Management and referral for high-risk conditions and complications during the antenatal period: knowledge, practice and attitude survey of providers in rural public healthcare in two states of India

Census block based loglinear regression analysis of health and social determinants of maternal mortality in Indonesia 2010-2021

Despite many health program efforts, the maternal mortality in Indonesia has slowly declined and remains high. A comprehensive understanding of social determinants of maternal mortality is needed to guide improved strategies to accelerate reductions in maternal mortality. This study aimed to assess the health-program and social factors that determine maternal mortality in Indonesia through census block-based log-linear regression analysis of recent large surveys. The following data sets were used: (1) the Indonesia Intercensal Population Survey 2015 merged to the Village Potential Census, 2014; and (2) the Indonesia Population Census 2020-Long Form (conducted in 2022) merged to the Village Potential Census, 2021. Both surveys used the same multistage sampling procedure to select 40,728 and 268,223 census blocks. In each selected census block, a "take all take some" procedure was used to randomly select 16 households. Maternal mortality, its health-program, and social factors were measured at the census block level. Since many census blocks had zero maternal death, a log-linear regression, modelled as Ln Y'i = α + βi Xi, was employed. Ln Y'i is the natural log transform of maternal mortality ratio; Xi are the factors investigated; βi is the regression coefficient of Xi on Ln Y'i. βi measures the extent influence of Xi on Yi. On the study results, the maternal mortality has declined but remains high, and geographic and socioeconomic disparities in maternal mortality have reduced, although they are still striking. There are many factors that have influenced the risk of maternal mortality. Proximity to hospital reduced the risk of maternal mortality. The primary health care system is not yet optimal for reducing the risk of maternal death. Traditional birth attendants hinder the referral for maternal complications. Lack of household transportation increases the risk of maternal mortality. The use of contraception to reduce high-risk births also reduces the risk of maternal mortality. Poverty and low maternal education independently increase the risk of maternal death. Households that are too large; have one or more disabled member; and have experienced child loss are at high risk of maternal mortality. Lack of village electrification and a polluted environment independently increase the risk of maternal mortality. The study results imply the need for multiple strategic interventions to accelerate the reduction of maternal mortality. Optimizing the coverage of quality referral hospitals, particularly in the eastern region, is required. There is a need to facilitate easy transportation from households to the nearest functional EmMONC. There is a need to strengthen the primary health care system to early detect, stabilize, and facilitate timely, safe, and effective referral of cases of maternal complications. Social health insurance should not only cover the cost of health care but also improve the quality of healthcare services. The role of traditional birth attendants should be shifted away from delivery care to improve maternal and neonatal health care. Family planning programs should focus on preventing high-risk births. Women's education needs to be improved. Electrification of all villages and control of environmental pollution to reduce maternal deaths.

Newborn morbidities and care procedures at the special newborn care units of Gandaki Province, Nepal: a retrospective study

BACKGROUND

Despite recent improvements in the overall health status of Nepal's population, newborn morbidities and mortalities have remained a challenge. This study explores the situation and care strategies for newborn health problems in the Gandaki Province of Nepal.

METHODS

This is a retrospective hospital records analysis. A structured questionnaire was employed to collect data on socio-demographic, clinical, and outcome variables in 1,355 newborns admitted to the Special Newborn Care Unit (SNCU) between May 1, 2021, and April 30, 2022, in five hospitals within the Gandaki Province.

RESULTS

Among all newborns, 60% were male, and 40% belonged to Janajati indigenous families. The mean age of mothers at the time of delivery was 24.4 years; the average birth weight of babies was 2.8 kg; and the gestational week was 38 weeks. Around 96% of births occurred in healthcare facilities. The average inpatient hospital stay was 4.7 days. The reasons for SNCU admission were newborn sepsis (51%), neonatal hyperbilirubinemia (23%), respiratory distress syndrome (18%), and low birth weight (11%). Approximately 7% of the newborns were found to have died due to various causes, including sepsis, asphyxia, and indirect medical reasons. Female newborns had a 0.45-times (CI: 0.23-0.84) lower risk of mortality compared to male newborns. Underweight newborns had 8.8 times (CI: 4.5-17.2) higher risk of death than newborns with a normal birth weight, even after adjusting for other factors like sex, delivery site, mode of delivery, mother's age, respiratory distress syndrome, neonatal hyperbilirubinemia, neonatal sepsis, and age at admission to SNCU. The most common treatments included injectable antibiotics (73%), intravenous fluids (53%), oxygen delivery (39%), and phototherapy (36%), while 3% received "Kangaroo Mother Care (KMC)".

CONCLUSIONS

The study showed that newborns suffered from multiple health complications such as sepsis, hyperbilirubinemia, or asphyxia, and many newborns received essential medical services from hospitals. Birth weight, sex of the newborn, and respiratory distress syndrome were significantly associated with neonatal mortality. Hospitals should focus on reinforcing KMC, neonatal resuscitation, and early infection control measures.

Enhancing the competencies of obstetrical nurses and midwives in high-risk pregnancy management through simulation-based training in Lao people's democratic republic: A pilot study

BACKGROUND

Simulation-based training has been widely used as a valuable strategy for learning and evaluating clinical skills at different levels of nursing and midwifery education. The impact of simulation training on intensive management for high-risk pregnancy in a low-resource setting has been limited.

AIM

To examine the effect of simulation-based training with low-fidelity mannequins on obstetrical nurses and midwives' knowledge, attitude, and skills for high-risk pregnancy management in a low-resource setting.

METHOD

During September 2023, twenty-five obstetrical nurses or midwives who worked in five tertiary public hospitals in Vientiane Prefecture participated in the three-day training workshops for intensive management in high-risk pregnant women and newborns that used a simulation-based training approach integrating problem-based learning. The evaluated criteria of knowledge, attitudes, and skills pre- and post-test scores were statistically compared.

FINDINGS

Workshop trainees demonstrated an increase significantly in knowledge for high-risk pregnancy management (p = 0.012), attitude toward high-risk pregnancy management (p = 0.000), and attitude toward simulation-based training design (p = 0.002). The clinical skills were used on the simulation performance checklist, and the pre-posttest gain in overall performance scores had a statistically significant difference (p = 0.000). The mean score of postpartum hemorrhage management skills was 11.48±2.23, which increased the highest score among all skills.

CONCLUSIONS

The simulation-based training in high-risk pregnancy management improves the knowledge, attitude, and skills of nurses and midwives in low-resource settings. Next steps include direct observation of trainees in the clinical setting to assess their competence in ensuring patient safety, achieving positive pregnancy outcomes, and enhancing satisfaction.

Methods and Measures to Assess Health Care Provider Behavior and Behavioral Determinants in Reproductive, Maternal, Newborn, and Child Health: A Rapid Review

BACKGROUND

Health care provider behavior is the outcome of a complex set of factors that are both internal and external to the provider. Social and behavior change (SBC) programs are increasingly engaging providers and introducing strategies to improve their service delivery. However, there is limited understanding of methods and measures applied to assess provider behavioral outcomes and strengthen provider behavior change programming.

METHODS

Using PubMed, we conducted a rapid review of published research on behaviors of health workers providing reproductive, maternal, newborn, and child health services in low- and middle-income countries (2010-2021). Information on study identifiers (e.g., type of provider), select domains from Green and Kreuter's PRECEDE-PROCEED framework (e.g., predisposing factors such as attitudes), study characteristics (e.g., study type and design), and evidence of theory-driven research were extracted from a final sample of articles (N=89) and summarized.

RESULTS

More than 80% of articles were descriptive/formative and examined knowledge, attitudes, and practice, mostly related to family planning. Among the few evaluation studies, training-focused interventions to increase provider knowledge or improve competency in providing a health service were dominant. Research driven by behavioral theory was observed in only 3 studies. Most articles (75%) focused on the quality of client-provider interaction, though topics and modes of measurement varied widely. Very few studies incorporated a validated scale to measure underlying constructs, such as attitudes and beliefs, and how these may be associated with provider behaviors.

CONCLUSION

A need exists for (1) theory-driven approaches to designing and measuring provider behavior change interventions and (2) measurement that addresses important internal and structural factors related to a provider's behavior (beyond knowledge-enhancing training approaches). Additional investment in implementation research is also needed to better understand which SBC approaches are shifting provider behavior and improving client-provider interactions. Finally, theory-driven approaches could help develop empirically measurable and comparable outcomes.

Social representations of pregnant women about high-risk pregnancy: repercussions for prenatal care

OBJECTIVE

To analyze the Social Representations of pregnant women about high-risk pregnancy and its repercussions for prenatal care.

METHOD

Qualitative study, based on the procedural aspect of the Theory of Social Representations, carried out with 62 high-risk prenatal pregnant women at a High Complexity Maternity, in Belém, PA, Brazil. Data from semi-structured interviews were processed by the software Interface de R pour les Analyzes Multidimensionnelles de Textes et de Questionnaires.

RESULTS

Four categories emerged, in which three dimensions of the Theory composing the genesis of Social Representations are considered: the affective dimension, the biological dimension and the sociocultural dimension.

CONCLUSION

Affects, negative feelings, and adaptations were revealed, with high-risk pregnancy being represented as an unusual and uncomfortable event, influenced by common sense and science, communication means, and dialogues with health professionals, with family support being considered of paramount importance. and prenatal care a propitious moment for establishing bonds with the health professional, seen as essential for their adherence to the care offered.

The place of prenatal visits in pregnancy care: Should we reconsider the current approach?

A well-conducted prenatal visit remains of paramount importance because it allows the preservation of mother and child health by reducing the rates of morbidity and mortality for them. However, the quality of prenatal visits remains a serious problem in our environment, and a new approach is urgently needed to improve the quality of prenatal visits in our environment.

Anemia in Pregnancy: A knowledge, Attitude and Practice Survey Amongst Obstetricians and Gynaecologists in India

Background

Anemia continues to affect one-third of the global population and is one of the most common reasons for large-scale morbidity and mortality especially among women. The importance of iron-rich diet has always been the backbone of preventing iron deficiency anemia (IDA) in vulnerable age groups followed by oral iron therapy and parenteral iron therapy as the next options in management of iron deficiency.

Objective

Objective of this survey was to assess the knowledge, attitude and practices of obstetricians and gynaecologists relevant to anemia in pregnancy and identify the practice gaps in management of anemia in pregnancy.

Methods

This was a knowledge, attitude and practice (KAP) survey involving obstetricians and gynaecologists (ObGyns) across India. A validated questionnaire of twenty questions was used to assess knowledge, attitude and practice about anemia and its management. Results were expressed as percentages.

Results

1974 ObGyns participated in the survey. 88.7% ObGyns screen anemia in first trimester, 53.7% ObGyns perform CBC along with RBC indices. Majority of ObGyns estimate Hb thrice during antenatal period. 50% ObGyns do not consider thalassemia screening routinely and deworming regularly. 92.4% ObGyns believe that iron supplementation is required even if Hb > 11 g/dL. Majority of them prefer low-dose iron therapy, 59.9% prefer to use 100 mg oral iron daily. Almost half of ObGyns prefer to change iron salt when patients do not respond, instead of escalating to injectable iron. Interestingly 52% ObGyns evaluate serum ferritin before starting intravenous iron therapy. 43.5% perform Hb estimation as early as 2 weeks after IV iron therapy. Majority (82.2%) of ObGyns prefer blood transfusion as a treatment of choice when Hb < 5 g/dl at 34 weeks gestation. Only 40.5% of participants are aware of the exact cut-off for diagnosing postpartum anemia. Majority of the ObGyns are aware of the iron prophylaxis in postpartum period till 3-6 months. More than 90% ObGyns consider intravenous iron for severe anemia of postpartum period.

Conclusion

The present KAP survey highlights the observation, perception and the practicing behaviour of obstetricians and gynaecologists on anemia in pregnancy and identifies practice gaps in anemia management.

Challenges influencing proper implementation of quality health care referral system in Kaloleni Sub-county, Kilifi County in Kenya

The reason behind having referral system in Kenya is to have proper distribution of effective health care services to all Kenyans as well as linking and integrating medical services across all levels of healthcare. In Kenya, most of levels of health care lacks specialized manpower and equipment, proper communication strategies, knowledge on referral system and skilled health workers to deal with referral system. Therefore, this study addresses the challenges influencing the proper implementation of quality referral system of health care in Kaloleni sub-county, Kilifi County in Kenya. Specifically, investigating gaps by the health workers, knowledge and communication factors on implementation of quality health care referral system. A cross-sectional research design was used targeting health care workers in public health care facilities. Self- administered questionnaires were used to obtain quantitative data. The data was cleaned, coded and analyzed using SPSS V. 22. The inferential statistics discussed finding from Chi-square showing the significance between independent and dependent variables. According to the results, Communication gap with p(0.18) showed to have more significant variable affecting the quality referral system followed by knowledge factor with significant of p(0.499) and finally Nurse's skills with significant ofp(0.99).

Systems E-approach for women at risk (SEWA)-A digital health solution for detection of high-risk pregnancies

Background

High-risk pregnancy (HRP) puts current pregnancy at an increased risk of complications. In the absence of pre-existing HRP implementation model of the country, in collaboration with the Government of Himachal Pradesh, a new digital HRP model called the 'SEWA-A System E-approach for Women at risk' was developed. The current article demonstrates a model for the early identification and line listing of high-risk pregnant women (PW) with appropriate referrals and increased engagement with the healthcare workers using a digital tool in the form of the Android App.

Methods

SEWA was implemented as a pilot intervention in two community development blocks of the Chamba district. The key implementation steps included finalizing protocols for the identification of HRPs, defining processes and roles, mapping health facilities, setting up the communication loop, and developing of digital solutions. The digital app, used by the auxiliary nurse midwife (ANM) and program officers, tracked PW for a year from October 19 to October 20 and recorded the ANC visits, referrals, and birth outcomes. A qualitative assessment was conducted among the health workers to find out their level of acceptance.

Results

A total of 1,340 high-risk PW were identified. The intervention year saw a rise in the identification of HRP to 27.9% from 3.5% in the previous year. A total of 2,559 conditions were tagged to the identified 1,340 women categorized into current pregnancy (81%), previous pregnancy (16%), and any existing chronic illness (3%). A majority of the women who required urgent referrals were provided referrals. The application recorded 53% of the delivered HRP with a digital birth preparedness plan, prepared and shared with the PW and Accredited Social Health Activists (ASHA), by text message for compliance.

Conclusion

The SEWA application is a feasible and sustainable solution to complement the competency of the care providers for early identification of the high-risk conditions and reduce the burden of preventable unprecedented deaths around the time of birth.

Effects of free maternal policies on quality and cost of care and outcomes: an integrative review

AIM

We conducted an integrative review of the global-free maternity (FM) policies and evaluated the quality of care (QoC) and cost and cost implications to provide lessons for universal health coverage (UHC).

METHODOLOGY

Using integrative review methods proposed by Whittemore and Knafl (2005), we searched through EBSCO Host, ArticleFirst, Cochrane Central Registry of Controlled Trials, Emerald Insight, JSTOR, PubMed, Springer Link, Electronic collections online, and Google Scholar databases guided by the preferred reporting item for systematic review and meta-analysis protocol (PRISMA) guideline. Only empirical studies that described FM policies with components of quality and cost were included. There were 43 papers included, and the data were analysed thematically.

RESULTS

Forty-three studies that met the criteria were all from developing countries and had implemented different approaches of FM policy. Review findings demonstrated that some of the quality issues hindering the policies were poor management of complications, worsened referral systems, overburdening of staff because of increased utilisation, lack of transport, and low supply of stock. There were some quality improvements on monitoring vital signs by nurses and some procedures met the recommended standards. Equally, mothers still bear the burden of some costs such as the purchase of drugs, transport, informal payments despite policies being 'free'.

CONCLUSIONS

FM policies can reduce the financial burden on the households if well implemented and sustainably funded. Besides, they may also contribute to a decline in inequity between the rich and poor though not independently. In order to achieve the SDG goal of UHC by 2030, there is a need to promote awareness of the policy to the poor and disadvantaged women in rural areas to help narrow the inequality gap on utilisation and provide a sustainable form of transport through collaboration with partners to help reduce impoverishment of households. Also, there is a need to address elements such as cultural barriers and the role of traditional birth attendants which hinder women from seeking skilled care even when they are freely available.

Do Blood-Borne Viruses Affect the Progression of Labor: A Hospital-Based Pilot Study

Background

Blood-borne viruses form the basis of enormous research on universal precautions. A paucity of research is noted regarding labor progression in seropositive women. Women testing positive for human immunodeficiency virus (HIV)/hepatitis B surface antigen (HBsAg)/hepatitis C virus (HCV) are often denied obstetric care and referred. Their need for safe delivery conditions propelled us to undertake this study to establish whether seropositive status affects labor progression or not.

Methods

Women in early labor (<4 cm cervical dilation) testing positive for HIV/HBV/HCV and delivering vaginally during the study period at All India Institute of Medical Sciences (AIIMS), Rishikesh, India, were included as Group A (n=36). The authors recruited an equal number of women with seronegative status with comparable age, parity, admission at or before 4 cm, body mass index (BMI) characteristics as Group B. They were compared in terms of effacement at 4 cm dilatation and time from 4 cm dilatation till delivery.

Results

The authors report a significant difference (p <0.05) between time to delivery between the two groups (2 hours vs. 2.43 hours in nulligravidas and multigravidas, respectively). Thirty-two (32) of 36 cases were already 70%-80% effaced at 4 cm dilation while only 25% of controls had similar findings. The present study suggests that seropositive women progress significantly faster in labor and need vigilant monitoring. We report such findings for the first time and aim to encourage similar research worldwide.

Referral chain of patients with obstetric emergency from primary care to tertiary care: A gap analysis

Background:

The referral system plays a crucial role in antenatal care and childbearing by providing access to emergency obstetric care. Excess referral from primary care and bypassing secondary levels of care leads to overcrowding of high risk and normal mothers in tertiary centers. Hence, this study aims to assess the gaps in the referral of patients with obstetric emergency from primary care to tertiary care.

Methodology:

In this hospital-based descriptive study, all obstetric patients referred to the Obstetric emergency facility and admitted in postnatal wards during the study period were included. They were interviewed using a pretested questionnaire. Data entry was performed using EpiData version 3.1 and analysis was done using SPSS version 22 software.

Results:

Of the 505 eligible women who attended the facility, 286 (56%) were referred from other institutions, while 44% were self-referred. Among those referred, one-third were from tertiary level facility and 40% from primary care facility. More than half of the referral was through verbal communication to the patient (60%); only one-third had referral slips. Around 40.4% chose bus and private vehicles (37.6%) as their means of transport; only around 10% traveled in 108 ambulances.

Conclusions:

Measures to improve the capacity building at primary setting, hierarchy of referral, quality of documentation, and emergency transport mechanism for obstetric patients are vital. The deficits identified in the existing referral system will be useful to give feedback to the health systems of the neighboring regions on emergency obstetrics referrals and to propose referral guidelines.