Walking beyond our borders with frontline health workers in Guatemala

In many developing countries, access to health care can be out of reach for many women and newborns. Trained frontline health workers serve as the first point of contact for medical care in many of these areas, and their efforts can prevent illness and death from conditions such as malaria, pneumonia and diarrhea. Their work is especially vital to reducing maternal and newborn morbidity and mortality. Due to the global shortage of health workers, nurses and organizations need to collectively advocate for the support and training of frontline health workers.

Community based interventions for the reduction of maternal mortality - the role of professional health associations, non-governmental organisations and community-based organisations in delta state, Nigeria

AIMS AND OBJECTIVES

This study was conducted to examine the contributions of professional health associations, non-governmental organisations, government ministries, and community-based organisations in implementing community-based interventions for the reduction of maternal mortality in Delta State Nigeria. It also seeks to demonstrate the challenge of coordinating activities of several stakeholders and quantifying the impact on reduction of maternal mortality.

MATERIALS AND METHODS

Various publications, reports, public presentations and policy documents on activities of professional health associations, non- governmental organisations, government ministries, and community-based organisations in Delta State of Nigeria were collected and analysed by the authors.

RESULTS

Professional health associations, non-governmental organisations and community-based organisations in Delta State have contributed to the reduction of maternal mortality through advocacy, awareness creation, and sensitisation programmes on reproductive health using behaviour change communication materials. Participation in programmes organised by the Delta State Ministry of Health has also contributed to some positive outcomes. These include the successful implementation of Delta State Free Maternal Health Care Programme since November 2007 and increase in contraceptive utilisation.

CONCLUSION

Professional health associations, non-governmental organisations, government ministries and community-based organisations have impacted positively in the quest for reduction of maternal mortality. The challenge is in coordination of interventions and tracking indicators to measure desired impact.

Mindful midwifery: a phenomenological paradigm

Mindfulness is a form of critical reflection that has been used by healthcare professionals for over a decade (Epstein 1999). Reflection and self-awareness are vital to being an ethical and trustworthy practitioner, to good communication and to establishing relationships (Johns 2000). Embedding reflection into the core of one's practice is a challenging task. It is easy to pay lip service to informed choice while in reality offering only a limited and predefined menu. Pressure to comply with guidelines can lead to subtle ways in which women are manipulated towards making a particular decision. Midwives are urged to provide woman-centred care, but often they are not taught or shown how to achieve this. This article explores how phenomenological research methodology provides a model for 'mindful midwifery' that seeks to improve the quality of midwives' relationships with the women in their care, through a process of 'bridling' and 'questioning'.

Emerging role of traditional birth attendants in mountainous terrain: a qualitative exploratory study from Chitral District, Pakistan

OBJECTIVES

This research endeavours to identify the role of traditional birth attendants (TBAs) in supporting the maternal, newborn and child health (MNCH) care, partnership mechanism with a formal health system and also explored livelihood options for TBAs in the health system of Pakistan.

SETTING

The study was conducted in district Chitral, Khyber Pakhtunkhwa province, covering the areas where the Chitral Child Survival programme was implemented.

PARTICIPANTS

A qualitative exploratory study was conducted, comprising seven key informant interviews with health managers, and four focus group discussions with community midwives (CMWs), TBAs, members of Community Based Saving Groups (CBSGs) and members of village health committees (VHCs).

RESULTS

The study identified that in the new scenario, after the introduction of CMWs in the health system, TBAs still have a pivotal role in health promotion activities such as breastfeeding promotion and vaccination. TBAs can assist CMWs in normal deliveries, and refer high-risk cases to the formal health system. Generally, TBAs are positive about CMWs' introduction and welcome this addition. Yet their livelihood has suffered after CMWs' deployment. Monetary incentives to them in recognition of referrals to CMWs could be one solution. The VHC is an active forum for strengthening co-ordination between the two service providers and to ensure an alternate and permanent livelihood support system for the TBAs.

CONCLUSIONS

TBAs have assured their continued support in provision of continuum of care for pregnant women, lactating mothers and children under the age of 5 years. The district health authorities must figure out ways to foster a healthy interface vis-à-vis roles and responsibilities of TBAs and CMWs. In time it would be worthwhile to do further research to look into the CMWs' integration in the system, as well as TBAs' continued role for provision of MNCH care.

Promoting preconception, pregnancy, and postpartum care following bariatric surgery: a best practice planning toolkit for patients and their physicians

Most bariatric procedures are performed in reproductive-aged women. Managing sequelae of postoperative anatomic and physiologic changes can be complex, particularly in women. Standardizing preconception, pregnancy, and postpartum management may limit practice variation and improve pore. We therefore provide a clinical toolkit consisting of physician checklists and corresponding written patient educational material to achieve these goals.

The use of digital media by women using the maternity services in a developed country

The provision of high quality healthcare information about pregnancy is important to women and to healthcare professionals and it is 1 driven, in part, by a desire to improve clinical outcomes,. The objective of this study was to examine the use of digital media by women' to access pregnancy information. A questionnaire was distributed to women attending a large maternity hospital. Of the 522 respondents, the mean age was 31.8 years, 45% (235/522) were nulliparous, 62% (324/522) lived in the capital city and 29% (150/522) attended the hospital as private patients. Overall 95% (498/522) used the internet for pregnancy information, 76% (399/522) had a smartphone and 59% (235/399) of smartphone owners had used a pregnancy smartapp. The nature of internet usage for pregnancy information included discussion forums (70%), social networks (67%), video media (48%), e-books (15%), blogs (13%), microblogs (9%) and podcasts (4%). Even women who were socially disadvantaged reported high levels of digital media usage. In contemporary maternity care women use digital media extensively for pregnancy information. All maternity services should have a digital media strategy.

Participatory training in monitoring and evaluation for maternal and newborn health programmes

In the context of slow progress towards Millennium Development Goals for child and maternal health, an innovative participatory training programme in the monitoring and evaluation (M&E) of Maternal and Newborn Health programmes was developed and delivered in six developing countries. The training, for health professionals and programme managers, aimed: (i) to strengthen participants' skills in M&E to enable more effective targeting of resources, and (ii) to build the capacity of partner institutions hosting the training to run similar courses. This review aims to assess the extent to which these goals were met and elicit views on ways to improve the training. An online survey of training participants and structured interviews with stakeholders were undertaken. Data from course reports were also incorporated. There was clearly a benefit to participants in terms of improved knowledge and skills. There is also some evidence that this translated into action through M&E implementation and tool development. Evidence of capacity-building at an institutional level was limited. Lessons for professional development training can be drawn from several aspects of the training programme that were found to facilitate learning, engagement and application. These include structuring courses around participant material, focussing on the development of practical action plans and involving multi-disciplinary teams. The need for strengthening follow-up and embedding it throughout the training was highlighted to overcome the challenges to applying learning in the 'real world'.

The effect of enhanced public-private partnerships on Maternal, Newborn and child Health Services and outcomes in Nairobi-Kenya: the PAMANECH quasi-experimental research protocol

INTRODUCTION

Rapid urbanisation in Kenya has resulted in growth of slums in urban centres, characterised by poverty, inadequate social services and poor health outcomes. The government's initiatives to improve access to quality healthcare for mothers and children are largely limited to public health facilities, which are few and/or inaccessible in underserved areas such as the slums. The 'Partnership for Maternal, Newborn and Child Health' (PAMANECH) project is being implemented in two Nairobi slums, Viwandani and Korogocho, to assess the impact of strengthening public-private partnerships for the delivery of healthcare on the health of mothers, newborns and young children in two informal settlements in Kenya.

METHODS AND ANALYSIS

This is a quasi-experimental study; our approach is to support private as well as public health providers and the community to enhance access to and demand for quality healthcare services. Key activities include: infrastructural upgrade of selected Private Not-For-Profit health facilities operating in the two slums, building capacity for healthcare providers as well as the Health Management Teams in Nairobi, facilitating provision of supportive supervision by the local health authorities and forming networks of Community Health Volunteers (CHVs) to create demand for health services. To assess the impact of the intervention, the study is utilising multiple data sources using a combination of qualitative and quantitative methods. A baseline survey was conducted in 2013 and an end-line survey will be conducted at least 1 year after full implementation of the intervention. Systematic monitoring and documentation of the intervention is on-going to strengthen the case for causal inference.

ETHICS AND DISSEMINATION

Ethical approval for the study was obtained from the Kenya Medical Research Institute. Key messages from the results will be packaged and widely disseminated through workshops, conference presentations, reports, factsheets and academic publications to facilitate uptake by policymakers.

PROTOCOL REGISTRATION NUMBER

KEMRI- NON-SSC-PROTOCOL No. 393.

Current evidence supporting obstetric fistula prevention strategies in sub Saharan Africa: a systematic review of the literature

Obstetric fistula has been eliminated in developed countries, but remains highly prevalent in sub-Saharan Africa. The End fistula campaign is the first concerted effort to eradicate the disease. The objective of this review is to retrieve and link available evidence to obstetric fistula prevention strategies in sub-Saharan Africa, since the campaign began. We searched databases for original research on obstetric fistula prevention. Fifteen articles meeting inclusion criteria were assessed for quality, and data extraction was performed. Grey literature provided context. Evidences from the articles were linked to prevention strategies retrieved from grey literature. The strategies were classified using an innovative target-focused method. Gaps in the literature show the need for fistula prevention research to aim at systematically measuring incidence and prevalence of the disease, identify the most effective and cost-effective strategies for fistula prevention and utilise innovative tools to measure impact of strategies in order to ensure eradication of fistula.

Essential interventions: implementation strategies and proposed packages of care

In an effort to accelerate progress towards achieving Millennium Development Goal (MDG) 4 and 5, provision of essential reproductive, maternal, newborn and child health (RMNCH) interventions is being considered. Not only should a state-of-the-art approach be taken for services delivered to the mother, neonate and to the child, but services must also be deployed across the household to hospital continuum of care approach and in the form of packages. The paper proposed several packages for improved maternal, newborn and child health that can be delivered across RMNCH continuum of care. These packages include: supportive care package for women to promote awareness related to healthy pre-pregnancy and pregnancy interventions; nutritional support package for mother to improve supplementation of essential nutrients and micronutrients; antenatal care package to detect, treat and manage infectious and noninfectious diseases and promote immunization; high risk care package to manage preeclampsia and eclampsia in pregnancy; childbirth package to promote support during labor and importance of skilled birth attendance during labor; essential newborn care package to support healthy newborn care practices; and child health care package to prevent and manage infections. This paper further discussed the implementation strategies for employing these interventions at scale.

Lifestyle interventions to reduce risk of diabetes among women with prior gestational diabetes mellitus

While lifestyle interventions involving exercise and a healthy diet in high-risk adults have been found to reduce progression to type 2 diabetes by >50%, little attention has been given to the potential benefits of such strategies in women with a history of gestational diabetes mellitus (GDM). We conducted a literature search of PubMed for English language studies of randomized controlled trials of lifestyle interventions among women with a history of GDM. In total, nine studies were identified which fulfilled the eligibility criteria. The majority of randomized trials of lifestyle interventions in women with GDM have been limited to pilot or feasibility studies. However, preliminary findings suggest that such interventions can improve diabetes risk factors in women with a history of GDM. Larger, well-designed controlled randomized trials are needed to assess the effects of lifestyle interventions on preventing subsequent progression to type 2 diabetes among women with GDM.

Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost?

Progress in newborn survival has been slow, and even more so for reductions in stillbirths. To meet Every Newborn targets of ten or fewer neonatal deaths and ten or fewer stillbirths per 1000 births in every country by 2035 will necessitate accelerated scale-up of the most effective care targeting major causes of newborn deaths. We have systematically reviewed interventions across the continuum of care and various delivery platforms, and then modelled the effect and cost of scale-up in the 75 high-burden Countdown countries. Closure of the quality gap through the provision of effective care for all women and newborn babies delivering in facilities could prevent an estimated 113,000 maternal deaths, 531,000 stillbirths, and 1·325 million neonatal deaths annually by 2020 at an estimated running cost of US$4·5 billion per year (US$0·9 per person). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1·9 million [range 1·6-2·1 million]), 33% of stillbirths (0·82 million [0·60-0·93 million]), and 54% of maternal deaths (0·16 million [0·14-0·17 million]) per year. These reductions can be achieved at an annual incremental running cost of US$5·65 billion (US$1·15 per person), which amounts to US$1928 for each life saved, including stillbirths, neonatal, and maternal deaths. Most (82%) of this effect is attributable to facility-based care which, although more expensive than community-based strategies, improves the likelihood of survival. Most of the running costs are also for facility-based care (US$3·66 billion or 64%), even without the cost of new hospitals and country-specific capital inputs being factored in. The maximum effect on neonatal deaths is through interventions delivered during labour and birth, including for obstetric complications (41%), followed by care of small and ill newborn babies (30%). To meet the unmet need for family planning with modern contraceptives would be synergistic, and would contribute to around a halving of births and therefore deaths. Our analysis also indicates that available interventions can reduce the three most common cause of neonatal mortality--preterm, intrapartum, and infection-related deaths--by 58%, 79%, and 84%, respectively.

Impact of community-based mitanin programme on undernutrition in rural Chhattisgarh State, India

BACKGROUND

Community health workers known as mitanins undertook family-level counseling and mobilized the community to improve coverage of maternal and child health services in the state of Chhattisgarh, India. The Nutrition Security Innovation (NSI) project was launched in selected blocks with additional inputs for promoting appropriate complementary feeding practices and disseminating information on Public Distribution System (PDS) entitlement. Within 3 years of project implementation, all NSI inputs in the project group (PG) were scaled up in the entire state.

OBJECTIVE

To study the impact of interventions on nutritional status in PG and non-NSI comparison group (CG) blocks.

METHODS

Quasi-experimental mixed methods were used. The sample consisted of 3,626 households with children under 3 years of age and 268 mitanins.

RESULTS

A ratio of 1 mitanin per 250 to 500 population was effective. The coverage of exclusive breastfeeding, timely introduction of complementary feeding, DPT immunization, and antenatal care services was more than 70%. The PDS reached almost 90% of beneficiaries. In both the PG and the CG, one-third of children were undernourished, with one-quarter of children undernourished by 6 months of age. The prevalence of low birthweight was over 40%, and half of all women were undernourished. The estimated annual average reduction rate (AARR) for the entire state was estimated to be 4.22% for underweight and 5.64% for stunting.

CONCLUSIONS

The strategy of Mitanin Programme in the Indian state of Chhattisgarh was unique with the implementation of direct nutrition actions being spearheaded by the health sector and community health volunteers in coordination with the Integrated Child Development Services (ICDS) and the Public Distribution System (PDS). The highest priority was given to interventions in the first 92 weeks of life. This implied ensuring frequent counseling and delivery of services through the entire pregnancy period and continued follow up till the children were at least one year of age. An accelerated decrease in the annual rate of reduction of underweight and stunting was observed. The emerging findings point to the significant contributions that can be made by the National Rural Health Mission (NRHM) in India by involvement of community health volunteers known as Accredited Social Health Activists (ASHAs) towards reducing the persistent problem of undernutrition in the country.

Proactive use of supervision

Midwifery supervision is the 13th series of 'Midwifery basics' targeted at practising midwives. The aim of these articles is to provide information to raise awareness of the impact of the work of midwives on women's experience, and encourage midwives to seek further information through a series of activities relating to the topic. In this seventh article of the series, RachelJokhi discusses how to use statutory supervision proactively in order to gain maximum benefit.

Assumptions and advice: mothers and Queensland well-baby clinics. A review

In 20th century Australia, free well-baby clinics were run by maternal and child health nurses, although the funding and organisational structure varied from state to state. It was assumed that women who attended followed the advice assiduously; yet attendance did not necessarily equate to practice. In Queensland, the state government's free Maternal and Child Welfare Service (MCW) advised mothers on infant feeding and care through well-baby clinics throughout the state, a correspondence section for mothers in remote areas and a railcar clinic to some western towns, under the state government's policy of covering every mother and baby in Queensland. Women in Queensland, as in other states, were exposed to other influences on how to feed babies and often exercised agency in making their own decisions according to their circumstances and their own judgment. This review will place research from Queensland on women's reasons for attending the clinics and adherence to the advice provided, during the period 1920-1965, within a wider context. This includes research on barriers to following advice, counselling versus imparting information and the mother's self-efficacy. The message for today is that adherence to advice still cannot be assumed and mothers' own circumstances need to be factored in.

The politics of maternity

Changes in the culture of health care require that, to be effective, midwifery practice should become more woman-centred. This may be facilitated by adopting a stronger community orientation. In this way the hegemony of maternity care may be addressed. This paper seeks to draw readers' attention to political developments and to inspire midwives to greater awareness and, possibly, activity.

Effect of primary care intervention on breastfeeding duration and intensity

OBJECTIVES

We determined the effectiveness of primary care-based, and pre- and postnatal interventions to increase breastfeeding.

METHODS

We conducted 2 trials at obstetrics and gynecology practices in the Bronx, New York, from 2008 to 2011. The Provider Approaches to Improved Rates of Infant Nutrition & Growth Study (PAIRINGS) had 2 arms: usual care versus pre- and postnatal visits with a lactation consultant (LC) and electronically prompted guidance from prenatal care providers (EP). The Best Infant Nutrition for Good Outcomes (BINGO) study had 4 arms: usual care, LC alone, EP alone, or LC+EP.

RESULTS

In BINGO at 3 months, high intensity was greater for the LC+EP (odds ratio [OR] = 2.72; 95% confidence interval [CI] = 1.08, 6.84) and LC (OR = 3.22; 95% CI = 1.14, 9.09) groups versus usual care, but not for the EP group alone. In PAIRINGS at 3 months, intervention rates exceeded usual care (OR = 2.86; 95% CI = 1.21, 6.76); the number needed to treat to prevent 1 dyad from nonexclusive breastfeeding at 3 months was 10.3 (95% CI = 5.6, 50.7).

CONCLUSIONS

LCs integrated into routine care alone and combined with EP guidance from prenatal care providers increased breastfeeding intensity at 3 months postpartum.

A cluster randomized controlled trial evaluating the efficacy of peer mentors to support South African women living with HIV and their infants

Objective

We evaluate the effect of clinic-based support by HIV-positive Peer Mentors, in addition to standard clinic care, on maternal and infant well-being among Women Living with HIV (WLH) from pregnancy through the infant's first year of life.

Methods

In a cluster randomized controlled trial in KwaZulu-Natal, South Africa, eight clinics were randomized for pregnant WLH to receive either: a Standard Care condition (SC; 4 clinics; n = 656 WLH); or an Enhanced Intervention (EI; 4 clinics; n = 544 WLH). WLH in the EI were invited to attend four antenatal and four postnatal meetings led by HIV-positive Peer Mentors, in addition to SC. WLH were recruited during pregnancy, and at least two post-birth assessment interviews were completed by 57% of WLH at 1.5, 6 or 12 months. EI's effect was ascertained on 19 measures of maternal and infant well-being using random effects regressions to control for clinic clustering. A binomial test for correlated outcomes evaluated EI's overall efficacy.

Findings

WLH attended an average of 4.1 sessions (SD = 2.0); 13% did not attend any sessions. Significant overall benefits were found in EI compared to SC using the binomial test. Secondarily, over time, WLH in the EI reported significantly fewer depressive symptoms and fewer underweight infants than WLH in the SC condition. EI WLH were significantly more likely to use one feeding method for six months and exclusively breastfeed their infants for at least 6 months.

Conclusions

WLH benefit by support from HIV-positive Peer Mentors, even though EI participation was partial, with incomplete follow-up rates from 6–12 months.

Trial Registration

ClinicalTrials.gov NCT00972699

Impact of conditional cash transfers on maternal and newborn health

Maternal and newborn health (MNH) is a high priority for global health and is included among the Millennium Development Goals (MDGs). However, the slow decline in maternal and newborn mortality jeopardizes achievements of the targets of MDGs. According to UNICEF, 60 million women give birth outside of health facilities, and family planning needs are satisfied for only 50%. Further, skilled birth attendance and the use of antenatal care are most inequitably distributed in maternal and newborn health interventions in low- and middle-income countries. Conditional cash transfer (CCT) programmes have been shown to increase health service utilization among the poorest but little is written on the effects of such programmes on maternal and newborn health. We carried out a systematic review of studies on CCT that report maternal and newborn health outcomes, including studies from 8 countries. The CCT programmes have increased antenatal visits, skilled attendance at birth, delivery at a health facility, and tetanus toxoid vaccination for mothers and reduced the incidence of low birthweight. The programmes have not had a significant impact on fertility while the impact on maternal and newborn mortality has not been well-documented thus far. Given these positive effects, we make the case for further investment in CCT programmes for maternal and newborn health, noting gaps in knowledge and providing recommendations for better design and evaluation of such programmes. We recommend more rigorous impact evaluations that document impact pathways and take factors, such as cost-effectiveness, into account.

Evidence acquisition and evaluation for evidence summit on enhancing provision and use of maternal health services through financial incentives

Recognizing the need for evidence to inform US Government and governments of the low- and middle-income countries on efficient, effective maternal health policies, strategies, and programmes, the US Government convened the Evidence Summit on Enhancing Provision and Use of Maternal Health Services through Financial Incentives in April 2012 in Washington, DC, USA. This paper summarizes the background and methods for the acquisition and evaluation of the evidence used for achieving the goals of the Summit. The goal of the Summit was to obtain multidisciplinary expert review of literature to inform both US Government and governments of the low- and middle-income countries on evidence-informed practice, policies, and strategies for financial incentives. Several steps were undertaken to define the tasks for the Summit and identify the appropriate evidence for review. The process began by identifying focal questions intended to inform governments of the low-and middle-income countries and the US Government about the efficacy of supply- and demand-side financial incentives for enhanced provision and use of quality maternal health services. Experts were selected representing the research and programme communities, academia, relevant non-governmental organizations, and government agencies and were assembled into Evidence Review Teams. This was followed by a systematic process to gather relevant peer-reviewed literature that would inform the focal questions. Members of the Evidence Review Teams were invited to add relevant papers not identified in the initial literature review to complete the bibliography. The Evidence Review Teams were asked to comply with a specific evaluation framework for recommendations on practice and policy based on both expert opinion and the quality of the data. Details of the search processes and methods used for screening and quality reviews are described.

Meeting community health worker needs for maternal health care service delivery using appropriate mobile technologies in Ethiopia

Background

Mobile health applications are complex interventions that essentially require changes to the behavior of health care professionals who will use them and changes to systems or processes in delivery of care. Our aim has been to meet the technical needs of Health Extension Workers (HEWs) and midwives for maternal health using appropriate mobile technologies tools.

Methods

We have developed and evaluated a set of appropriate smartphone health applications using open source components, including a local language adapted data collection tool, health worker and manager user-friendly dashboard analytics and maternal-newborn protocols. This is an eighteen month follow-up of an ongoing observational research study in the northern of Ethiopia involving two districts, twenty HEWs, and twelve midwives.

Results

Most health workers rapidly learned how to use and became comfortable with the touch screen devices so only limited technical support was needed. Unrestricted use of smartphones generated a strong sense of ownership and empowerment among the health workers. Ownership of the phones was a strong motivator for the health workers, who recognised the value and usefulness of the devices, so took care to look after them. A low level of smartphones breakage (8.3%,3 from 36) and loss (2.7%) were reported. Each health worker made an average of 160 mins of voice calls and downloaded 27Mb of data per month, however, we found very low usage of short message service (less than 3 per month).

Conclusions

Although it is too early to show a direct link between mobile technologies and health outcomes, mobile technologies allow health managers to more quickly and reliably have access to data which can help identify where there issues in the service delivery. Achieving a strong sense of ownership and empowerment among health workers is a prerequisite for a successful introduction of any mobile health program.

Costs of inaction on maternal mortality: qualitative evidence of the impacts of maternal deaths on living children in Tanzania

Background

Little is known about the interconnectedness of maternal deaths and impacts on children, beyond infants, or the mechanisms through which this interconnectedness is established. A study was conducted in rural Tanzania to provide qualitative insight regarding how maternal mortality affects index as well as other living children and to identify shared structural and social factors that foster high levels of maternal mortality and child vulnerabilities.

Methods and Findings

Adult family members of women who died due to maternal causes (N = 45) and key stakeholders (N = 35) participated in in-depth interviews. Twelve focus group discussions were also conducted (N = 83) among community leaders in three rural regions of Tanzania. Findings highlight the widespread impact of a woman’s death on her children’s health, education, and economic status, and, by inference, the roles that women play within their families in rural Tanzanian communities.

Conclusions

The full costs of failing to address preventable maternal mortality include intergenerational impacts on the nutritional status, health, and education of children, as well as the economic capacity of families. When setting priorities in a resource-poor, high maternal mortality country, such as Tanzania, the far-reaching effects that reducing maternal deaths can have on families and communities, as well as women’s own lives, should be considered.

A two-way text-messaging system answering health questions for low-income pregnant women

OBJECTIVE

The purpose of the study was to gauge the effectiveness of a low-cost, automated, two-way text-messaging system to distribute pregnancy and health-related information to low-income expectant women.

METHODS

In total, 20 participants were recruited for a one-month intervention involving the use of cell phones to text pregnancy-related questions to the system. Participants received either a direct answer or encouragement to seek answers from health care providers. Pre- and post-tests as well as a focus group at the end of the intervention were conducted.

RESULTS

Participants uniformly found the system easy to use and accessible. Using the system increased levels of perceived pregnancy-related knowledge and facilitated patient-provider communication. Moreover, participants reported significant reductions in stress and depression and improved mental health after using the system. The system responded to most known questions quickly and accurately, and also encountered many new topics and linguistic expressions.

CONCLUSION

Overall, the data indicated that the text messaging system offered psychological benefits and promoted health communication by providing health information and encouraging patient-provider communication.

PRACTICE IMPLICATIONS

An automated, two-way text messaging system is an efficient, cost-effective, and acceptable method for providing health information to low-income pregnant women.

Breast milk and labour support: lactation consultants' and doulas' strategies for navigating the medical context of maternity care

This article provides a comparison of two occupational groups working in maternity care: International Board Certified Lactation Consultants, who assist women with breastfeeding, and DONA International certified birth doulas, who provide physical, emotional and informational support to birthing women. Using interviews with 18 lactation consultants and 16 doulas working in the USA, I compare these two groups' strategies for gaining entrance to the maternity care team and their abilities to create change in maternity care practices. Due to the organisation of occupational boundaries in maternity care and differences between the influence of the medicalisation of breastfeeding versus that of childbirth on those boundaries, lactation consultants are able to utilise a front-door entrance to the medical maternity system, entering as lactation specialists and advocates, while doulas use a back-door entrance, emphasising their care work and downplaying their advocacy. These different strategies result in different methods being available to each for effecting change. Lactation consultants create formal change, such as changing hospital policies and practices to be more pro-breastfeeding. Doulas create change informally, 'one birth at a time', by creating space for natural birth to occur in the hospital, as well as exposing medical providers to non-medical ways of giving birth.

Reducing maternal mortality in Nigeria: the need for urgent changes in financing for maternal health in the Nigerian health system

AIMS AND OBJECTIVES

Nigeria's maternal mortality indices are among the worst in the world. Various approaches aimed at combatting the persistently high maternal mortality rates in the past have been ineffective. The objective of this article was to evaluate the fairness and equitability of financing for maternal health in the Nigerian health system.

METHODS

A review of the performance of the Nigerian Health system with regards to financing for maternal healthcare and comparison with other health systems utilising internationally accepted criteria was done.

RESULTS

Household out-of -pocket payment was found to be the largest source of health care financing in the Nigerian health system contributing as much as 65.6 % of total health expenditure. This is in sharp contrast to the performance of more effective health systems like that in South Africa where health care is free for pregnant and breast feeding mothers. The result is that South Africa reports less than a tenth of total maternal mortalities reported from Nigeria annually. The current Nigeria health financing system is not equitable and appears to encourage maternal mortalities since it does not cater for the most vulnerable.

CONCLUSION

There is an urgent need for a review of financing of maternal health in Nigeria to achieve universal access to maternal health care. An urgent overhaul of the currently under performing National Health Insurance scheme or adoption of the simpler system based on funding from taxation with universal access for health care including maternal care and services free at the point of access is suggested.

Outcomes of home visits for pregnant mothers and their infants: a cluster randomized controlled trial

OBJECTIVE

To evaluate the effect of home visits by community health workers (CHWs) on maternal and infant well being from pregnancy through the first 6 months of life for women living with HIV (WLH) and all neighborhood mothers.

DESIGN AND METHODS

In a cluster randomized controlled trial in Cape Town townships, neighborhoods were randomized within matched pairs to either standard care, comprehensive healthcare at clinics (n=12 neighborhoods; n=169 WLH; n=594 total mothers); or Philani Intervention Program, home visits by CHWs in addition to standard care (PIP; n=12 neighborhoods; n=185 WLH; n=644 total mothers). Participants were assessed during pregnancy (2% refusal) and reassessed at 1 week (92%) and 6 months (88%) postbirth. We analyzed PIP's effect on 28 measures of maternal and infant well being among WLH and among all mothers using random effects regression models. For each group, PIP's overall effectiveness was evaluated using a binomial test for correlated outcomes.

RESULTS

Significant overall benefits were found in PIP compared to standard care among WLH and among all participants. Secondarily, compared to standard care, PIP WLH were more likely to complete tasks to prevent vertical transmission, use one feeding method for 6 months, avoid birth-related medical complications, and have infants with healthy height-for-age measurements. Among all mothers, compared to standard care, PIP mothers were more likely to use condoms consistently, breastfeed exclusively for 6 months, and have infants with healthy height-for-age measurements.

CONCLUSION

PIP is a model for countries facing significant reductions in HIV funding whose families face multiple health risks.

Ensuring intercultural maternal health care for Mayan women in Guatemala: a qualitative assessment

Indigenous (Mayan) women in Guatemala experience a disproportionate burden of maternal mortality and morbidity, as well as institutional failures to respect their rights. The Guatemalan Ministry of Health has started to offer 'intercultural' services that respect Mayan obstetric practices and integrate them with biomedical care. We purposefully selected 19 secondary-level public health facilities of 9 departments that provided maternal healthcare to indigenous women. We carried out semi-structured interviews with biomedical providers (44), Mayan midwives or comadronas (45), and service users (18), exploring the main characteristics of intercultural care. We found that most facilities initiated the implementation of culturally appropriate services, such as accompaniment by a comadrona or family member, use the traditional teas or choosing the birthing position, but they still lacked standardisation. Comadronas generally felt excluded from the health system, although most biomedical providers reported that they were making important strides to be respectful and inclusive. Most users wanted the option of culturally appropriate services but typically did not receive them. In the health facilities, biomedicine is still the dominant discourse. Efforts at offering intercultural care still need strengthening and further monitoring. Involvement and participation of comadronas and indigenous women is key to moving forward to true intercultural services.

Striving for excellence: nurturing midwives' skills in Freetown, Sierra Leone

Midwives provide critical, life-saving care to women and babies. Effective midwives must be clinically competent, with the required knowledge, skills, and attitudes to provide quality care. Their success depends on an environment of supportive supervision, continuing education, enabling policies, and access to equipment and referral facilities. In Freetown, Sierra Leone, the Aberdeen Women's Centre launched a maternity unit with an emphasis on striving for excellence and providing ongoing professional development to its staff midwives. Its success was built upon fostering a sense of responsibility and teamwork, providing necessary resources, conforming to evidence-based standards, and building partnerships. An explicit philosophy of care was crucial for guiding clinical decision making. In its first two years of operation, the Aberdeen Women's Centre assisted 2076 births with two maternal deaths and 92 perinatal deaths. In-service education and supportive supervision facilitated the midwives' professional growth, leading to capable future leaders who are providing exemplary care to delivering mothers and their newborns in Freetown.

Preference for institutional delivery and caesarean sections in Bangladesh

In Bangladesh, preference for place of delivery and socioeconomic factors associated with caesarean section are not well-understood. This paper examines the socioeconomic correlates of preference for institutional delivery and caesarean sections in Bangladesh. The study used data from the nationally-representative 2007 Bangladesh Demographic and Health Survey. Both bivariate and multivariate binary logistic regression models were constructed to assess the effect of sociodemographic factors on the use of medical facilities and caesarean section for childbirth. Overall, 15% of women underwent institutional delivery, and 8% deliveries were performed by caesarean sections. Both institutional deliveries and caesarean sections have increased in recent years. The bivariate and multivariate analyses both confirmed that place of residence, religion, birth order, frequent pregnancy, antenatal care-seeking, and wealth index were important predictors of the use of medical facilities and caesarean sections for childbirth. Women's education appeared as the most single significant determinant for the use of both services. The findings underlie the importance of monitoring caesarean section as well as professional attendance for safe motherhood. Programmes should aim to inform women highlighting the benefits of the use of skilled maternal healthcare services and demerits of home-delivery practices.

Nutritional management of the low birth weight/preterm infant in community settings: a perspective from the developing world

Globally, about 20 million infants are born with low birth weight (LBW; <2500 g). Of all LBW infants, approximately 95% are born in developing countries. The greatest incidence of LBW occurs in South-Central Asia; the second greatest is in Africa. The two main reasons for LBW are preterm birth (<37 weeks) and intrauterine growth restriction (IUGR), which are risk factors for increased morbidity and mortality in newborn infants. Maternal nutrition status is one of the most important risk factors for LBW/IUGR. Providing balanced protein energy and multiple micronutrient supplements to pregnant women will reduce incidence of IUGR. Calcium supplementation during pregnancy will reduce the incidence of pre-eclampsia and preterm birth in developing countries. Exclusive breastfeeding is protective for a mother and her infant and has been shown to reduce morbidity and mortality in infancy. Kangaroo mother care for preterm infants will reduce severe morbidity and mortality as well. Community-based intervention packages are among the most effective methods of reducing morbidity and mortality in mothers and children. Future research should focus on improving triage of preterm and IUGR infants. Exclusive breastfeeding should be promoted, and appropriate alternative food supplements should be provided when breastfeeding is not possible.

Volunteering in the maternity services: for whose benefit?

In recent years volunteers have become part of the maternity services to support midwives in the UK. Future midwifery students are being expected to have gained such experience when applying for courses. They are providing significant support for women in relation to breastfeeding and in other supportive roles. However this article aims to explore what volunteers are doing, questions whether the recent shortage of midwives is leading to volunteers being asked to take on tasks that are beyond their unpaid status and asks who is really benefiting from this role.

Neonatal abstinence syndrome clinical practice guidelines for Ontario

Ontario's clinical practice guidelines for neonatal abstinence syndrome (NAS) provide evidence-informed recommendations that address the needs of substance using pregnant women and newborns at risk of NAS. NAS is a complex and multifaceted issue that is escalating along with rapidly rising opioid use in Ontario. Reducing the incidence and impact of NAS requires immediate action in order to improve the care of affected women and infants. This includes optimizing and standardizing treatment strategies, assessing and managing social risk, better monitoring of prescribing practices and facilitating the implementation of better treatment and prevention strategies as they become available. These clinical practice guidelines provide the framework to inform and support the development of a coordinated strategy to address this important issue and to promote safe and effective care.

'Every pregnant woman needs a midwife'--the experiences of HIV affected women in maternity care

TITLE

'Every pregnant woman needs a midwife'-the experiences of HIV affected women in Northern Ireland.

OBJECTIVE

to explore HIV positive women's experiences of pregnancy and maternity care, with a focus on their interactions with midwives.

DESIGN

a prospective qualitative study.

SETTING

regional HIV unit in Northern Ireland.

PARTICIPANTS

22 interviews were conducted with 10 women at different stages of their reproductive trajectories.

FINDINGS

the pervasive presence of HIV related stigma threatened the women's experience of pregnancy and care. The key staff attributes that facilitated a positive experience were knowledge and experience, empathy and understanding of their unique needs and continuity of care.

KEY CONCLUSIONS

pregnancy in the context of HIV, whilst offering a much needed sense of normality, also increases woman's sense of anxiety and vulnerability and therefore the need for supportive interventions that affirm normality is intensified. A maternity team approach, with a focus on providing 'balanced care' could meet all of the woman and child's medical needs, whilst also emphasising the normalcy of pregnancy.

Development and psychometric properties of the Early Labour Experience Questionnaire (ELEQ)

OBJECTIVE

to describe the development and psychometric properties of the Early Labour Experiences Questionnaire (ELEQ).

DESIGN

randomized controlled trial.

SETTING

hospitals serving obstetric populations in metropolitan and suburban Vancouver, British Columbia, Canada.

PARTICIPANTS

423 healthy nulliparous women in labour at term with uncomplicated pregnancies.

INTERVENTION

women were randomized to telephone support (n=241) or home visit (n=182) study groups and completed the ELEQ during the postpartum phase of their hospital stay.

MEASUREMENT

the ELEQ contains 26 self-report items, rated on a 5-point scale, that measure women's affective experience of early labour (14 items), perceptions of nursing care (12 items), whether they would recommend this type of early labour care to a friend (1 item), and whether they believed they went to the hospital at the right time (1 item). An exploratory factor analysis was conducted to determine whether the items grouped together into subscales. The structural reliability of the extracted subscales and total scores were evaluated using a number of coefficients. To test criterion validity, we compared ELEQ item, subscale and total scores between the study groups.

FINDINGS

item and total scores showed significant variability. Factor analysis yielded three subscales: Emotional Well-Being, Emotional Distress and Perceptions of Nursing Care. The subscale and total scores showed good internal consistency and item homogeneity, and were interrelated in the expected direction. Items evidenced strong associations with the subscale and total scores. Comparisons between study groups offered some support for criterion validity.

KEY CONCLUSIONS

pending further validation, the ELEQ can contribute to the assessment of women's experiences with different aspects of maternity care, evaluation of the quality of maternity care, and improvement of maternity services.

Women with pre-existing diabetes and their experiences of maternity care services

AIMS AND OBJECTIVES

the aims of the study were to explore the experience of maternity care services used by women whose pregnancy is complicated by pre-existing diabetes, to gain a deeper understanding of service use and to identify aspects of services that women with pre-existing diabetes would like improved.

BACKGROUND

for women with pre-existing diabetes; pregnancy, birth and the transition to motherhood can be complex and even chaotic. The aim of specialist diabetes care given during pregnancy and delivered by a specialist team of health-care professionals is to optimise pregnancy outcome. However, how health-care professionals within maternity services provide care and support women with pre-existing diabetes during pregnancy and early motherhood has received limited attention.

DESIGN

an exploratory study utilising a grounded theory approach was conducted. Data were collected via in-depth interviews with 20 respondents; one-to-one, dyad and group interviews were undertaken to fully explore issues. Analysis was undertaken by sub-groups of the research team with at least two members working on each of them.

FINDINGS

three themes were identified from interviews: empathic care with care more focused on diabetes not pregnancy; feeling judged by health-care professionals (with nearly all respondents reporting negative encounters of consultation with the specialist team); and the notion of expertise (with respondents reporting feeling frustrated when it seemed health-care professionals did not value their expertise).

CONCLUSIONS

the study emphasised the importance of the health-care relationship for pregnant women with pre-existing diabetes. For outcomes to be optimised women need to be able to form open and trusting relationships with the health-care team.

RELEVANCE TO CLINICAL PRACTICE

this study highlights the need for the health-care team not only to provide physical care to optimise outcome but also supportive care to assist women with pregnancies complicated by diabetes to achieve the best possible physical and emotional health and well-being.

Evaluation of Lay Support in Pregnant women with Social risk (ELSIPS): a randomised controlled trial

BACKGROUND

Maternal, neonatal and child health outcomes are worse in families from black and ethnic minority groups and disadvantaged backgrounds. There is little evidence on whether lay support improves maternal and infant outcomes among women with complex social needs within a disadvantaged multi-ethnic population in the United Kingdom (UK).

METHOD/DESIGN

The aim of this study is to evaluate a lay Pregnancy Outreach Worker (POW) service for nulliparous women identified as having social risk within a maternity service that is systematically assessing social risks alongside the usual obstetric and medical risks. The study design is a randomised controlled trial (RCT) in nulliparous women assessed as having social risk comparing standard maternity care with the addition of referral to the POW support service. The POWs work alongside community midwifery teams and offer individualised support to women to encourage engagement with services (health and social care) from randomisation (before 28 weeks gestation) until 6 weeks after birth. The primary outcomes have been chosen on the basis that they are linked to maternal and infant health. The two primary outcomes are engagement with antenatal care, assessed by the number of antenatal visits; and maternal depression, assessed using the Edinburgh Postnatal Depression Scale at 8-12 weeks after birth. Secondary outcomes include maternal and neonatal morbidity and mortality, routine child health assessments, including immunisation uptake and breastfeeding at 6 weeks. Other psychological outcomes (self efficacy) and mother-to-infant bonding will also be collected using validated tools.A sample size of 1316 will provide 90% power (at the 5% significance level) to detect increased engagement with antenatal services of 1.5 visits and a reduction of 1.5 in the average EPDS score for women with two or more social risk factors, with power in excess of this for women with any social risk factor. Analysis will be by intention to treat. Qualitative research will explore the POWs' daily work in context. This will complement the findings of the RCT through a triangulation of quantitative and qualitative data on the process of the intervention, and identify other contextual factors that affect the implementation of the intervention.

DISCUSSION

The trial will provide high quality evidence as to whether or not lay support (POW) offered to women identified with social risk factors improves engagement with maternity services and reduces numbers of women with depression. MREC NUMBER: 10/H1207/23

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN35027323.