"There is nothing to protect us from dying": Black women's perceived sense of safety accessing pregnancy and intrapartum care

Pregnancy and childbirth have become a dangerous journey for Black women as harrowing stories of death and near-death experiences resonate within Black communities. While the causes of pregnancy-related morbidity and mortality are well documented, little is known about how Black Canadian women feel protected from undesirable maternal health outcomes when accessing and receiving pregnancy and intrapartum care. This critical qualitative inquiry sheds light on Black women's perceived sense of safety in accessing pregnancy and intrapartum care. Twenty-four in-depth interviews were conducted with Black women who were pregnant or had given birth. Five interconnected themes were generated through thematic analysis: (1) There is a lot of prejudice towards us, (2) We are treated as sick bodies, (3) There is a lot of stereotypes towards us, (4) Our care is lacking in quality, and (5) We feel unsafe in the healthcare system. These themes highlight the perils faced by Black women accessing pregnancy and intrapartum care. The right to safe motherhood and equitable care for Black women should be a national priority in Canada to avert a looming crisis.

Stakeholders' perceived achievements and challenges after the safe motherhood project in Northern Uganda

The Japanese Red Cross Society (JRCS) and the Uganda Red Cross Society (URCS) implemented the Safe Motherhood project to promote mother-friendly society in northern Uganda from 2010 to 2016. The follow-up study has not been conducted and the information on achievements and challenges after the project were limited. To review the safe motherhood project in northern Uganda, the purpose of the study was to explore the stakeholders' perceived achievements and challenges after the project. Study design was qualitative content analysis using interview guides. After the approval of Institutional Review Board Clearance, the study was started (Approval Number: 2017-034). The subjects were informed about the ethical considerations (informed consent, participation on free will, confidentiality, and anonymity) in participating in the research, and they participated after signing the consent form. Six volunteers, 2 health center staff, and 2 former Uganda Red Cross staff were interviewed. Achievements were the acquisition of knowledge, attitudes changes, behavioural changes, linkage of all stakeholders, and positive influence on Safe Motherhood in community. Challenges of sociocultural barriers, attitudes toward women, accessibility and human resources, incentives and facilities, and sustainability of the project were derived from the interview. The study revealed that the project linked all stakeholders to achieve Safe Motherhood in community and all the developed registration systems were taken over. Long-term support is necessary for Safe Motherhood to take root.

Exploring community support on safe motherhood: A case of Lilongwe District, Malawi

BACKGROUND

Malawi is grappling with a high maternal mortality of 439 per 100 000 live births. It is estimated that 80% of maternal deaths can be prevented by actively engaging the community in the country. However, community support on safe motherhood remains unknown.

AIM

This study, therefore, explored community support rendered to mothers and babies during antenatal, intrapartum and postpartum periods.

SETTING

This study was conducted in the Lilongwe District, Malawi.

METHODS

This was a qualitative study that collected data from 30 village health committee members through Focus Group Discussions (FGDs). Data were analysed using thematic analysis.

RESULTS

This study found that community support on safe motherhood rendered to women varied. The following five themes emerged from FGDs data on community support on safe motherhood: antenatal support, intrapartum support, postpartum support, bylaws reinforced by chiefs in the community and safe motherhood support groups. Community members encourage pregnant women to attend antenatal care, escorted pregnant women to the hospital for delivery and assisted women to care for a child and go for postpartum checkups. Community bylaws were considered as a necessary tool for encouraging women to attend antenatal care, deliver at the health facility and attend postpartum checkups.

CONCLUSION

This study suggests that community members play a crucial role in providing support to women and newborns during antenatal, intrapartum and postpartum periods.

Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants

Nepal made impressive progress in reducing maternal mortality until 2015. Since then, progress has stagnated, coinciding with Nepal’s transition to a federation with significant devolution in health management. In this context, we conducted key informant interviews (KII) to solicit perspectives on policies responsible for the reduction in maternal mortality, reasons for the stagnation in maternal mortality, and interventions needed for a faster decline in maternal mortality. We conducted 36 KIIs and analysed transcripts using standard framework analysis methods. The key informants identified three policies as the most important for maternal mortality reduction in Nepal: the Safe Motherhood Policy, Skilled Birth Attendant Policy, and Safe Abortion Policy. They opined that policies were adequate, but implementation was weak and ineffective, and strategies needed to be tailored to the local context. A range of health system factors, including poor quality of care, were identified by key informants as underlying the stagnation in Nepal’s maternal mortality ratio, as well as a few demand-side aspects. According to key informants, to reduce maternal deaths further Nepal needs to ensure that the current family planning, birth preparedness, financial incentives, free delivery services, abortion care, and community post-partum care programmes reach marginalised and vulnerable communities. Facilities offering comprehensive emergency obstetric care need to be accessible, and in hill and mountain areas, access could be supported by establishing maternity waiting homes. Social accountability can be strengthened through social audits, role models, and empowerment of health and management committees.

Developing operational standards for Midwifery Centers

BACKGROUND

Midwifery centres have been identified in over 56 countries. Consensus was reached on a global definition for midwifery centres, yet there is a lack of standards to assure consistent quality of care is provided.

METHODS

Evidence-based standards and guidelines developed from American Association of Birth Centres (USA), Midwifery Unity Network (UK/EU), World Health Organization, International Childbirth Initiative, and White Ribbon Alliance, were gathered, duplicate standards were removed, and language was adapted for global use with sensitivity to low and middle countries (LMIC). An initial list of 52 midwifery centre standards were identified. Through an informal modified Delphi process these were reviewed by global midwifery centres experts, researchers, and midwifery centre staff at focus groups in Haiti, Mexico and Bangladesh for significance, language, and usability. The standards were then piloted at midwifery centres in eight countries (Sierra Leone, Cambodia, Bangladesh, Mexico, Haiti, Peru, Uganda and Trinidad). All feedback was incorporated into the final standards.

RESULTS

A final list of 43 standards, organized into 3 domains including quality standards for care providers, dignity standards for women, and community standards for administration, were agreed on.

CONCLUSION

Midwifery centres are prevalent around the globe. Identifying standards for quality of care provides a foundation for the midwifery centre model to be replicated and ensure consistent quality of care. Evidence based standards for midwifery centres in LMIC, allows systems to embrace and encourage the implementation and growth of midwifery centres to address accessible, acceptable, respectful, woman-centred, community-engaged maternal health care that participates fully in the health care system.

Promoting equity in maternal, newborn and child health - how does gender factor in? Perceptions of public servants in the Ethiopian health sector

Background: Advancing gender equality and health equity are concurrent priorities of the Ethiopian health sector. While gender is regarded as an important determinant of health, there is a paucity of literature that considers the interface between how these two priorities are pursued.

Objective: This article explores how government stakeholders understand gender issues (gender barriers and roles) in the promotion of maternal, newborn and child health equity in Ethiopia.

Methods: Adopting an exploratory qualitative case study design, we conducted semi-structured interviews with 17 purposively-selected stakeholders working in leadership positions with the Federal Ministry of Health and Federal Ministry of Women and Children Affairs as part of a larger study regarding the promotion of health equity in maternal, newborn and child health. A post hoc content and thematic sub-analysis was done to explore how participants raised gender issues in conversations about health equity.

Results: Efforts to address gender inequalities were synonymous with the promotion of a women’s health agenda, which was largely oriented towards promoting health service use. Men were predominant decision makers with regards to women’s health and health care seeking in both public and private spheres. Participants reported persisting gender-related barriers to health stemming from traditional gender roles, and noted the increased inclusion of women in the health workforce since the introduction of the Health Extension Program.

Conclusions: The framing of gender as a women’s health issue, advanced through patriarchal structures, does little to elevate the status of women, or promote power differentials that contribute to health inequity. Encouraging leadership roles for women as health decision makers and redressing certain gender-based norms, attitudes, practices and discrimination are possible ways forward in re-orienting gender equality efforts to align with the promotion of health equity.

Safe Motherhood Initiative: Early Impact of Severe Hypertension in Pregnancy Bundle Implementation

Objective  To describe the implementation and early results of the American College of Obstetricians and Gynecologists District II Safe Motherhood Initiative's Severe Hypertension in Pregnancy bundle on the timely treatment of severe hypertension in New York State obstetric hospitals. Methods  This is a retrospective comparative study of two time periods during voluntary implementation of the Severe Hypertension in Pregnancy bundle in New York State's obstetric hospitals. The main outcome measure was the administration of an appropriate antihypertensive agent within 1 hour of the second elevated value for all pregnant or postpartum patients with severe hypertension. Results  Of the 117 obstetric hospitals participating in the Safe Motherhood Initiative, 111 (94.9%) submitted data included in this analysis. During the study period, 80 of the 111 (72.0%) hospitals reported implementing the hypertension bundle. Overall, 2.4% of pregnant women were diagnosed with severe hypertension, and 60 to 65% of patients were treated within an hour of the second elevated value. Although not statistically significant, a greater numbers of patients were treated within an hour of the second elevated value in the second time period compared with the first in most obstetric hospitals (overall 64.8 vs. 60.8%; p  = 0.33). Conclusion  There were increasing numbers of patients receiving timely treatment of severe hypertension during early implementation of a Severe Hypertension in Pregnancy bundle in New York State obstetric hospitals. However, bundle implementation requires significant financial and human resources and the long-term impact on maternal morbidity and mortality in our state remains uncertain. Precis There was a tendency toward more timely treatment of severe hypertension following implementation of a Severe Hypertension in Pregnancy bundle in New York obstetric hospitals.

Cost-effectiveness analysis and mortality impact estimation of scaling-up pregnancy test kits in Madagascar, Ethiopia and Malawi

Cost-effective, innovative approaches are needed to accelerate progress towards ending preventable infant, child and maternal mortality. To inform policy decisions, we conducted a cost-effectiveness analysis of adding urine pregnancy test kits to the maternal and reproductive services package offered at the community level in Madagascar, Ethiopia and Malawi. We used a decision tree model to compare the intervention with the status quo for each country. We also completed single factor sensitivity analyses and Monte Carlo simulations with 10 000 iterations to generate the probability distribution of the estimates and uncertainty limits. Among a hypothetical cohort of 100 000 women of reproductive age, we estimate that over a 1-year period, the intervention would save 26, 35 and 48 lives in Madagascar, Ethiopia, and Malawi, respectively. The Incremental Cost Effectiveness Ratio (ICER) for the cost per life saved varies by country: $2311 [95% Uncertainty Interval (UI): $1699; $3454] in Madagascar; $2969 [UI: $2260; $5041] in Ethiopia and $1228 [UI: $918; $1777] in Malawi. This equates to an average cost per Disability Adjusted Life Year (DALY) averted of $36.28, $47.95 and $21.92, respectively. Based on WHO criteria and a comparison with other maternal, newborn, and child health interventions, we conclude that the addition of urine pregnancy tests to an existing community health worker maternal and reproductive services package is highly cost-effective in all three countries. To optimize uptake of family planning and antenatal care services and, in turn, accelerate the reduction of mortality and DALYs, decision makers and program planners should consider adding urine pregnancy tests to the community-level package of services.

"Lives in the balance": The politics of integration in the Partnership for Maternal, Newborn and Child Health

A decade ago, the Partnership for Maternal, Newborn and Child Health (PMNCH) was established to combat the growing fragmentation of global health action into uncoordinated, issue-specific efforts. Inspired by dominant global public-private partnerships for health, the PMNCH brought together previously competing advocacy coalitions for safe motherhood and child survival and attracted support from major donors, foundations and professional bodies. Today, its founders highlight its achievements in generating priority for 'MNCH', encouraging integrated health systems thinking and demonstrating the value of collaboration in global health endeavours. Against this dominant discourse on the success of the PMNCH, this article shows that rhetoric in support of partnership and integration often masks continued structural drivers and political dynamics that bias the global health field towards vertical goals. Drawing on ethnographic research, this article examines the Safe Motherhood Initiative's evolution into the PMNCH as a response to the competitive forces shaping the current global health field. Despite many successes, the PMNCH has struggled to resolve historically entrenched programmatic and ideological divisions between the maternal and child health advocacy coalitions. For the Safe Motherhood Initiative, the cost of operating within an extremely competitive policy arena has involved a partial renouncement of ambitions to broader social transformations in favour of narrower, but feasible and 'sellable' interventions. A widespread perception that maternal health remains subordinated to child health even within the Partnership has elicited self-protective responses from the safe motherhood contingent. Ironically, however, such responses may accentuate the kind of fragmentation to global health governance, financing and policy solutions that the Partnership was intended to challenge. The article contributes to the emerging critical ethnographic literature on global health initiatives by highlighting how integration may only be possible with a more radical conceptualization of global health governance.

Barriers to initiating antiretroviral therapy during pregnancy: a qualitative study of women attending services in Cape Town, South Africa

Despite the rapid expansion of antiretroviral therapy (ART) programmes, uptake of ART in pregnancy remains suboptimal. Little is known about the barriers to initiating lifelong ART in pregnancy and the challenges to postpartum retention in HIV care, particularly in sub-Saharan African contexts with a high burden of disease. In this qualitative study, 28 HIV-positive pregnant or postpartum women, who either had initiated ART or were eligible for ART, and 21 service providers were interviewed in Cape Town, South Africa, to investigate these barriers. Prevention of vertical transmission of HIV was often the primary motivation for starting treatment. Key challenges to ART initiation included late first presentation, denial of an HIV diagnosis, fear of disclosure, and treatment side-effects. The women expressed difficulties in accepting a lifelong commitment to treatment for maternal health benefit. Pregnant women who require ART face a triple burden of transitioning into pregnancy, accepting the HIV diagnosis, and recognising the urgent requirement to start lifelong ART before delivery. Focused interventions are required to address the psychosocial barriers to ART uptake and the linkages to care for pregnant HIV-positive women.

Depressive disorder in pregnant Latin women: does intimate partner violence matter?

AIMS AND OBJECTIVES

To identify the association of antenatal depressive symptoms with intimate partner violence during the current pregnancy in Brazilian women.

BACKGROUND

Intimate partner violence is an important risk factor for antenatal depression. To the authors' knowledge, there has been no study to date that assessed the association between intimate partner violence during pregnancy and antenatal depressive symptoms among Brazilian women.

DESIGN

Cross-sectional study.

METHODS

Three hundred and fifty-eight pregnant women were enrolled in the study. The Edinburgh Postnatal Depression Scale and an adapted version of the instrument used in the World Health Organization Multi-country Study on Women's Health and Domestic Violence were used to measure antenatal depressive symptoms and psychological, physical and sexual acts of intimate partner violence during the current pregnancy respectively. Multiple logistic regression and multiple linear regression were used for data analysis.

RESULTS

The prevalence of antenatal depressive symptoms, as determined by the cut-off score of 12 in the Edinburgh Postnatal Depression Scale, was 28·2% (101). Of the participants, 63 (17·6%) reported some type of intimate partner violence during pregnancy. Among them, 60 (95·2%) reported suffering psychological violence, 23 (36·5%) physical violence and one (1·6%) sexual violence. Multiple logistic regression and multiple linear regression indicated that antenatal depressive symptoms are extremely associated with intimate partner violence during pregnancy.

CONCLUSION

Among Brazilian women, exposure to intimate partner violence during pregnancy increases the chances of experiencing antenatal depressive symptoms.

RELEVANCE TO CLINICAL PRACTICE

Clinical nurses and nurses midwifes should pay attention to the particularities of Brazilian women, especially with regard to the occurrence of intimate partner violence, whose impacts on the mental health of this population are extremely significant, both during the gestational period and postpartum.

'Desa SIAGA', the 'Alert Village': the evolution of an iconic brand in Indonesian public health strategies

In 1999, the Ministry of Women's Empowerment in Indonesia worked with advertisers in Jakarta and international technical advisors to develop the concept of 'Suami SIAGA', the 'Alert Husband', confronting Indonesian males with their responsibilities to be aware of their wives' needs and ensure early access if needed to trained obstetrics care. The model was rapidly expanded to apply to the 'Desa SIAGA', the 'Alert Village', with communities assuming the responsibility for awareness of the risks of pregnancy and childbirth, and supporting registered pregnant mothers with funding and transportation for emergency obstetric assistance, and identified blood donors. Based on the participant observation, interviews and documentary analysis, this article uses a systems perspective to trace the evolution of that iconic 'brand' as new national and international actors further developed the concept and its application in provincial and national programmes. In 2010, it underwent a further transformation to become 'Desa Siaga Aktif', a national programme with responsibilities expanded to include the provision of basic health services at village level, and the surveillance of communicable disease, monitoring of lifestyle activities and disaster preparedness, in addition to the management of obstetric emergencies. By tracking the use of this single 'brand', the study provides insights into the complex adaptive system of policy and programme development with its rich interactions between multiple international, national, provincial and sectoral stakeholders, the unpredictable responses to feedback from these actors and their activities and the resultant emergence of new policy elements, new programmes and new levels of operation within the system.

A protocol for a systematic review of birth preparedness and complication readiness programs

BACKGROUND

One of the effective strategies for reducing the number of maternal deaths is delivery by a skilled birth attendant. Low utilization of skilled birth attendants has been attributed to delay in seeking care, delay in reaching a health facility and delay in receiving adequate care. Health workers could play a role in helping women prepare for birth and anticipate complications, in order to reduce delays. There is little evidence to support these birth preparedness and complication readiness (BP/CR) programs; however, BP/CR programs are frequently implemented. The objective of this review is to assess the effect of BP/CR programs on increasing skilled birth attendance in low-resource settings.

METHODS

Due to the complexity of BP/CR programs and the need to understand why certain programs are more effective than others, we will combine both quantitative and qualitative studies in this systematic review. Search terms were selected with the assistance of a health information specialist. Three reviewers will independently select and assess studies for quality. Data will be extracted by one reviewer and checked for accuracy and completeness by a second reviewer. Discussion between the reviewers will resolve disagreements. If disagreements remain, a third party will be consulted. Data analysis will be carried out in accordance with the BP/CR matrix, developed by the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO). Study data will be grouped and analyzed by quality and study design and regrouped according to type of intervention strategy.

DISCUSSION

This review will provide: 1) an insight into existing BP/CR programs, 2) recommendations on effective elements of the different approaches, 3) proposals for concrete action plans for health professionals in the field of reproductive health in resource-poor settings and 4) an overview of existing knowledge gaps requiring further research.

TRIAL REGISTRATION

PROSPERO registration no.: CRD42012003124.

New hope: community-based misoprostol use to prevent postpartum haemorrhage

The wide gap in maternal mortality ratios worldwide indicates major inequities in the levels of risk women face during pregnancy. Two priority strategies have emerged among safe motherhood advocates: increasing the quality of emergency obstetric care facilities and deploying skilled birth attendants. The training of traditional birth attendants, a strategy employed in the 1970s and 1980s, is no longer considered a best practice. However, inadequate access to emergency obstetric care and skilled birth attendants means women living in remote areas continue to die in large numbers from preventable maternal causes. This paper outlines an intervention to address the leading direct cause of maternal mortality, postpartum haemorrhage. The potential for saving maternal lives might increase if community-based birth attendants, women themselves, or other community members could be trained to use misoprostol to prevent postpartum haemorrhage. The growing body of evidence regarding the safety and efficacy of misoprostol for this indication raises the question: if achievement of the fifth Millennium Development Goal is truly a priority, why can policy makers and women's health advocates not see that misoprostol distribution at the community level might have life-saving benefits that outweigh risks?

A policy analysis of the implementation of a Reproductive Health Vouchers Program in Kenya

BACKGROUND

Innovative financing strategies such as those that integrate supply and demand elements like the output-based approach (OBA) have been implemented to reduce financial barriers to maternal health services. The Kenyan government with support from the German Development Bank (KfW) implemented an OBA voucher program to subsidize priority reproductive health services. Little evidence exists on the experience of implementing such programs in different settings. We describe the implementation process of the Kenyan OBA program and draw implications for scale up.

METHODS

Policy analysis using document review and qualitative data from 10 in-depth interviews with facility in-charges and 18 with service providers from the contracted facilities, local administration, health and field managers in Kitui, Kiambu and Kisumu districts as well as Korogocho and Viwandani slums in Nairobi.

RESULTS

The OBA implementation process was designed in phases providing an opportunity for learning and adapting the lessons to local settings; the design consisted of five components: a defined benefit package, contracting and quality assurance; marketing and distribution of vouchers and claims processing and reimbursement. Key implementation challenges included limited feedback to providers on the outcomes of quality assurance and accreditation and budgetary constraints that limited effective marketing leading to inadequate information to clients on the benefit package. Claims processing and reimbursement was sophisticated but required adherence to time consuming procedures and in some cases private providers complained of low reimbursement rates for services provided.

CONCLUSIONS

OBA voucher schemes can be implemented successfully in similar settings. For effective scale up, strong partnership will be required between the public and private entities. The government's role is key and should include provision of adequate funding, stewardship and looking for opportunities to utilize existing platforms to scale up such strategies.

Maternal mortality-reduction programme in Andhra Pradesh

Andhra Pradesh, a large state in southern India, has a high maternal mortality ratio of 195 per 100,000 livebirths despite the improvements in social, demographic and health indicators over the last two decades. This contrary situation has been analyzed using findings of different studies on maternal mortality, and four factors have been presented for consistently-high maternal mortality in the state. First, the disproportionately-high focus on family planning towards population stabilization reduced the emphasis on maternal health in the peripheral hospitals, resulting in low use of these facilities for childbirths. Second, the growth of services in Primary Health Centres was not given adequate emphasis, resulting in the weakening of the peripheral health system. Third, there was little emphasis on developing a cadre of midwives who would have primarily focused on maternal health. Lastly, the low status of women in the state has hampered timely referral and access to services.

Maternal and newborn-care practices during pregnancy, childbirth, and the postnatal period: a comparison in three rural districts in Bangladesh

The aim of this study was to examine the prevalence of maternal and newborn-care practices among women reporting a birth in the previous year in three districts in different divisions of Bangladesh. In 2003, 6,785 women, who had delivered a newborn infant in the previous year, across three districts in Bangladesh, were interviewed. Overall, less than half of the women received any antenatal care, and 11% received a minimum of four check-ups. Only 18% took iron tablets for at least four months during pregnancy. Over 90% of the 6,785 deliveries took place at home, and only 11% were attended either by a doctor or by a nurse. The mothers reported three key hygienic practices in 54% of deliveries: attendants washing their hands with soap and boiling cord-tie and blade for cutting the cord. Forty-four percent of the 6,785 infants were bathed immediately after delivery, and 42% were given colostrum as their first food. The results suggest that maternal and newborn-care remains a cause of concern in rural Bangladesh. Short-term policies to promote healthy behaviour in the home are needed, in addition to the long-term goal of skilled birth attendance.

Perceived delay in healthcare-seeking for episodes of serious illness and its implications for safe motherhood interventions in rural Bangladesh

Delay in accessing emergency obstetric-care facilities during life-threatening obstetric complications is a significant determinant of high maternal mortality in developing countries. To examine the factors associated with delays in seeking care for episodes of serious illness and their possible implications for safe motherhood interventions in rural Bangladesh, a cross-sectional study was initiated in Matlab sub-district on the perceptions of household heads regarding delays in seeking care for episodes of serious illness among household members. Of 2,177 households in the study, 881 (40.5%) reported at least one household member who experienced an illness perceived to be serious enough to warrant care-seeking either from health facilities or from providers. Of these, 775 (88.0%) actually visited some providers for treatment, of whom 79.1% used transport. Overall, 69.3% perceived a delay in deciding to seek care, while 12.1% and 24.6% perceived a delay in accessing transport and in reaching the provider respectively. The median time required to make a decision to seek care was 72 minutes, while the same was 10 minutes to get transport and 80 minutes to reach a facility or a provider. Time to decide to seek care was shortest for pregnancy-related conditions and longest for illnesses classified as chronic, while time to reach a facility was longest for pregnancy-related illnesses and shortest for illnesses classified as acute. However, the perceived delay in seeking care did not differ significantly across socioeconomic levels or gender categories but differed significantly between those seeking care from informal providers compared to formal providers. Reasons for the delay included waiting time for results of informal treatment, inability to judge the graveness of disease, and lack of money. For pregnancy-related morbidities, 45% reported 'inability to judge the graveness of the situation' as a reason for delay in making decision. After controlling for possible confounders in multivariate analysis, type of illness and facility visited were the strongest determinants of delay in making decision to seek care. To reduce delays in making decision to seek care in rural Bangladesh, safe motherhood interventions should intensify behaviour change-communication efforts to educate communities to recognize pregnancy-danger signs for which a prompt action must be taken to save life. This strategy should be combined with efforts to train community-based skilled birth attendants, upgrading public facilities to provide emergency obstetric care, introduce voucher schemes to improve access by the poorest of the poor, and improve the quality of care at all levels.

Are birth-preparedness programmes effective? Results from a field trial in Siraha district, Nepal

The birth-preparedness package (BPP) promotes active preparation and decision-making for births, including pregnancy/postpartum periods, by pregnant women and their families. This paper describes a district-wide field trial of the BPP implemented through the government health system in Siraha, Nepal, during 2003-2004. The aim of the field trial was to determine the effectiveness of the BPP to positively influence planning for births, household-level behaviours that affect the health of pregnant and postpartum women and their newborns, and their use of selected health services for maternal and newborn care. Community health workers promoted desired behaviours through inter-personal counselling with individuals and groups. Content of messages included maternal and newborn-danger signs and encouraged the use of healthcare services and preparation for emergencies. Thirty-cluster baseline and endline household surveys of mothers of infants aged less than one year were used for estimating the change in key outcome indicators. Fifty-four percent of respondents (n=162) were directly exposed to BPP materials while pregnant. A composite index of seven indicators that measure knowledge of respondents, use of health services, and preparation for emergencies increased from 33% at baseline to 54% at endline (p=0.001). Five key newborn practices increased by 19 to 29 percentage points from baseline to endline (p values ranged from 0.000 to 0.06). Certain key maternal health indicators, such as skilled birth attendance and use of emergency obstetric care, did not change. The BPP can positively influence knowledge and intermediate health outcomes, such as household practices and use of some health services. The BPP can be implemented by government health services with minimal outside assistance but should be comprehensively integrated into the safe motherhood programme rather than implemented as a separate intervention.

Care for perinatal illness in rural Nepal: a descriptive study with cross-sectional and qualitative components

BACKGROUND: Maternal, perinatal and neonatal mortality rates remain high in rural areas of developing countries. Most deliveries take place at home and care-seeking behaviour is often delayed. We report on a combined quantitative and qualitative study of care seeking obstacles and practices relating to perinatal illness in rural Makwanpur district, Nepal, with particular emphasis on consultation strategies. METHODS: The analysis included a survey of 8798 women who reported a birth in the previous two years [of whom 3557 reported illness in their pregnancy], on 30 case studies of perinatal morbidity and mortality, and on 43 focus group discussions with mothers, other family members and health workers. RESULTS: Early pregnancy was often concealed, preparation for birth was minimal and trained attendance at birth was uncommon. Family members were favoured attendants, particularly mothers-in-law. The most common recalled maternal complications were prolonged labour, postpartum haemorrhage and retained placenta. Neonatal death, though less definable, was often associated with cessation of suckling and shortness of breath. Many home-based care practices for maternal and neonatal illness were described. Self-medication was common.There were delays in recognising and acting on danger signs, and in seeking care beyond the household, in which the cultural requirement for maternal seclusion, and the perceived expense of care, played a part. Of the 760 women who sought care at a government facility, 70% took more than 12 hours from the decision to seek help to actual consultation. Consultation was primarily with traditional healers, who were key actors in the ascription of causation. Use of the government primary health care system was limited: the most common source of allopathic care was the district hospital. CONCLUSIONS: Major obstacles to seeking care were: a limited capacity to recognise danger signs; the need to watch and wait; and an overwhelming preference to treat illness within the community. Safer motherhood and newborn care programmes in rural communities, must address both community and health facility care to have an impact on morbidity and mortality. The roles of community actors such as mothers-in-law, husbands, local healers and pharmacies, and increased access to properly trained birth attendants need to be addressed if delays in reaching health facilities are to be shortened.