Assessing knowledge and behavioural changes on maternal and newborn health among mothers following post-earthquake health promotion in Nepal

Association between earthquakes and perinatal outcomes: A systematic review and meta-analysis

BACKGROUND

Evidence for the association between earthquakes and adverse perinatal outcomes is limited.

OBJECTIVES

To evaluate the association between earthquakes and perinatal outcomes including preterm birth and low birth weight.

SEARCH STRATEGY

We searched studies using MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, World Health Organization International Clinical Trials Platform Search Portal, and ClinicalTrials.gov on February 9, 2023.

SELECTION CRITERIA

We included before-and-after studies that evaluated the associations between earthquakes and perinatal outcomes in women living in affected areas.

DATA COLLECTION AND ANALYSIS

Two independent reviewers extracted data. We calculated the pooled odds ratio (OR) with the random-effects model. We analyzed outcomes in subgroups of Asians and others. We evaluated the certainty of evidence with the Grading of Recommendations Assessment, Development and Evaluation system.

MAIN RESULTS

We included 2 607 405 women in 13 studies. Earthquakes may not increase preterm birth (nine studies, 1 761 760 participants: OR 1.10, 95% confidence interval [CI] 0.98-1.24, low certainty of evidence) or low birth weight (seven studies, 1 753 891 participants: OR 1.10, 95% CI 0.94-1.28, low certainty of evidence). Subgroup analyses showed that earthquakes may be associated with an increase of preterm birth among populations in Asia (OR 1.44, 95% CI 1.07-1.95), but this was not evident in others (OR 0.93, 95% CI 0.83-1.05).

CONCLUSIONS

Perinatal outcomes might not change after earthquakes. Further research on the association between earthquakes and perinatal outcomes, combined with an assessment of the characteristics of the region, is needed.

Health Mothers' Groups in Nepal: Barriers, Facilitators, and Recommendations

Background

Nepal's female community health volunteers (FCHVs) each lead a monthly health mothers' group (HMG) to share health-related information and engage communities in the health system. Suaahara II (SII), a US Agency for International Development-funded multisectoral nutrition program, uses social and behavior change interventions to promote HMG participation and uses its health systems interventions to strengthen HMG quality.

Objectives

This study aimed to explore HMG functionality and variation across Nepal, including barriers and facilitators to attending HMG meetings.

Methods

SII's cross-sectional annual survey data from 16 districts (n = 192 FCHVs and 1850 mothers with children <2 y) were used. Descriptive and logistic regression analyses were conducted where the outcome variable was whether mothers were active HMG members or not, with FCHV and maternal characteristics as explanatory variables. Qualitative data were obtained from 3 of 16 survey districts (n = 30 observations, n = 30 in-depth interviews with mothers, and n = 16 focus group discussions with mothers, family members, FCHVs, health workers, and SII staff).

Results

Among FCHVs, 90% reported facilitating HMG meetings, whereas 64% of mothers reported HMG availability, and only 25% reported participating actively in meetings. Household head sex, maternal age, maternal education, maternal self-efficacy, and engagement with an FCHV and SII were associated with whether mothers were active participants in HMG meetings. Qualitative findings highlighted systems-level barriers, including lack of FCHV skills, demotivation, and heavy workload. Mothers noted time as the major constraint and family support, the HMG's savings component, and active FCHVs as facilitators to participation.

Conclusions

Findings suggest that both supply- and demand-side solutions are needed to improve HMG performance and uptake in Nepal. These solutions need to include improving FCHV skills and motivating them to provide high-quality HMG services, as well as encouraging family members to support women so that they have time to participate in the HMGs.

Evaluating the impact of female community health volunteer involvement in a postpartum family planning intervention in Nepal: A mixed-methods study at one-year post-intervention

Introduction

This is a one-year post-intervention study following an initiative to provide orientation to female community health volunteers (FCHVs) on postpartum family planning in Nepal. In light of positive results in the earlier post-intervention study, this study was designed to provide a more long-term perspective on sustainability by assessing the effect at one-year post-intervention.

Methods

This mixed-methods study was conducted in January 2020 in Morang district, Nepal. We collected quantitative data from a knowledge assessment of FCHVs who had participated in the intervention on postpartum family planning, data on their community-based counseling coverage and through interviews with postpartum mothers in two selected hospitals. Qualitative data were collected through six key informant interviews with health providers and four focus group discussions with FCHVs involved in the intervention. We performed descriptive and multivariate analyses for quantitative data and thematic analysis for qualitative data.

Results

In total, 206 FCHVs participated in the one-year post-intervention study with significant improvement in knowledge of postpartum family planning as compared to pre-intervention period. The adjusted odds ratios (AOR) for knowledge of the 5 key messages on postpartum family planning as compared to the pre-intervention period included 1) knowledge on postpartum family planning can be used immediately after birth (AOR = 18.1, P<0.001), 2) postpartum intra-uterine device (PPIUD) can provide protection up to 12 years (AOR = 2.9, P = 0.011), 3) mothers who undergo cesarean section can use PPIUD (AOR = 2.3, P<0.001), 4) PPIUD can be inserted immediately after birth (AOR = 6.2, P <0.001), and 5) women should go for follow-up immediately if the IUD strings are seen outside vulva (AOR = 2.0, P = 0.08). The FCHVs answering 4 or more questions correctly was 10 times higher (AOR = 10.1, P<0.001) at one-year post-intervention, whereas it was 25 times higher at immediate-post-test (AOR = 25.1, p<0.001) as compared to pre-intervention phase.

The FCHVs had counseled 71% of the pregnant women (n = 538) within their communities at one-year post-intervention. The postpartum mothers in hospitals had a 2 times higher odds of being counseled by FCHVs during their pregnancy at one-year post-intervention (AOR = 1.8, P = 0.039) than in pre-intervention phase. The qualitative findings suggested a positive impression regarding the FCHV’s involvement in postpartum family planning counseling in the communities, however, supervision and monitoring over a longer term was identified as a key challenge and that may influence sustainability of community-based and hospital-based postpartum family planning services.

Conclusion

The FCHVs’ knowledge and community-based activities on postpartum family planning remained higher than in the pre-intervention. However, it declined when compared to the immediate post-intervention period. We propose regular supervision and monitoring of the work of the FCHVs to sustain progress.

Response strategies for promoting gender equality in public health emergencies: a rapid scoping review

OBJECTIVES

The COVID-19 pandemic threatens to widen existing gender inequities worldwide. A growing body of literature assesses the harmful consequences of public health emergencies (PHEs) for women and girls; however, evidence of what works to alleviate such impacts is limited. To inform viable mitigation strategies, we reviewed the evidence on gender-based interventions implemented in PHEs, including disease outbreaks and natural disasters.

METHODS

We conducted a rapid scoping review to identify eligible studies by systematically searching the databases MEDLINE, Global Health and Web of Science with the latest search update on 28 May 2021. We used the Sustainable Development Goals as a guiding framework to identify eligible outcomes of gender (in)equality.

RESULTS

Out of 13 920 records, 16 studies met our eligibility criteria. These included experimental (3), cohort (2), case-control (3) and cross-sectional (9) studies conducted in the context of natural disasters (earthquakes, droughts and storms) or epidemics (Zika, Ebola and COVID-19). Six studies were implemented in Asia, seven in North/Central America and three in Africa. Interventions included economic empowerment programmes (5); health promotion, largely focused on reproductive health (10); and a postearthquake resettlement programme (1). Included studies assessed gender-based outcomes in the domains of sexual and reproductive health, equal opportunities, access to economic resources, violence and health. There was a dearth of evidence for other outcome domains relevant to gender equity such as harmful practices, sanitation and hygiene practices, workplace discrimination and unpaid work. Economic empowerment interventions showed promise in promoting women's and girls' economic and educational opportunities as well as their sexual and reproductive health during PHEs. However, some programme beneficiaries may be at risk of experiencing unintended harms such as an increase in domestic violence. Focused reproductive health promotion may also be an effective strategy for supporting women's sexual and reproductive health, although additional experimental evidence is needed.

CONCLUSIONS

This study identified critical evidence gaps to guide future research on approaches to alleviating gender inequities during PHEs. We further highlight that interventions to promote gender equity in PHEs should take into account possible harmful side effects such as increased gender-based violence.

REVIEW REGISTRATION

DOI 10.17605/OSF.IO/8HKFD.

Difference in factors associated with continuum of care completion rate from pregnancy to postpartum period in rural Nepal: a community-based, cross-sectional study

OBJECTIVES

This study aimed to investigate the continuum of care (CoC) completion rate in maternal, neonatal and child health and its associated factors among mothers in two ecological regions in Nepal.

DESIGN

This was a community-based, cross-sectional study, for which data were collected through face-to-face interviews using a structured questionnaire. Multiple logistic regression analyses were conducted to determine the associated factors.

SETTING

This was carried out in two rural districts of Nepal, in different regions: one in the hills (Dhading) and another in the flatlands called Terai (Nawalparasi). The data were collected between July and December 2016.

PARTICIPANTS

Mothers who gave birth within a year before this study were included as participants. In total, there were 1803 participants.

AN OUTCOME MEASURE

The outcome of this study was measured by the CoC completion rate when a mother completes four antenatal check-ups, deliver at a health facility and receives postnatal care within 24 hours of delivery.

RESULTS

The CoC completion rates were 41% in Dhading and 28% in Nawalparasi. In Dhading, shorter travel time to a health facility and higher wealth quintiles were associated with a better CoC completion rate. In Nawalparasi, the CoC completion rate was affected by parity and decision-making for pregnancy care.

CONCLUSIONS

The CoC completion rate was low in both districts in Nepal. However, factors associated with the CoC completion rate varied by district. Differences in these factors might be reflected by geographical and socioeconomic conditions and the characteristics of household decision making in these districts.

Effects of Hurricane Michael on Access to Care for Pregnant Women and Associated Pregnancy Outcomes

Background: Disasters are associated with worse perinatal outcomes, perhaps due to inadequate prenatal care (PNC). Methods: Using 2017-2019 Florida vital statistics, we compared PNC use before and after Hurricane Michael. We categorized counties as most affected (Area A) or less affected (Area B and C). We examined whether Michael's effects on perinatal outcomes varied by maternity care availability and used the Baron and Kenny method to assess whether delayed PNC initiation mediated perinatal outcomes. Log-binomial regression and semi-parametric linear regression were used, controlling for maternal and ZIP code tabulation area characteristics. Results: Compared to the one-year period pre-Michael, the week of the first PNC was later in all areas in the one-year period post-Michael, with the largest change in Area A (adjusted difference 0.112, 95% CI: 0.055-0.169), where women were less likely to receive PNC overall (aRR = 0.994, 95% CI = 0.990-0.998) and more likely to have inadequate PNC (aRR = 1.193, 95% CI = 1.127-1.264). Michael's effects on perinatal outcomes did not vary significantly by maternity care availability within Area A. Delayed PNC initiation appeared to mediate an increased risk in small for gestational age (SGA) births after Michael. Conclusion: Women in Area A initiated PNC later and had a higher likelihood of inadequate PNC. Delayed PNC initiation may partially explain increased risk of SGA.

Improving post-partum family planning services provided by female community health volunteers in Nepal: a mixed methods study

Background

Family planning services in the post-partum period, termed post-partum family planning (PPFP) is critical to cover the unmet need for contraception, especially when institutional delivery rates have increased. However, the intention to choose PPFP methods such as post-partum intrauterine devices (PPIUD) remains low in countries such as Nepal. Community health workers such as Female Community Health Volunteers (FCHVs) could play an important role in improving the service coverage of PPFP in Nepal. However, their knowledge of PPFP and community-based services related to PPFP remain unclear. This study aims to assess the effect on community-based PPFP services by improving FCHV’s knowledge through orientation on PPFP.

Methods

We conducted this mixed-methods study in Morang District in Nepal. The intervention involved orientation of FCHVs on PPFP methods. We collected quantitative data from three sources; via a survey of FCHVs that assessed their knowledge before and after the intervention, from their monthly reporting forms on counseling coverage of women at different stages of pregnancy from the communities, and by interviewing mothers in their immediate post-partum period in two selected hospitals. We also conducted six focus group discussions with the FCHVs to understand their perception of PPFP and the intervention. We performed descriptive and multivariable analyses for quantitative results and thematic analysis for qualitative data.

Results

In total, 230 FCHVs participated in the intervention and their knowledge of PPFP improved significantly after it. The intervention was the only factor significantly associated with their improved knowledge (adjusted odds ratio = 24, P < 0.001) in the multivariable analysis. FCHVs were able to counsel 83.3% of 1872 mothers at different stages of pregnancy in the communities. In the two hospitals, the proportion of mothers in their immediate post-partum period whom reported they were counseled by FCHVs during their pregnancy increased. It improved from 7% before the intervention to 18.1% (P < 0.001) after the intervention. The qualitative findings suggested that the intervention improved their knowledge in providing PPFP counseling.

Conclusion

The orientation improved the FCHV’s knowledge of PPFP and their community-based counseling. Follow-up studies are needed to assess the longer term effect of the FCHV’s role in improving community-based PPFP services.