antenatal care (ANC) models often do not meet women's needs for information, counseling, and support, resulting in gaps in quality and coverage. Group ANC (GANC) provides an alternative, person-centered approach where pregnant women of similar gestational age meet with the same health provider for facilitated discussion. F studies show associations between GANC and various outcomes. METHODS We employed a pre-post quasi-experimental design using mixed methods to assess a GANC model (Lea Mimba Pregnancy Clubs) at six health facilities in Kakamega County, Kenya. Between April 2018 and January 2019, we tracked 1652 women assigned to 162 GANC cohorts. Using an intention-to-treat approach, we conducted baseline (N = 112) and endline surveys (N = 360) with women attending immunization visits to assess outcomes including experience of care, empowerment and self-efficacy, knowledge of healthy practices and danger signs, and practice of healthy behaviors, including ANC retention. At endline, we conducted 29 in-depth interviews (IDIs) and three focus group discussions with women who were currently and previously participating in GANC, and 15 IDIs with stakeholders. RESULTS The proportion of survey respondents with knowledge of three or more danger signs during pregnancy more than tripled, from 7.1% at baseline to 26.4% at endline (OR: 4.58; 95% CI: 2.26-10.61). We also found improvements in women's reports about their experience of care between baseline and endline, particularly in their assessment of knowledge and competence of health workers (OR: 2.52 95% CI: 1.57-4.02), respect shown by ANC providers (OR: 1.82, 95% CI: 1.16-2.85), and women's satisfaction with overall quality of care (OR: 1.62, 95% CI: 1.03-2.53). We saw an increase from 58.9% at baseline to 71.7% at endline of women who strongly agreed that they shared their feelings and experiences with other women (OR: 1.73, 95% CI: 1.1-2.7). The mean number of ANC visits increased by 0.89 visits (95% CI: 0.47-1.42) between baseline (4.21) and endline (5.08). No changes were seen in knowledge of positive behaviors, empowerment, self-efficacy, and several aspects related to women's experience of care and adoption of healthy behavior constructs. Qualitatively, women and stakeholders noted improved interactions between health providers and women, improved counseling, increased feelings of empowerment to ask questions and speak freely and strengthened social networks and enhanced social cohesion among women. CONCLUSIONS GANC offers promise for enhancing women's experience of care by providing improved counseling and social support. Additional research is needed to develop and test measures for empowerment, self-efficacy, and experience of care, and to understand the pathways whereby GANC effects changes in specific outcomes.
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Affiliation(s)
- Aleefia Somji
- Management Sciences for Health (MSH), Alexandria, USA
| | | | - Sean Dryer
- Globally Minded Foundation, Burgas, Bulgaria
| | | | | | | | - Kathleen Booth
- Columbia University Mailman School of Public Health, New York, USA
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Oka M, Madeni F, Horiuchi S. Effects of prenatal group program in rural Tanzania: A quasi-experimental study. Jpn J Nurs Sci 2022; 19:e12502. [PMID: 35678369 DOI: 10.1111/jjns.12502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/15/2022] [Accepted: 05/07/2022] [Indexed: 11/30/2022]
Abstract
AIM This study conducted in rural Tanzania examined the effects of a midwife-led prenatal group program on: (1) improvement of knowledge of the physiological symptoms of pregnancy; (2) promotion of pregnancy-related empowerment; (3) enhancement of intention to self-care behaviors for safer childbirth; and (4) gaining satisfaction with antenatal care visits. METHODS This work was a quasi-experimental study with a control group using a pre-post study design conducted in two district hospitals in Tanzania. Data were collected from 108 analyzed pregnant women from the prenatal group program (n = 54) and control program (n = 54) using questionnaires before (baseline) and after (endline) the program. The program consisted of lecture, sharing, and review sessions. The control program consisted of the same lectures. The contents of both programs included physiological symptoms of pregnancy and self-care behaviors. The primary outcome was knowledge of common symptoms of pregnancy. The secondary outcomes were Pregnancy-Related Empowerment Scale score, intention to self-care behaviors, and satisfaction. RESULTS The primary outcome of knowledge of common symptoms of pregnancy was significantly increased in the intervention group compared with the control group (t = 2.677, p = .009). The secondary outcome of one of the Pregnancy-Related Empowerment Scale statements about midwife's respectful attitude toward women's decision was significantly increased in the intervention group compared with the control group (U = 2.076, p = .038). CONCLUSIONS The interventional prenatal group program during pregnancy was effective in increasing knowledge of common symptoms of pregnancy and in identifying favorable midwife connectedness.
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Affiliation(s)
- Miyuki Oka
- St. Luke's International University, Tokyo, Japan
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Gamberini C, Angeli F, Ambrosino E. Exploring solutions to improve antenatal care in resource-limited settings: an expert consultation. BMC Pregnancy Childbirth 2022; 22:449. [PMID: 35637425 PMCID: PMC9150046 DOI: 10.1186/s12884-022-04778-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background Shortage or low-quality antenatal care is a complex and “wicked” problem relying heavily on contextual, socio-cultural, environmental and intersectional aspects. We report the outcome of an expert consultation discussing solutions to improve antenatal care quality, access and delivery in low- and middle-income countries, and providing recommendations for implementation. Methods The social ecological model was used as an analytical lens to map and interpret discussion points and proposed solutions. In addition, a conceptual framework for maternal and neonatal health innovation based on the building blocks of the World Health Organization health system and the Tanahashi Health Systems Performance Model provided a logical overview of discussed solutions. Results Many barriers and norms continue to hinder antenatal care access. From values, beliefs, traditions, customs and norms, to poor resource allocation, there is a need of reshaping health systems in order to provide high quality, respectful maternal and childcare. The burden of poor maternal health, morbidity and mortality is concentrated among populations who are vulnerable due to gender and other types of discrimination, have financial constraints and are affected by humanitarian crises. Conclusions In order to address maternal health issues, good quality and evidence-based services should be guaranteed. Investments in strengthening health systems, including data and surveillance systems and skilled health workforce, should be considered an essential step towards improving maternal health services.
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Affiliation(s)
- Carlotta Gamberini
- Institute for Public Health Genomics, Department of Genetics and Cell Biology, School for Oncology and Developmental Biology (GROW), Faculty of Health, Medicine and Life Sciences, University of Maastricht, Maastricht, The Netherlands
| | - Federica Angeli
- University of York Management School, University of York, York, UK
| | - Elena Ambrosino
- Institute for Public Health Genomics, Department of Genetics and Cell Biology, School for Oncology and Developmental Biology (GROW), Faculty of Health, Medicine and Life Sciences, University of Maastricht, Maastricht, The Netherlands.
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Grenier L, Onguti B, Whiting-Collins LJ, Omanga E, Suhowatsky S, Winch PJ. Transforming women’s and providers’ experience of care for improved outcomes: A theory of change for group antenatal care in Kenya and Nigeria. PLoS One 2022; 17:e0265174. [PMID: 35503773 PMCID: PMC9064109 DOI: 10.1371/journal.pone.0265174] [Citation(s) in RCA: 4] [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: 05/06/2021] [Accepted: 02/24/2022] [Indexed: 11/19/2022] Open
Abstract
Background Group antenatal care (G-ANC) is a promising model for improving quality of maternal care and outcomes in low- and middle-income countries (LMICs) but little has been published examining the mechanisms by which it may contribute to those improvements. Substantial interplay can be expected between pregnant women and providers’ respective experiences of care, but most studies report findings separately. This study explores the experience and effects of G-ANC on both women and providers to inform an integrated theory of change for G-ANC in LMICs. Methods This paper reports on multiple secondary outcomes from a pragmatic cluster randomized controlled trial of group antenatal care in Kenya and Nigeria conducted from October 2016—November 2018 including 20 clusters per country. We collected qualitative data from providers and women providing or receiving group antenatal care via focus group discussions (19 with women; 4 with providers) and semi-structured interviews (42 with women; 4 with providers). Quantitative data were collected via surveys administered to 1) providers in the intervention arm at enrollment and after facilitating 4 cohorts and 2) women in both study arms at enrollment; 3–6 weeks postpartum; and 1 year postpartum. Through an iterative approach with framework analysis, we explored the interactions of voiced experience and perceived effects of care and placed them relationally within a theory of change. Selected variables from baseline and final surveys were analyzed to examine applicability of the theory to all study participants. Results Findings support seven inter-related themes. Three themes relate to the shared experience of care of women and providers: forming supportive relationships and open communication; becoming empowered partners in learning and care; and providing and receiving meaningful clinical services and information. Four themes relate to effects of that experience, which are not universally shared: self-reinforcing cycles of more and better care; linked improvements in health knowledge, confidence, and healthy behaviors; improved communication, support, and care beyond G-ANC meetings; and motivation to continue providing G-ANC. Together these themes map to a theory of change which centers the shared experience of care for women and providers among multiple pathways to improved outcomes. Discussion The reported experience and effects of G-ANC on women and providers are consistent with other studies in LMICs. This study is novel because it uses the themes to present a theory of change for G-ANC in low-resource settings. It is useful for G-ANC implementation to inform model development, test adaptations, and continue exploring mechanisms of action in future research.
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Affiliation(s)
- Lindsay Grenier
- Maternal and Newborn Health Unit, Jhpiego, Baltimore, Maryland, United States of America
- * E-mail:
| | | | - Lillian J. Whiting-Collins
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Eunice Omanga
- Department of Monitoring, Evaluation, and Research, Jhpiego, Nairobi, Kenya
| | - Stephanie Suhowatsky
- Maternal and Newborn Health Unit, Jhpiego, Baltimore, Maryland, United States of America
| | - Peter J. Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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21
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The challenges and opportunities for implementing group antenatal care (‘Pregnancy Circles’) as part of standard NHS maternity care: A co-designed qualitative study. Midwifery 2022; 109:103333. [DOI: 10.1016/j.midw.2022.103333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 03/12/2022] [Accepted: 03/29/2022] [Indexed: 11/19/2022]
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Heller C, LaFond A, Murthy L. Methods and Benefits of Measuring Human-Centered Design in Global Health. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:S274-S282. [PMID: 34845050 PMCID: PMC8628500 DOI: 10.9745/ghsp-d-21-00207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 08/26/2021] [Indexed: 11/15/2022]
Abstract
Monitoring and evaluation (M&E), a new frontier for human-centered design (HCD), is still largely unexplored. In global health, M&E is considered essential to good practice, and evidence and data are critical tools in program design, performance monitoring, impact evaluation, and adaptation and learning. As HCD is increasingly integrated into global health practice, designers and global health practitioners are learning as they go how to integrate measurement into design and adapt traditional M&E approaches to design-influenced global health projects. This article illustrates some of the tensions inherent in the way global health and HCD practitioners approach measurement, using several cases to illustrate the ways in which tensions can be managed. Using framing introduced by the MeasureD project, which aimed to audit measurement practices in HCD (called social design in the MeasureD project), we explore 3 recent examples of design-influenced global health interventions: 1 focusing on products, 1 on behavior change, and 1 on service improvement, to extract learning about how teams used measurement, for what purpose, and to what effect. In comparing these examples and recent experience, we report on the steps being taken toward greater alignment in the use of measurement to advance human-centered global health programming.
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Ala SH, Husain S, Husain S. Reasons for presenting to antenatal care clinics in a sample of Pakistani women and their knowledge of WHO antenatal care package. Eur J Midwifery 2021; 5:43. [PMID: 34693217 PMCID: PMC8486015 DOI: 10.18332/ejm/140794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/20/2021] [Accepted: 08/02/2021] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION The purpose of antenatal care is to ensure that a woman has a safe pregnancy and that does not mean absence of any disease during this period. Antenatal care allows screening of preeclampsia, fetal abnormalities and other prevention strategies to be incorporated. The purpose of this study was to assess the reason for attending antenatal care clinics and knowledge of antenatal care content package in women. METHODS A cross-sectional study was conducted on 395 pregnant women attending antenatal care clinic at the Ruth K. M. Pfau Civil hospital, Karachi, Pakistan from 1 July 2019 to 31 December 2019. Each eligible woman was asked about the reason for attendance and her knowledge about WHO standardized antenatal care package. RESULTS The commonest reason for utilizing antenatal care in booked attendees was place of birth concern (25.9%) and in not booked was referral from private centers (33.6%) which was statistically significant (p=0.006). Both booked and not booked women (67.9% vs 59.1%, p=0.409) stated avoidance of complication during pregnancy and labor as the commonest reason for attendance. Women with higher parity were more likely to identify weight measurement (p=0.001), iron and folic acid supplementation (p=0.001), and urine detailed report (p=0.002), as content of the standard package. CONCLUSIONS Our study shows that women did not utilize antenatal care clinics for improving their health or the health of their fetus. The knowledge of the antenatal care package was limited to weight measurement and supplements. Moreover, attendance and visits at an antenatal care facility do not equate to good service provision.
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Affiliation(s)
- Syed H Ala
- Department of Obstetrics and Gynecology, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Samia Husain
- Department of Obstetrics and Gynecology, Aziz Medical Center, Karachi, Pakistan
| | - Saba Husain
- Department of Obstetrics and Gynecology, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
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Vandermorris A, McKinnon B, Sall M, Witol A, Traoré M, Lamesse-Diedhiou F, Bassani DG. Adolescents' experiences with group antenatal care: Insights from a mixed-methods study in Senegal. Trop Med Int Health 2021; 26:1700-1708. [PMID: 34669987 DOI: 10.1111/tmi.13692] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Group antenatal care (G-ANC) is an innovative model in which antenatal care is delivered to a group of 8-12 women of similar gestational age. Evidence from high-income countries suggests G-ANC is particularly effective for women from marginalised populations, including adolescents. The objective of this study was to examine the experiences of Senegalese adolescents engaged in group antenatal care. METHODS This convergent parallel mixed-methods study is derived from a larger effectiveness-implementation hybrid pilot study conducted in Kaolack district, Senegal. Quantitative data for adolescent participants were collected through baseline and postnatal surveys and descriptively analysed. One-on-one interviews and focus-group discussions were conducted with adolescent participants, and qualitative data were analysed using qualitative descriptive analysis. RESULTS Forty-five adolescents aged 15-19 participated in G-ANC, with a median age of 18 years. The majority (93.3%) were married, and 64.4% were nulliparous. Findings indicated similar levels of G-ANC participation for adolescent and adult women. The majority (93.1%) of participants who had previously attended individual ANC indicated they would prefer G-ANC to individual care for a future pregnancy. Qualitative findings indicated key facets of consideration relevant to G-ANC for adolescents include social connectedness, the influence of social norms and the opportunity for engagement in healthcare. CONCLUSIONS This study suggests that G-ANC has the potential to be an adolescent-responsive and culturally appropriate method of delivering antenatal care in Senegal.
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Affiliation(s)
- Ashley Vandermorris
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada.,Division of Adolescent Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Britt McKinnon
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Mohamadou Sall
- Institut de Recherche et Formation en Population, Developpement et Sante ́de la Reproduction, Universite ́ Cheik Anta Diop, Dakar, Senegal
| | - Adrian Witol
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mahamadou Traoré
- Institut de Recherche et Formation en Population, Developpement et Sante ́de la Reproduction, Universite ́ Cheik Anta Diop, Dakar, Senegal
| | - Fatma Lamesse-Diedhiou
- Institut de Recherche et Formation en Population, Developpement et Sante ́de la Reproduction, Universite ́ Cheik Anta Diop, Dakar, Senegal
| | - Diego G Bassani
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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The Clinical Application and Prospect of Smart Prenatal Care and Postpartum Recovery. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:3279714. [PMID: 34659684 PMCID: PMC8514900 DOI: 10.1155/2021/3279714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/08/2021] [Indexed: 11/17/2022]
Abstract
Scientific and technological advancement has increased the requirement for modern medical systems, leading to smartphone-based intelligent prenatal care and postpartum recovery. This kind of prenatal care and postpartum recovery including a remote monitoring system for fetal heart monitoring, blood glucose, and weight overcomes the restrictions of time and space and provides all-round, convenient, rapid, and accurate services to the medical systems, doctors, and pregnant women. This paper reviews the current research on intelligent medical services for pregnant women, particularly for prenatal care and postpartum recovery.
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Ssegujja E, Mulumba Y, Guttmacher S, Andipatin M. The role and attributes of social networks in the provision of support to women after stillbirth: experiences from Uganda. BMC Womens Health 2021; 21:352. [PMID: 34615502 PMCID: PMC8496046 DOI: 10.1186/s12905-021-01498-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 09/17/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Communities exert stigma on mothers after stillbirth despite their potential to offer social support to the grieving family. Maternal healthcare-seeking behaviors are socially reinforced rendering a social network approach vital in understanding support dynamics which when utilized can improve community response to mothers experiencing stillbirth. However, the form and direction of social support for women when in need is not clear. The study explored the role and attributes of women's social networks in the provision of support to mothers who have experienced a stillbirth in Uganda. METHODS An exploratory cross-sectional study design adopting a social network approach was conducted. Data collection following established procedures was conducted on a convenient sample of 17 mothers who had experienced a stillbirth six months before the study. Frequencies and bivariate analysis were conducted to determine the factors influencing the provision of social support from 293 network members elicited during the alter generation. We then performed a Poisson regression on each of the social support forms and the explanatory variables. Network structure variables were calculated using UCINET version 6 while Netdraw facilitated the visualization of networks. RESULTS Overall, social support was available from all network relations mentioned by the respondents. No major variations were observed between the two time periods during pregnancy and following a stillbirth. The most common support received was in form of intangible support such as emotional and information support, mainly from females who were married and from the naturally occurring networks such as family and friends. We also observed that social support followed patterns of network relational characteristics including trust, frequency of contact and alters counted on for support more likely to provide the same. CONCLUSIONS A great potential for social support exists within women's social networks to help address stillbirth risk factors during pregnancy and cope after experiencing the same. Alter characteristics like being female, married, and from naturally occurring networks together with relational characteristics such as trust, frequency of contact, and count on alter for support were predictors of eventual social support. Interventions aiming at addressing stillbirth risks at the community level ought to harness these network characteristics for benefits to the mothers.
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Affiliation(s)
- Eric Ssegujja
- Makerere University School of Public Health, Kampala, Uganda.
- School of Public Health, University of the Western Cape, Cape Town, South Africa.
| | - Yusuf Mulumba
- Uganda Cancer Institute, Mulago National Referral Hospital, Kampala, Uganda
| | - Sally Guttmacher
- School of Global Public Health, New York University, New York, NY, USA
| | - Michelle Andipatin
- Department of Psychology, University of the Western Cape, Cape Town, South Africa
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Lazar J, Boned-Rico L, Olander EK, McCourt C. A systematic review of providers' experiences of facilitating group antenatal care. Reprod Health 2021; 18:180. [PMID: 34493314 PMCID: PMC8425020 DOI: 10.1186/s12978-021-01200-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 06/24/2021] [Indexed: 11/25/2022] Open
Abstract
Background Group antenatal care is a rapidly expanding alternative antenatal care delivery model. Research has shown it to be a safe and effective care model for women, but less is known about the perspectives of the providers leading this care. This systematic review examined published literature that considered health care professionals’ experiences of facilitating group antenatal care. Methods Systematic searches were conducted in seven databases (Cinahl, Medline, Psychinfo, Embase, Ovid Emcare, Global Health and MIDRS) in April 2020. Qualitative or mixed methods studies with a significant qualitative component were eligible for inclusion if they included a focus on the experiences of health care providers who had facilitated group antenatal care. Prisma screening guidelines were followed and study quality was critically appraised by three independent reviewers. The findings were synthesised thematically. Results Nineteen papers from nine countries were included. Three main themes emerged within provider experiences of group antenatal care. The first theme, ‘Giving women the care providers feel they want and need’, addresses richer use of time, more personal care, more support, and continuity of care. The second theme, ‘Building skills and relationships’, highlights autonomy, role development and hierarchy dissolution. The final theme, ‘Value proposition of group antenatal care’, discusses provider investment and workload. Conclusions Health care providers’ experience of delivering group antenatal care was positive overall. Opportunities to deliver high-quality care that benefits women and allows providers to develop their professional role were appreciated. Questions about the providers’ perspectives on workload, task shifting, and the structural changes needed to support the sustainability of group antenatal care warrant further exploration. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01200-0. Receiving antenatal care in a group setting has been found to be safe and satisfying for women and is supported by international public health guidelines. However, questions remain about the experience of health care professionals tasked with providing this model, such as whether they like working in this model and whether they support its expansion. To answer these questions, the team searched for studies about the experiences of health care providers with group antenatal care, and only included those studies where providers themselves spoke about their own experiences of providing this kind of care. Our review demonstrated that midwives, doctors, nurses and community health workers mostly enjoyed facilitating group antenatal care. They particularly appreciated the ability to give women the kind of care they felt women want and need. Health care providers also experienced some changes in their professional roles, in relation to both the women they serve and their colleagues and organizations. In order to determine if group antenatal care models are a satisfying and sustainable option for health care professionals in the long term, more research is needed.
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Merriel A, Maharjan N, Clayton G, Toolan M, Lynch M, Barnard K, Lavender T, Larkin M, Rai N, Thapa M, Caldwell DM, Burden C, Manandhar DS, Fraser A. A cross-sectional study to evaluate antenatal care service provision in 3 hospitals in Nepal. AJOG GLOBAL REPORTS 2021; 1:100015. [PMID: 36277254 PMCID: PMC9564025 DOI: 10.1016/j.xagr.2021.100015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND OBJECTIVE STUDY DESIGN RESULTS CONCLUSION
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Roney E, Morgan C, Gatungu D, Mwaura P, Mwambeo H, Natecho A, Comrie-Thomson L, Gitaka JN. Men's and women's knowledge of danger signs relevant to postnatal and neonatal care-seeking: A cross sectional study from Bungoma County, Kenya. PLoS One 2021; 16:e0251543. [PMID: 33984032 PMCID: PMC8118271 DOI: 10.1371/journal.pone.0251543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/28/2021] [Indexed: 11/24/2022] Open
Abstract
Background Neonatal and maternal mortality rates remain high in Kenya. Knowledge of neonatal danger signs may reduce delay in deciding to seek care. Evidence is emerging on the influential role of male partners in improving maternal and newborn health. This study analysed the factors that determine men’s and women’s knowledge and practices in postnatal and neonatal care-seeking, in order to inform design of future interventions. Methods A quantitative, cross-sectional study was undertaken in Bungoma County, Kenya. Women who had recently given birth (n = 348) and men whose wives had recently given birth (n = 82) completed questionnaires on knowledge and care-seeking practices relating to the postnatal period. Univariate and multivariate logistic regression analyses were performed to investigate associations with key maternal and newborn health outcomes. Results 51.2% of women and 50.0% of men knew at least one neonatal danger sign, however women knew more individual danger signs than men. In the univariate model, women’s knowledge of a least one neonatal danger sign was associated with attending antenatal care ≥4 times (OR 4.46, 95%CI 2.73–7.29, p<0.001), facility birth (OR 3.26, 95%CI 1.89–5.72, p<0.001), and having a male partner accompany them to antenatal care (OR 3.34, 95%CI 1.35–8.27, p = 0.009). Higher monthly household income (≥10,000KSh, approximately US$100) was associated with facility delivery (AOR 11.99, 95%CI 1.59–90.40, p = 0.009). Conclusion Knowledge of neonatal danger signs was low, however there was an association between knowledge of danger signs and increased healthcare service use, including male partner involvement in antenatal care. Future interventions should consider the extra costs of facility delivery and the barriers to men participating in antenatal and postnatal care.
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Affiliation(s)
- Emma Roney
- Burnet Institute, Melbourne, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Christopher Morgan
- Burnet Institute, Melbourne, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Daniel Gatungu
- Directorate of Research and Innovation, Mount Kenya University, Thika, Kenya
| | - Peter Mwaura
- Directorate of Research and Innovation, Mount Kenya University, Thika, Kenya
| | - Humphrey Mwambeo
- Directorate of Research and Innovation, Mount Kenya University, Thika, Kenya
| | | | - Liz Comrie-Thomson
- Burnet Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Uro-Gynaecology, Ghent University, Ghent, Belgium
| | - Jesse N. Gitaka
- Directorate of Research and Innovation, Mount Kenya University, Thika, Kenya
- * E-mail:
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Honorato DJP, Fulone I, Silva MT, Lopes LC. Risks of Adverse Neonatal Outcomes in Early Adolescent Pregnancy Using Group Prenatal Care as a Strategy for Public Health Policies: A Retrospective Cohort Study in Brazil. Front Public Health 2021; 9:536342. [PMID: 33898367 PMCID: PMC8062755 DOI: 10.3389/fpubh.2021.536342] [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: 04/17/2020] [Accepted: 03/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Adolescent pregnancy is a public health concern and many studies have evaluated neonatal outcomes, but few have compared younger adolescents with older using adequate prenatal care. Objective: To compare the risks of adverse neonatal outcomes in younger pregnant adolescents who are properly followed through group prenatal care (GPC) delivered by specialized public services. Methods: This retrospective cohort study followed pregnant adolescents (aged 10-17 years) who received GPC from specialized public services in Brazil from 2009 to 2014. Data were obtained from medical records and through interviews with a multidisciplinary team that treated the patients. The neonatal outcomes (low birth weight, prematurity, Apgar scores with 1 and 5 min, and neonatal death) of newborns of adolescents aged 10-13 years were compared to those of adolescents aged 14-15 years and 16-17 years. Incidence was calculated with 95% confidence intervals (CIs) and compared over time using a chi-squared test to observe trends. Poisson Multivariate logistic regression was used to adjust for confounding variables. The results are presented as adjusted relative risks or adjusted mean differences. Results: Of the 1,112 adolescents who were monitored, 758 were included in this study. The overall incidence of adverse neonatal outcomes (low birth weight and prematurity) was measured as 10.2% (95% CI: 9.7-11.5). Apgar scores collected at 1 and 5 min were found to be normal, and no instance of fetal death occurred. The incidence of low birth weight was 16.1% for the 10-13 age group, 8.7% for the 14-15 age group and 12.1% for the 16-17 age group. The incidence of preterm was measured at 12, 8.5, and 12.6% for adolescents who were 10-13, 14-15, and 16-17 years of age, respectively. Neither low birth weight nor prematurity levels significantly differed among the groups (p > 0.05). The infants born to mothers aged 10-13 years presented significantly (p < 0.05) lower Apgar scores than other age groups, but the scores were within the normal range. Conclusions: Our findings showed lower incidence of neonatal adverse outcomes and no risk difference of neonatal outcomes in younger pregnancy adolescents. It potentially suggests that GPC model to care pregnant adolescents is more important than the age of pregnant adolescent, however further research is needed.
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Affiliation(s)
| | | | | | - Luciane Cruz Lopes
- Pharmaceutical Sciences Graduate Course, University of Sorocaba (UNISO), Sorocaba, Brazil
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Ramdas K, Swaminathan S. Patients could share virtual medical appointments for better access to telemedicine. Nat Med 2021; 27:14-16. [PMID: 33442005 DOI: 10.1038/s41591-020-01187-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kamalini Ramdas
- Management Science and Operations, London Business School, London, UK.
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Galle A, Semaan A, Huysmans E, Audet C, Asefa A, Delvaux T, Afolabi BB, El Ayadi AM, Benova L. A double-edged sword-telemedicine for maternal care during COVID-19: findings from a global mixed-methods study of healthcare providers. BMJ Glob Health 2021; 6:e004575. [PMID: 33632772 PMCID: PMC7908054 DOI: 10.1136/bmjgh-2020-004575] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/03/2021] [Accepted: 02/10/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic has led to a rapid implementation of telemedicine for the provision of maternal and newborn healthcare. The objective of this study was to document the experiences with providing telemedicine for maternal and newborn healthcare during the pandemic among healthcare professionals globally. METHODS The second round of a global online survey of maternal and newborn health professionals was conducted, disseminated in 11 languages. Data were collected between 5 July and 10 September 2020. The questionnaire included questions regarding background, preparedness and response to COVID-19, and experiences with providing telemedicine. Descriptive statistics and qualitative thematic analysis were used to analyse responses, disaggregated by country income level. RESULTS Responses from 1060 maternal and newborn health professionals were analysed. Telemedicine was used by 58% of health professionals and two-fifths of them reported not receiving guidelines on the provision of telemedicine. Key telemedicine practices included online birth preparedness classes, antenatal and postnatal care by video/phone, a COVID-19 helpline and online psychosocial counselling. Challenges reported lack of infrastructure and technological literacy, limited monitoring, financial and language barriers, lack of non-verbal feedback and bonding, and distrust from patients. Telemedicine was considered as an important alternative to in-person consultations. However, health providers emphasised the lower quality of care and risk of increasing the already existing inequalities in access to healthcare. CONCLUSIONS Telemedicine has been applied globally to address disruptions of care provision during the COVID-19 pandemic. However, some crucial aspects of maternal and newborn healthcare seem difficult to deliver by telemedicine. More research regarding the effectiveness, efficacy and quality of telemedicine for maternal healthcare in different contexts is needed before considering long-term adaptations in provision of care away from face-to-face interactions. Clear guidelines for care provision and approaches to minimising socioeconomic and technological inequalities in access to care are urgently needed.
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Affiliation(s)
- Anna Galle
- ICRH, Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Aline Semaan
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Elise Huysmans
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Constance Audet
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Anteneh Asefa
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Therese Delvaux
- Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | | | - Alison Marie El Ayadi
- Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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Lasater ME, Murray SM, Keita M, Souko F, Surkan PJ, Warren NE, Winch PJ, Ba A, Doumbia S, Bass JK. Integrating Mental Health into Maternal Health Care in Rural Mali: A Qualitative Study. J Midwifery Womens Health 2020; 66:233-239. [PMID: 33325644 DOI: 10.1111/jmwh.13184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 08/24/2020] [Accepted: 08/31/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Common perinatal mental disorders are prevalent in low- and middle-income countries. The gap between the need for and availability of mental health services, also known as the mental health treatment gap, is particularly acute for women during the perinatal period in rural Mali. This qualitative study aimed to identify a feasible and acceptable integrated care approach for the provision of maternal mental health care in rural Mali to help narrow the treatment gap and increase access to care. METHODS From April to June 2016, qualitative data were collected in the Sélingué health district and Bamako, Mali. In-depth interviews were conducted among women, community health workers, midwives, and mental health specialists. Focus group participants included community health workers, midwives, and an obstetric nurse. All data were inductively coded and analyzed using a thematic analysis approach. RESULTS Women described several coping strategies to manage their distress, including visiting their parents; confiding in a friend, relative, or community health worker; and participating in women's association groups. Mental health-related stigma was described as being widespread in the community and among health providers. In response to the lack of mental health services, midwives and community health workers supported the feasibility and acceptability of the integration of mental health services into maternal health services. Midwives were discussed as being key providers to conduct mental health screenings and provide initial psychosocial care for women. DISCUSSION Integrated maternal and mental health interventions are needed to narrow the gap between the need for and availability of mental health services in rural Mali. Findings from this study underscore the great need for mental health services for women in the perinatal period who reside in rural Mali and that it is both feasible and acceptable to integrate mental health screening and low-level psychosocial care into antenatal care, delivered by midwives.
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Affiliation(s)
- Molly E Lasater
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah M Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mariam Keita
- Department of Public Health, University of Sciences, Techniques, and Technology of Bamako, Bamako, Mali
| | - Fatoumata Souko
- Department of Public Health, University of Sciences, Techniques, and Technology of Bamako, Bamako, Mali
| | - Pamela J Surkan
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nicole E Warren
- Department of Community Public Health Nursing, Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Peter J Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Aissata Ba
- Department of Public Health, University of Sciences, Techniques, and Technology of Bamako, Bamako, Mali
| | - Seydou Doumbia
- Faculty of Medicine and Odontostomatology, University of Sciences, Techniques, and Technology of Bamako, Bamako, Mali.,University Clinical Research Center/ICER-Mali, University of Sciences, Techniques, and Technology of Bamako, Bamako, Mali
| | - Judith K Bass
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Ibañez-Cuevas M, Heredia-Pi IB, Fuentes-Rivera E, Andrade-Romo Z, Alcalde-Rabanal J, Cacho LBB, Guzmán-Delgado X, Jurkiewicz L, Darney BG. Group Prenatal Care in Mexico: perspectives and experiences of health personnel. Rev Saude Publica 2020; 54:140. [PMID: 33331532 PMCID: PMC7703532 DOI: 10.11606/s1518-8787.2020054002175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 04/08/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Identify barriers and facilitators to implementing the Group Prenatal Care model in Mexico (GPC) from the health care personnel's perspective. METHODS We carried out a qualitative descriptive study in four clinics of the Ministry of Health in two states of Mexico (Morelos and Hidalgo) from June 2016 to August 2018. We conducted 11 semi-structured interviews with health care service providers, and we examined their perceptions and experiences during the implementation of the GPC model. We identified the barriers and facilitators for its adoption in two dimensions: a) structural (space, resources, health personnel, patient volume, community) and b) attitudinal (motivation, leadership, acceptability, address problems, work atmosphere and communication). RESULTS The most relevant barriers reported at the structural level were the availability of physical space in health units and the work overload of health personnel. We identified the difficulty in adopting a less hierarchical relationship during the pregnant women's care at the attitudinal level. The main facilitator at the attitudinal level was the acceptability that providers had of the model. One specific finding for Mexico's implementation context was the resistance to change the doctor-patient relationship; it is difficult to abandon the prevailing hierarchical model and change to a more horizontal relationship with pregnant women. CONCLUSION Analyzing the GPC model's implementation in Mexico, from the health care personnel's perspective, has revealed barriers and facilitators similar to the experiences in other contexts. Future efforts to adopt the model should focus on timely attention to identified barriers, especially those identified in the attitudinal dimension that can be modified by regular health care personnel training.
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Affiliation(s)
- Midiam Ibañez-Cuevas
- Instituto Nacional de Salud Pública. Centro de Investigación en Sistemas de Salud. Cuernavaca, MOR, México
| | - Ileana Beatriz Heredia-Pi
- Instituto Nacional de Salud Pública. Centro de Investigación en Sistemas de Salud. Cuernavaca, MOR, México
| | - Evelyn Fuentes-Rivera
- Instituto Nacional de Salud Pública. Centro de Investigación en Sistemas de Salud. Cuernavaca, MOR, México
| | - Zafiro Andrade-Romo
- Instituto Nacional de Salud Pública. Centro de Investigación en Sistemas de Salud. Cuernavaca, MOR, México
| | - Jacqueline Alcalde-Rabanal
- Instituto Nacional de Salud Pública. Centro de Investigación en Sistemas de Salud. Cuernavaca, MOR, México
| | | | - Xochitl Guzmán-Delgado
- Instituto Nacional de Salud Pública. Centro de Investigación en Sistemas de Salud. Cuernavaca, MOR, México
| | - Laurie Jurkiewicz
- University of California San Francisco. San Francisco General Hospital. Department of ObGyn & Reproductive Sciences. San Francisco, CA, USA
| | - Blair G Darney
- Oregon Health & Science University. Department of Obstetrics & Gynecology. Portland, OR, USA
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Gaur BPS, Vasudevan J, Pegu B. Group Antenatal Care: A Paradigm Shift to Explore for Positive Impacts in Resource-poor Settings. J Prev Med Public Health 2020; 54:81-84. [PMID: 33618503 PMCID: PMC7939754 DOI: 10.3961/jpmph.20.349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/23/2020] [Indexed: 11/09/2022] Open
Abstract
The delivery of high-quality antenatal care is a perennial global concern for improving maternal and neonatal outcomes. Antenatal care is currently provided mainly on a one-to-one basis, but growing evidence has emerged to support the effectiveness of group antenatal care. Providing care in a small group gives expectant mothers the opportunity to have discussions with their peers about certain issues and concerns that are unique to them and to form a support system that will improve the quality and utilization of antenatal care services. The aim of this article is to promote group antenatal care as a means to increase utilization of healthcare.
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Affiliation(s)
- Bhanu Pratap Singh Gaur
- Department of Community Medicine, Mahatma Gandhi Medical College & Research Institute (MGMCRI), Puducherry, India
| | - Jyothi Vasudevan
- Department of Community Medicine, Mahatma Gandhi Medical College & Research Institute (MGMCRI), Puducherry, India
| | - Bhabani Pegu
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
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Therrien AS, Buffa G, Roome AB, Standard E, Pomer A, Obed J, Taleo G, Tarivonda L, Chan CW, Kaneko A, Olszowy KM, Dancause KN. Relationships between mental health and diet during pregnancy and birth outcomes in a lower-middle income country: "Healthy mothers, healthy communities" study in Vanuatu. Am J Hum Biol 2020; 33:e23500. [PMID: 32918311 DOI: 10.1002/ajhb.23500] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 12/15/2022] Open
Abstract
Poor maternal mental health during pregnancy is associated with adverse birth outcomes, including lower birthweight and gestational age. However, few studies assess both mental health and diet, which might have interactive effects. Furthermore, most studies are in high-income countries, though patterns might differ in low- and middle-income countries (LMICs). OBJECTIVES To analyze relationships between mental health and diet during pregnancy with birth outcomes in Vanuatu, a lower-middle income country. METHODS We assessed negative emotional symptoms of depression, anxiety, and stress (referred to as "distress") and dietary diversity during pregnancy, and infant weight and gestational age at birth, among 187 women. We used multivariate linear regression to analyze independent and interactive relationships between distress, dietary diversity, and birth outcomes, controlling for sociodemographic and maternal health covariates. RESULTS There were no direct linear relationships between dietary diversity or distress with infant birthweight or gestational age, and no curvilinear relationships between distress and infant outcomes. We observed interactive relationships between distress and dietary diversity on birthweight, explaining 2.1% of unique variance (P = .024). High levels of distress predicted lower birthweights among women with low dietary diversity. These relationships were not evident among women with moderate or high dietary diversity. CONCLUSIONS Relationships between mental health and diet might underlie inconsistencies in past studies of prenatal mental health and birthweight. Results highlight the importance of maternal mental health on birthweight in LMICs. Interactive relationships between mental health and diet might ultimately point to new intervention pathways to address the persistent problem of low birthweight in LMICs.
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Affiliation(s)
- Ann-Sophie Therrien
- Department of Physical Activity Sciences, University of Quebec in Montréal, Montreal, Quebec, Canada
| | - Giovanna Buffa
- Department of Anthropology, Binghamton University, Binghamton, New York, USA
| | - Amanda B Roome
- Bassett Research Institute, Mary Imogene Bassett Hospital, Cooperstown, New York, USA
| | - Elizabeth Standard
- Department of Anthropology, Binghamton University, Binghamton, New York, USA
| | - Alysa Pomer
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Jimmy Obed
- Ministry of Health, Port Vila, Republic of Vanuatu
| | - George Taleo
- Ministry of Health, Port Vila, Republic of Vanuatu
| | | | - Chim W Chan
- Department of Parasitology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Akira Kaneko
- Department of Parasitology, Graduate School of Medicine, Osaka City University, Osaka, Japan.,Island Malaria Group, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Kathryn M Olszowy
- Department of Anthropology, New Mexico State University, Las Cruces, New Mexico, USA
| | - Kelsey N Dancause
- Department of Physical Activity Sciences, University of Quebec in Montréal, Montreal, Quebec, Canada
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Hackett K, Huber-Krum S, Francis JM, Senderowicz L, Pearson E, Siril H, Ulenga N, Shah I. Evaluating the Implementation of an Intervention to Improve Postpartum Contraception in Tanzania: A Qualitative Study of Provider and Client Perspectives. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:270-289. [PMID: 32606094 PMCID: PMC7326523 DOI: 10.9745/ghsp-d-19-00365] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 06/02/2020] [Indexed: 11/26/2022]
Abstract
Training and supervision to improve interpersonal aspects of care, including an emphasis on patient-centered counseling, informed choice, and respectful and nondiscriminatory service delivery, should be integrated into future postpartum family planning initiatives. Background: This qualitative study assessed implementation of the Postpartum Intrauterine Device (PPIUD) Initiative in Tanzania, a country with high rates of unintended pregnancy and low contraceptive prevalence. The PPIUD Initiative was implemented to reduce unmet need for contraception among new mothers through postpartum family planning counseling delivered during antenatal care and offering PPIUD insertion immediately following birth. Methods: We used the implementation outcomes framework and an ecological framework to analyze in-depth interviews with providers (N=15) and women (N=47) participating in the initiative. We applied a multistage coding protocol and used thematic content analysis to identify the factors influencing implementation. Results: Both women and providers were enthusiastic and receptive to the PPIUD Initiative. Health system and resource constraints made adoption and fidelity to the intended intervention challenging. Many providers questioned the sustainability of the initiative, and most agreed that changes to the initiative’s design (e.g., additional training opportunities, improved staffing, and availability of PPIUD supplies) would strengthen future iterations of the initiative. According to women, interpersonal aspects of care varied, with some women reporting rushed or incomplete counseling or an emphasis on the PPIUD over other methods. The perception that some providers treat older married women more favorably suggests that fidelity to the intended PPIUD Initiative was not uniformly achieved. Conclusions: Study findings inform initiatives seeking to develop and adopt postpartum family planning programs and enhance program implementation. A comprehensive needs assessment to evaluate feasibility and identify potential adaptations for the local context is recommended. Training and supervision to improve interpersonal aspects of care, including an emphasis on patient-centered counseling, informed choice, and respectful and nondiscriminatory service delivery should be integrated into future postpartum family planning initiatives.
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Affiliation(s)
- Kristy Hackett
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Sarah Huber-Krum
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Joel M Francis
- Management and Development for Health, Dar es Salaam, Tanzania.,Department of Family Medicine and Primary Care, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Leigh Senderowicz
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Erin Pearson
- Technical Innovation and Evidence, Ipas, Chapel Hill, NC, USA
| | - Hellen Siril
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Iqbal Shah
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Fuentes-Rivera E, Heredia-Pi I, Andrade-Romo Z, Alcalde-Rabanal J, Bravo L, Jurkiewicz L, Darney BG. Evaluating process fidelity during the implementation of Group Antenatal Care in Mexico. BMC Health Serv Res 2020; 20:559. [PMID: 32552889 PMCID: PMC7301482 DOI: 10.1186/s12913-020-05430-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/15/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND CenteringPregnancy (CP) is a group antenatal care (G-ANC) model that has proven beneficial for mothers and their newborns. We conducted a feasibility study beginning in 2016 as part of the Mexican effort to implement G-ANC locally. This study reports on fidelity to the essential elements of CP during its implementation in Mexico. METHODS We collected prospective data using a standardized checklist at four primary-care centers that implemented our adapted G-ANC model. We performed a descriptive analysis of fidelity to 28 processes per G-ANC session (71 sessions made up of 10 groups and 129 women across 4 health centers). We calculated fidelity to each process as a proportion with 95% confidence intervals. We present overall results and stratified by health center and by facilitation team. RESULTS Overall fidelity to the G-ANC intervention was 82%, with variability by health center (78-88%). The elements with the highest fidelity were having space for activities such as checking vital signs, conversation in a circle, and medical check-ups (100% each) and the element with the lowest fidelity was using music to enhance privacy (27.3%). Fidelity was not significantly different by center. CONCLUSIONS Our study suggests good model fidelity during the implementation of G-ANC in Mexico. Our findings also contribute useful information about where to focus efforts in the future to maintain and improve G-ANC model fidelity.
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Affiliation(s)
- Evelyn Fuentes-Rivera
- Center for Health Systems Research, National Institute of Public Health, Av. Universidad 655, Col. Santa María Ahuacatitlán, 62100 Cuernavaca, Morelos Mexico
| | - Ileana Heredia-Pi
- Center for Health Systems Research, National Institute of Public Health, Av. Universidad 655, Col. Santa María Ahuacatitlán, 62100 Cuernavaca, Morelos Mexico
| | - Zafiro Andrade-Romo
- Center for Health Systems Research, National Institute of Public Health, Av. Universidad 655, Col. Santa María Ahuacatitlán, 62100 Cuernavaca, Morelos Mexico
| | - Jacqueline Alcalde-Rabanal
- Center for Health Systems Research, National Institute of Public Health, Av. Universidad 655, Col. Santa María Ahuacatitlán, 62100 Cuernavaca, Morelos Mexico
| | - Lourdes Bravo
- Center for Health Systems Research, National Institute of Public Health, Av. Universidad 655, Col. Santa María Ahuacatitlán, 62100 Cuernavaca, Morelos Mexico
| | - Laurie Jurkiewicz
- Department of ObGyn & Reproductive Sciences, UCSF/SFGH, San Francisco, CA USA
| | - Blair G. Darney
- OHSU, Oregon Health & Science University, Portland, OR USA
- National Institute of Public Health, Cuernavaca, Mexico
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McKinnon B, Sall M, Vandermorris A, Traoré M, Lamesse-Diedhiou F, McLaughlin K, Bassani D. Feasibility and preliminary effectiveness of group antenatal care in Senegalese health posts: a pilot implementation trial. Health Policy Plan 2020; 35:587-599. [PMID: 32155254 DOI: 10.1093/heapol/czz178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2019] [Indexed: 11/14/2022] Open
Abstract
Almost all pregnant women in Senegal receive some antenatal care (ANC), yet only around half receive four or more visits and provision of education and counselling during ANC is often inadequate and, in some cases, non-existent. This results in missed opportunities to provide support and to counsel women regarding appropriate care-seeking practices and health behaviours during pregnancy and across the continuum of care. This pilot effectiveness-implementation randomized controlled trial explored whether group ANC (G-ANC), a model that integrates standard individual pregnancy care with facilitated participatory group education activities and peer support, could potentially address some of these challenges. The G-ANC model adapted for Senegal builds on local healthcare delivery systems and aligns with World Health Organization recommendations for a shift towards women-centred models of maternity services. It was implemented at the health post level, and a total of 330 pregnant women participated in the study, of whom 85% were followed up at 6-10 weeks post-delivery. We assessed implementation outcomes (e.g. acceptability, cost) to establish the feasibility of the model in Senegal and explored effectiveness outcomes related to maternal and infant health for the planning of a large-scale trial. Results indicate that women and ANC providers were overwhelmingly enthusiastic about the G-ANC model, and exploratory analyses suggested improvements in exclusive breastfeeding, intention to use family planning, birth preparations and knowledge around maternal and newborn danger signs. This article provides timely and relevant evidence on the feasibility of G-ANC as an alternative model of care during pregnancy and a solid basis for recommending the conduct of a large-scale implementation study of G-ANC in Senegal.
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Affiliation(s)
- Britt McKinnon
- Centre for Global Child Health, The Hospital for Sick Children, 686 Bay Street, Toronto, ON M5G 0A4, Canada.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON M5T 3M7, Canada
| | - Mohamadou Sall
- Institut de Recherche et Formation en Population, Développement et Santé de la Reproduction, Université Cheik Anta Diop, P.O. Box 45 550 Dakar Fann, Dakar, Senegal
| | - Ashley Vandermorris
- Division of Adolescent Medicine, The Hospital for Sick Children, 686 Bay Street, Toronto, ON M5G 0A4, Canada.,Department of Pediatrics, University of Toronto, 555 University Ave, Toronto, ON M5G 1X8, Canada
| | - Mahamadou Traoré
- Institut de Recherche et Formation en Population, Développement et Santé de la Reproduction, Université Cheik Anta Diop, P.O. Box 45 550 Dakar Fann, Dakar, Senegal
| | - Fatma Lamesse-Diedhiou
- Institut de Recherche et Formation en Population, Développement et Santé de la Reproduction, Université Cheik Anta Diop, P.O. Box 45 550 Dakar Fann, Dakar, Senegal
| | - Katie McLaughlin
- Centre for Global Child Health, The Hospital for Sick Children, 686 Bay Street, Toronto, ON M5G 0A4, Canada
| | - Diego Bassani
- Centre for Global Child Health, The Hospital for Sick Children, 686 Bay Street, Toronto, ON M5G 0A4, Canada.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON M5T 3M7, Canada.,Department of Pediatrics, University of Toronto, 555 University Ave, Toronto, ON M5G 1X8, Canada
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Debnath F, Chakraborty D, Deb AK. Re: "Outpatient Breastfeeding Champion Program: Breastfeeding Support in Primary Care" by Patterson et al. ( Breastfeed Med 2020;15(1):44-48. DOI: 10.1089/bfm.2019.0108). Breastfeed Med 2020; 15:349-350. [PMID: 32208928 DOI: 10.1089/bfm.2020.0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Falguni Debnath
- Department of Epidemiology, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Debjit Chakraborty
- Department of Epidemiology, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Alok Kumar Deb
- Department of Epidemiology, National Institute of Cholera and Enteric Diseases, Kolkata, India
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Christou A, Alam A, Sadat Hofiani SM, Rasooly MH, Mubasher A, Rashidi MK, Dibley MJ, Raynes-Greenow C. Understanding pathways leading to stillbirth: The role of care-seeking and care received during pregnancy and childbirth in Kabul province, Afghanistan. Women Birth 2020; 33:544-555. [PMID: 32094034 DOI: 10.1016/j.wombi.2020.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/20/2020] [Accepted: 02/12/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND The underlying pathways leading to stillbirth in low- and middle-income countries are not well understood. Context-specific understanding of how and why stillbirths occur is needed to prioritise interventions and identify barriers to their effective implementation and uptake. AIM To explore the contribution of contextual, individual, household-level and health system factors to stillbirth in Afghanistan. METHODS Using a qualitative approach, we conducted semi-structured in-depth interviews with women and men that experienced stillbirth, female elders, community health workers, healthcare providers, and government officials in Kabul province, Afghanistan between October-November 2017. We used thematic analysis to identify contributing factors and developed a conceptual map describing possible pathways to stillbirth. FINDINGS We found that low utilisation and access to healthcare was a key contributing factor, as were unmanaged conditions in pregnancy that increased women's risk of complications and stillbirth. Sociocultural factors related to the treatment of women and perceptions about medical interventions deprived women of interventions that could potentially prevent stillbirth. The quality of care from public and private providers during pregnancy and childbirth was a recurring concern exacerbated by health system constraints that led to unnecessary delays; while environmental factors linked to the ongoing conflict were also perceived to contribute to stillbirth. These pathways were underscored by social, cultural, economic factors and individual perceptions that contributed to the three-delays. DISCUSSION Efforts are needed at the community-level to facilitate care-seeking and raise awareness of stillbirth risk factors and the facility-level to strengthen antenatal and childbirth care quality, ensure culturally appropriate and respectful care, and reduce treatment delays.
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Affiliation(s)
- Aliki Christou
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Ashraful Alam
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | | | - Mohammad Hafiz Rasooly
- Afghanistan National Public Health Institute, Ministry of Public Health, Kabul, Afghanistan
| | | | | | - Michael J Dibley
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Camille Raynes-Greenow
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Thapa P, Bangura AH, Nirola I, Citrin D, Belbase B, Bogati B, Nirmala BK, Khadka S, Kunwar L, Halliday S, Choudhury N, Ozonoff A, Tenpa J, Schwarz R, Adhikari M, Kalaunee SP, Rising S, Maru D, Maru S. The power of peers: an effectiveness evaluation of a cluster-controlled trial of group antenatal care in rural Nepal. Reprod Health 2019; 16:150. [PMID: 31640770 PMCID: PMC6805428 DOI: 10.1186/s12978-019-0820-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 09/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Reducing the maternal mortality ratio to less than 70 per 100,000 live births globally is one of the Sustainable Development Goals. Approximately 830 women die from pregnancy- or childbirth-related complications every day. Almost 99% of these deaths occur in developing countries. Increasing antenatal care quality and completion, and institutional delivery are key strategies to reduce maternal mortality, however there are many implementation challenges in rural and resource-limited settings. In Nepal, 43% of deliveries do not take place in an institution and 31% of women have insufficient antenatal care. Context-specific and evidence-based strategies are needed to improve antenatal care completion and institutional birth. We present an assessment of effectiveness outcomes for an adaptation of a group antenatal care model delivered by community health workers and midwives in close collaboration with government staff in rural Nepal. METHODS The study was conducted in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized, cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allowed for iterative improvement in design by making changes to improve the quality of the intervention. We evaluated effectiveness through a difference in difference analysis of institutional birth rates between groups prior to implementation of the intervention and 1 year after implementation. Additionally, we assessed the change in knowledge of key danger signs and the acceptability of the group model compared with individual visits in a nested cohort of women receiving home visit care and home visit care plus group antenatal care. Using a directed content and thematic approach, we analyzed qualitative interviews to identify major themes related to implementation. RESULTS At baseline, there were 457 recently-delivered women in the six village clusters receiving home visit care and 214 in the seven village clusters receiving home visit care plus group antenatal care. At endline, there were 336 and 201, respectively. The difference in difference analysis did not show a significant change in institutional birth rates nor antenatal care visit completion rates between the groups. There was, however, a significant increase in both institutional birth and antenatal care completion in each group from baseline to endline. We enrolled a nested cohort of 52 participants receiving home visit care and 62 participants receiving home visit care plus group antenatal care. There was high acceptability of the group antenatal care intervention and home visit care, with no significant differences between groups. A significantly higher percentage of women who participated in group antenatal care found their visits to be 'very enjoyable' (83.9% vs 59.6%, p = 0.0056). In the nested cohort, knowledge of key danger signs during pregnancy significantly improved from baseline to endline in the intervention clusters only (2 to 31%, p < 0.001), while knowledge of key danger signs related to labor and childbirth, the postpartum period, and the newborn did not in either intervention or control groups. Qualitative analysis revealed that women found that the groups provided an opportunity for learning and discussion, and the groups were a source of social support and empowerment. They also reported an improvement in services available at their village clinic. Providers noted the importance of the community health workers in identifying pregnant women in the community and linking them to the village clinics. Challenges in birth planning were brought up by both participants and providers. CONCLUSION While there was no significant change in institutional birth and antenatal care completion at the population level between groups, there was an increase of these outcomes in both groups. This may be secondary to the primary importance of community health worker involvement in both of these groups. Knowledge of key pregnancy danger signs was significantly improved in the home visit plus group antenatal care cohort compared with the home visit care only group. This initial study of Nyaya Health Nepal's adapted group care model demonstrates the potential for impacting women's antenatal care experience and should be studied over a longer period as an intervention embedded within a community health worker program. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02330887 , registered 01/05/2015, retroactively registered.
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Affiliation(s)
- Poshan Thapa
- University of New South Wales, School of Public Health and Community Medicine, Sydney, NSW Australia
| | | | - Isha Nirola
- Harvard T.H. Chan School of Public Health, Boston, MA USA
| | - David Citrin
- Nyaya Health Nepal, Kathmandu, Nepal
- Department of Anthropology, University of Washington, Seattle, WA USA
- Department of Global Health, University of Washington, Seattle, WA USA
- University of Washington, Henry M. Jackson School of International Studies, Seattle, WA USA
- Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue, Fifth Floor, Room 556, New York, NY 10029 USA
| | | | | | - B. K. Nirmala
- Om Health Science Campus, Purbanchal University, Kathmandu, Nepal
| | | | | | - Scott Halliday
- Nyaya Health Nepal, Kathmandu, Nepal
- Department of Global Health, University of Washington, Seattle, WA USA
- University of Washington, Henry M. Jackson School of International Studies, Seattle, WA USA
- Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue, Fifth Floor, Room 556, New York, NY 10029 USA
| | - Nandini Choudhury
- Nyaya Health Nepal, Kathmandu, Nepal
- Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue, Fifth Floor, Room 556, New York, NY 10029 USA
| | - Al Ozonoff
- Center for Patient Safety and Quality Research, Boston Children’ Hospital, Boston, MA USA
- Department of Medicine, Harvard Medical School, Boston, MA USA
| | - Jasmine Tenpa
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA USA
| | - Ryan Schwarz
- Nyaya Health Nepal, Kathmandu, Nepal
- Department of Medicine, Harvard Medical School, Boston, MA USA
- Department of Medicine, Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
- Department of Medicine, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA USA
| | | | - S. P. Kalaunee
- Nyaya Health Nepal, Kathmandu, Nepal
- Eastern University, College of Leadership and Development, St. Davids, PA USA
| | | | - Duncan Maru
- Nyaya Health Nepal, Kathmandu, Nepal
- Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue, Fifth Floor, Room 556, New York, NY 10029 USA
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Sheela Maru
- Nyaya Health Nepal, Kathmandu, Nepal
- Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue, Fifth Floor, Room 556, New York, NY 10029 USA
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY USA
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Grenier L, Suhowatsky S, Kabue MM, Noguchi LM, Mohan D, Karnad SR, Onguti B, Omanga E, Gichangi A, Wambua J, Waka C, Oyetunji J, Smith JM. Impact of group antenatal care (G-ANC) versus individual antenatal care (ANC) on quality of care, ANC attendance and facility-based delivery: A pragmatic cluster-randomized controlled trial in Kenya and Nigeria. PLoS One 2019; 14:e0222177. [PMID: 31577797 PMCID: PMC6774470 DOI: 10.1371/journal.pone.0222177] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/20/2019] [Indexed: 11/18/2022] Open
Abstract
Background Low quality and frequency of antenatal care (ANC) are associated with lower uptake of facility-based deliveries—a key intervention to reduce maternal and neonatal mortality. We implemented group ANC (G-ANC), an alternative service delivery model, in Kenya and Nigeria, to assess its impact on quality and attendance at ANC and uptake of facility-based delivery. Methods From October 2016‒January 2018, we conducted a facility-based, pragmatic, cluster-randomized controlled trial with 20 clusters per country. We recruited women <24 weeks gestation during their first ANC visit and enrolled women at intervention facilities who agreed to attend G-ANC in lieu of routine individual ANC. The G-ANC model consisted of five monthly 2-hour meetings with clinical assessments alongside structured gestationally specific group discussions and activities. Quality of care was defined as receipt of eight specific ANC interventions. Data were obtained through facility records and self-report during a home-based postpartum survey. Analysis was by intention to treat. Findings All women who completed follow up are included in the analysis (Nigeria: 1018/1075 enrolled women [94.7%], Kenya: 826/1013 [81.5%]). In Nigeria women in the intervention arm were more likely to have a facility-based delivery compared to those in the control arm (Nigeria: 76.7% [391/510] versus 54.1% [275/508]; aOR 2.30, CI 1.51–3.49). In both countries women in the intervention arm were more likely than those in the control arm to receive quality ANC (Nigeria: aOR 5.8, CI 1.98–17.21, p<0.001; Kenya: aOR 5.08, CI 2.31–11.16, p<0.001) and to attend at least four ANC visits (Nigeria: aOR 13.30, CI 7.69–22.99, p<0.001; Kenya: aOR 7.12, CI 3.91–12.97, p<0.001). Conclusions G-ANC was associated with higher facility-based delivery rates in Nigeria, where those rates associated with individual ANC were low. In both Kenya and Nigeria it was associated with a higher proportion of women receiving quality ANC and higher frequency of ANC visits.
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Affiliation(s)
- Lindsay Grenier
- Department of Maternal and Newborn Health, Jhpiego, Baltimore, MD, United States of America
- * E-mail: (LG); (SS)
| | - Stephanie Suhowatsky
- Department of Maternal and Newborn Health, Jhpiego, Baltimore, MD, United States of America
- * E-mail: (LG); (SS)
| | - Mark M. Kabue
- Department of Monitoring, Evaluation and Research, Jhpiego, Baltimore, MD, United States of America
| | - Lisa M. Noguchi
- Department of Maternal and Newborn Health, Jhpiego, Baltimore, MD, United States of America
| | - Diwakar Mohan
- Global Epidemiology and Control, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | | | - Brenda Onguti
- Innovations and Technical Leadership, Jhpiego, Nairobi, Kenya
| | - Eunice Omanga
- Department of Monitoring, Evaluation, and Research, Jhpiego, Nairobi, Kenya
| | - Anthony Gichangi
- Department of Monitoring, Evaluation, and Research, Jhpiego, Nairobi, Kenya
| | - Jonesmus Wambua
- Department of Monitoring, Evaluation, and Research, Jhpiego, Nairobi, Kenya
| | - Charles Waka
- Department of Monitoring, Evaluation, and Research, Jhpiego, Nairobi, Kenya
| | | | - Jeffrey M. Smith
- Technical Leadership Office, Jhpiego, Baltimore, MD, United States of America
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Andrade-Romo Z, Heredia-Pi IB, Fuentes-Rivera E, Alcalde-Rabanal J, Cacho LBB, Jurkiewicz L, Darney BG. Group prenatal care: effectiveness and challenges to implementation. Rev Saude Publica 2019; 53:85. [PMID: 31576945 PMCID: PMC6763281 DOI: 10.11606/s1518-8787.2019053001303] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 04/07/2019] [Indexed: 11/13/2022] Open
Abstract
Group prenatal care is an alternative model of care during pregnancy, replacing standard individual prenatal care. The model has shown maternal benefits and has been implemented in different contexts. We conducted a narrative review of the literature in relation to its effectiveness, using databases such as PubMed, EBSCO, Science Direct, Wiley Online and Springer for the period 2002 to 2018. In addition, we discussed the challenges and solutions of its implementation based on our experience in Mexico. Group prenatal care may improve prenatal knowledge and use of family planning services in the postpartum period. The model has been implemented in more than 22 countries and there are challenges to its implementation related to both supply and demand. Supply-side challenges include staff, material resources and organizational issues; demand-side challenges include recruitment and retention of participants, adaptation of material, and perceived privacy. We highlight specific solutions that can be applied in diverse health systems.
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Affiliation(s)
- Zafiro Andrade-Romo
- Instituto Nacional de Salud Pública. Centro de Investigación en Sistemas de Salud. Cuernavaca, MOR, México
| | - Ileana B Heredia-Pi
- Instituto Nacional de Salud Pública. Centro de Investigación en Sistemas de Salud. Cuernavaca, MOR, México
| | - Evelyn Fuentes-Rivera
- Instituto Nacional de Salud Pública. Centro de Investigación en Sistemas de Salud. Cuernavaca, MOR, México
| | - Jacqueline Alcalde-Rabanal
- Instituto Nacional de Salud Pública. Centro de Investigación en Sistemas de Salud. Cuernavaca, MOR, México
| | | | - Laurie Jurkiewicz
- University of California San Francisco. San Francisco General Hospital. Department of ObGyn & Reproductive Sciences. San Francisco, CA, USA
| | - Blair G Darney
- Oregon Health & Science University. Department of Obstetrics & Gynecology. Portland, OR, USA
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Byrskog U, Ahrne M, Small R, Andersson E, Essen B, Adan A, Ahmed FH, Tesser K, Lidén Y, Israelsson M, Åhman-Berndtsson A, Schytt E. Rationale, development and feasibility of group antenatal care for immigrant women in Sweden: a study protocol for the Hooyo Project. BMJ Open 2019; 9:e030314. [PMID: 31371301 PMCID: PMC6677950 DOI: 10.1136/bmjopen-2019-030314] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Somali-born women comprise a large group of immigrant women of childbearing age in Sweden, with increased risks for perinatal morbidity and mortality and poor experiences of care, despite the goal of providing equitable healthcare for the entire population. Rethinking how care is provided may help to improve outcomes. OVERALL AIM To develop and test the acceptability, feasibility and immediate impacts of group antenatal care for Somali-born immigrant women, in an effort to improve experiences of antenatal care, knowledge about childbearing and the Swedish healthcare system, emotional well-being and ultimately, pregnancy outcomes. This protocol describes the rationale, planning and development of the study. METHODS AND ANALYSIS An intervention development and feasibility study. Phase I includes needs assessment and development of contextual understanding using focus group discussions. In phase II, the intervention and evaluation tools, based on core values for quality care and person-centred care, are developed. Phase III includes the historically controlled evaluation in which relevant outcome measures are compared for women receiving individual care (2016-2018) and women receiving group antenatal care (2018-2019): care satisfaction (Migrant Friendly Maternity Care Questionnaire), emotional well-being (Edinburgh Postnatal Depression Scale), social support, childbirth fear, knowledge of Swedish maternity care, delivery outcomes. Phase IV includes the process evaluation, investigate process, feasibility and mechanisms of impact using field notes, observations, interviews and questionnaires. All phases are conducted in collaboration with a stakeholder reference group. ETHICS AND DISSEMINATION The study is approved by the Regional Ethical Review Board, Stockholm, Sweden. Participants receive information about the study and their right to decline/withdraw without consequences. Consent is given prior to enrolment. Findings will be disseminated at antenatal care units, national/international conferences, through publications in peer-reviewed journals, seminars involving stakeholders, practitioners, community and via the project website. Participating women will receive a summary of results in their language.
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Affiliation(s)
- Ulrika Byrskog
- School of Education, Health and Social sciences, Dalarna University, Falun, Sweden
| | - Malin Ahrne
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Rhonda Small
- Mother and Child Health Research, La Trobe University, Melbourne, Victoria, Australia
| | - Ewa Andersson
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Birgitta Essen
- Womens and Childrens Health, Uppsala University, Uppsala, Sweden
| | - Aisha Adan
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Fardosa Hassen Ahmed
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Karin Tesser
- Antenatal Care Clinic, Domnarvet, Borlänge, Sweden
| | | | | | | | - Erica Schytt
- Centre for Clinical Research Dalarna-Uppsala University, Falun, Sweden
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
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Kabue MM, Grenier L, Suhowatsky S, Oyetunji J, Ugwa E, Onguti B, Omanga E, Gichangi A, Wambua J, Waka C, Enne J, Don-Aki J, Ali M, Buba M, Ang’aha J, Iya D, Washika E, Mohan D, Smith JM. Group versus individual antenatal and first year postpartum care: Study protocol for a multi-country cluster randomized controlled trial in Kenya and Nigeria. Gates Open Res 2019; 2:56. [PMID: 30706056 PMCID: PMC6350506 DOI: 10.12688/gatesopenres.12867.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2019] [Indexed: 06/22/2024] Open
Abstract
Background: Antenatal care (ANC) in many low- and middle-income countries is under-utilized and of sub-optimal quality. Group ANC (G-ANC) is an intervention designed to improve the experience and provision of ANC for groups of women (cohorts) at similar stages of pregnancy. Methods: A two-arm, two-phase, cluster randomized controlled trial (cRCT) (non-blinded) is being conducted in Kenya and Nigeria. Public health facilities were matched and randomized to either standard individual ANC (control) or G-ANC (intervention) prior to enrollment. Participants include pregnant women attending first ANC at gestational age <24 weeks, health care providers, and sub-national health managers. Enrollment ended in June 2017 for both countries. In the intervention arm, pregnant women are assigned to cohorts at first ANC visit and receive subsequent care together during five meetings facilitated by a health care provider (Phase 1). After birth, the same cohorts meet four times over 12 months with their babies (Phase 2). Data collection was performed through surveys, clinical data extraction, focus group discussions, and in-depth interviews. Phase 1 data collection ended in January 2018 and Phase 2 concludes in November 2018. Intention-to-treat analysis will be used to evaluate primary outcomes for Phases 1 and 2: health facility delivery and use of a modern method of family planning at 12 months postpartum, respectively. Data analysis and reporting of results will be consistent with norms for cRCTs. General estimating equation models that account for clustering will be employed for primary outcome analyzes. Results: Overall 1,075 and 1,013 pregnant women were enrolled in Nigeria and Kenya, respectively. Final study results will be available in February 2019. Conclusions: This is the first cRCT on G-ANC in Africa. It is among the first to examine the effects of continuing group care through the first year postpartum. Registration: Pan African Clinical Trials Registry PACTR201706002254227 May 02, 2017.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Mairo Ali
- Jhpiego, Nigeria, Abuja, FCT, Nigeria
| | | | | | - Daniel Iya
- Nasarawa State Ministry of Health, Akwanga, Nasarawa, Nigeria
| | | | - Diwakar Mohan
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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47
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Kabue MM, Grenier L, Suhowatsky S, Oyetunji J, Ugwa E, Onguti B, Omanga E, Gichangi A, Wambua J, Waka C, Enne J, Don-Aki J, Ali M, Buba M, Ang'aha J, Iya D, Washika E, Mohan D, Smith JM. Group versus individual antenatal and first year postpartum care: Study protocol for a multi-country cluster randomized controlled trial in Kenya and Nigeria. Gates Open Res 2019; 2:56. [PMID: 30706056 PMCID: PMC6350506 DOI: 10.12688/gatesopenres.12867.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2019] [Indexed: 01/07/2023] Open
Abstract
Background: Antenatal care (ANC) in many low- and middle-income countries is under-utilized and of sub-optimal quality. Group ANC (G-ANC) is an intervention designed to improve the experience and provision of ANC for groups of women (cohorts) at similar stages of pregnancy. Methods: A two-arm, two-phase, cluster randomized controlled trial (cRCT) (non-blinded) is being conducted in Kenya and Nigeria. Public health facilities were matched and randomized to either standard individual ANC (control) or G-ANC (intervention) prior to enrollment. Participants include pregnant women attending first ANC at gestational age <24 weeks, health care providers, and sub-national health managers. Enrollment ended in June 2017 for both countries. In the intervention arm, pregnant women are assigned to cohorts at first ANC visit and receive subsequent care together during five meetings facilitated by a health care provider (Phase 1). After birth, the same cohorts meet four times over 12 months with their babies (Phase 2). Data collection was performed through surveys, clinical data extraction, focus group discussions, and in-depth interviews. Phase 1 data collection ended in January 2018 and Phase 2 concludes in November 2018. Intention-to-treat analysis will be used to evaluate primary outcomes for Phases 1 and 2: health facility delivery and use of a modern method of family planning at 12 months postpartum, respectively. Data analysis and reporting of results will be consistent with norms for cRCTs. General estimating equation models that account for clustering will be employed for primary outcome analyzes. Results: Overall 1,075 and 1,013 pregnant women were enrolled in Nigeria and Kenya, respectively. Final study results will be available in February 2019. Conclusions: This is the first cRCT on G-ANC in Africa. It is among the first to examine the effects of continuing group care through the first year postpartum. Registration: Pan African Clinical Trials Registry PACTR201706002254227 May 02, 2017.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Mairo Ali
- Jhpiego, Nigeria, Abuja, FCT, Nigeria
| | | | | | - Daniel Iya
- Nasarawa State Ministry of Health, Akwanga, Nasarawa, Nigeria
| | | | - Diwakar Mohan
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Khorrami N, Stone J, Small MJ, Stringer EM, Ahmadzia HK. An overview of advances in global maternal health: From broad to specific improvements. Int J Gynaecol Obstet 2019; 146:126-131. [PMID: 31058318 DOI: 10.1002/ijgo.12841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/15/2019] [Accepted: 05/03/2019] [Indexed: 11/12/2022]
Abstract
After the declaration of the Millennium Development Goals in 2000 by the United Nations, many stakeholders allocated financial resources to "global maternal health." Research to expand care and improve delivery of maternal health services has exponentially increased. The present article highlights an overview, namely 10 of the health system, clinical, and technology-based advancements that have occurred in the past three decades in the field of global maternal health. The list of topics has been selected through the cumulative clinical and public health expertise of the authors and is certainly not exhaustive. Rather, the list is intended to provide a mapping of key topics arranged from broad to specific that span from the global policy level to the level of individual care. The list of health system, clinical, and technology-based advancements include: (10) Millennium Development Goals and Sustainable Development Goals; (9) Development of clinical training programs, including the potential for subspecialty development; (8) Prenatal care expansion and potential; (7) Decentralized health systems, including the use of skilled birth attendants; (6) Antiretroviral therapy for HIV; (5) Essential medicines; (4) Vaccines; (3) mHealth/eHealth; (2) Ultrasonography; and (1) Obstetric hemorrhage management. With the Sustainable Development Goals now underway, the field must build upon past successes to sustain maternal and neonatal well-being in the future global health agenda.
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Affiliation(s)
- Najma Khorrami
- Gratitude Circle, LLC, Centreville, VA, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Juliana Stone
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Maria J Small
- Division of Maternal Fetal Medicine, Duke University Medical Center, Durham, NC, USA
| | - Elizabeth M Stringer
- Division of Maternal Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Homa K Ahmadzia
- Department of Obstetrics and Gynecology, Medical Faculty Associates, George Washington University, Washington, DC, USA
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Musabyimana A, Lundeen T, Butrick E, Sayinzoga F, Rwabufigiri BN, Walker D, Musange SF. Before and after implementation of group antenatal care in Rwanda: a qualitative study of women's experiences. Reprod Health 2019; 16:90. [PMID: 31248425 PMCID: PMC6595554 DOI: 10.1186/s12978-019-0750-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 06/05/2019] [Indexed: 11/17/2022] Open
Abstract
Background The Preterm Birth Initiative-Rwanda is conducting a 36-cluster randomized controlled trial of group antenatal and postnatal care. In the context of this trial, we collected qualitative data before and after implementation. The purpose was two-fold. First, to inform the design of the group care program before implementation and second, to document women’s experiences of group care at the mid-point of the trial to make ongoing programmatic adjustments and improvements. Methods We completed 8 focus group discussions among women of reproductive age before group care implementation and 6 focus group discussions among women who participated in group antenatal care and/or postnatal care at 18 health centers that introduced the model, approximately 9 months after implementation. Results Before implementation, focus group participants reported both enthusiasm for the potential for support and insight from a group of peers and concern about the risk of sharing private information with peers who may judge, mock, or gossip. After implementation, group care participants reported benefits including increased knowledge, peer support, and more satisfying relationships with providers. When asked about barriers to group care participation, none of them cited concern about privacy but instead cited lack of financial resources, lack of cooperation from a male partner, and long distances to the health center. Finally, women stated that the group care experience would be improved if all participants and providers arrived on time and remained focused on the group care visit throughout. Discussion These results are consistent with other published reports of women’s perceptions of group antenatal care, especially increased pregnancy- and parenting-related knowledge, peer support, and improved relationships with health care providers. Some results were unexpected, especially the consequences of staff allocation patterns that resulted in providers arriving late for group visits or having to leave during group visits to attend to other facility services, which diminished women’s experiences of care. Conclusion Group antenatal and postnatal care provide compelling benefits to women and families. If the model requires the addition of human resources at the health center, intensive reminder communications, and large-scale community outreach to benefit the largest number of pregnant and postnatal mothers, those additional resources required must be factored into any future decision to scale a group care model. Trial registration This trial is registered at clinicaltrials.gov as NCT03154177. Electronic supplementary material The online version of this article (10.1186/s12978-019-0750-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Angele Musabyimana
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, P.O Box 3286, Kigali, Rwanda
| | - Tiffany Lundeen
- Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94158, USA.
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94158, USA
| | - Felix Sayinzoga
- Maternal, Child and Community Health Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Bernard Ngabo Rwabufigiri
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, P.O Box 3286, Kigali, Rwanda
| | - Dilys Walker
- Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94158, USA
| | - Sabine F Musange
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, P.O Box 3286, Kigali, Rwanda
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Thapa K, Dhital R, Rajbhandari S, Acharya S, Mishra S, Pokhrel SM, Pande S, Tunnacliffe EA, Makins A. Factors affecting the behavior outcomes on post-partum intrauterine contraceptive device uptake and continuation in Nepal: a qualitative study. BMC Pregnancy Childbirth 2019; 19:148. [PMID: 31046715 PMCID: PMC6498647 DOI: 10.1186/s12884-019-2310-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/23/2019] [Indexed: 11/25/2022] Open
Abstract
Background The use of post-partum family planning (PPFP) methods such as post-partum intrauterine device (PPIUD) in general remains low despite its benefits for the women. The reasons or factors affecting the uptake and continuation of such PPFP methods in developing countries such as Nepal remains unclear. This qualitative research aims to explore the factors affecting PPIUD uptake and continuation related behaviors among post-partum mothers within 6 weeks of childbirth in Nepal. Methods This qualitative study was conducted through 43 in-depth interviews among post-partum mothers who delivered in 3 selected hospitals in Nepal. Data were analyzed through content analysis using the theory of planned behavior (TPB) as the theoretical framework. Results The themes and categories were structured around the three major components of the TPB on attitude, subjective norms, and behavioral control. Majority of the women in this study, irrespective of their behavioral outcome expressed a positive attitude towards PPIUD use. However, the women who expressed an unfavorable attitude towards PPIUD influenced their behavior to not choose or discontinue PPIUD. Subjective norms such as the family, peer, and societal influences against PPIUD negatively affected the women’s intention and behavior related to PPIUD. Whereas, the positive influence of the health providers positively affected their behavior. Regarding the behavior control, women who had their own control over decisions tended to use PPIUD. However, external factors such as their husband’s preference or medical conditions also played a prominent role in preventing many to use PPIUD despite their positive intentions. Conclusion As suggested in TPB, this study shows that multiple factors that are interlinked affected the behaviors related to uptake and continuation of PPIUD. The attitude helped in s`haping intention but did not always lead to the behavioral outcome of PPIUD uptake and continuation. Subjective norms had a strong influence on both intention and behavior. Behavior control belief also had an important role in the outcome with respect to PPIUD uptake and continuation. Thus, a more layered, multidimensional and interlinked intervention is necessary to bring positive behavior changes related to PPIUD. Electronic supplementary material The online version of this article (10.1186/s12884-019-2310-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kusum Thapa
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal.
| | - Rolina Dhital
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal
| | - Sameena Rajbhandari
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal
| | - Shreedhar Acharya
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal.,Department of Obstetrics and Gynecology, Lumbini Zonal Hospital, Butwal, Nepal
| | - Sangeeta Mishra
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal.,Department of Obstetrics and Gynecology, Koshi Zonal Hospital, Biratnagar, Nepal
| | - Sunil Mani Pokhrel
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal.,Department of Obstetrics and Gynecology, Bharatpur Hospital, Bharatpur, Nepal
| | - Saroja Pande
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal
| | | | - Anita Makins
- International Federation of Obstetrics and Gynaecology, London, UK
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