What Makes a Good Family‐Centered Partnership Between Women and Their Practitioners? A Qualitative Study

Abstract: Background : Family‐centered maternity care is an approach based on mutually beneficial partnerships between health care providers and families. It offers new ways of thinking about the relationship among childbearing women, their families, and health caregivers. This study was designed to identify health care practices that promoted or limited a family‐centered philosophy. Methods : A qualitative design, using reflexive interviews and focus groups, investigated the perspectives of 34, primarily African American women who used maternity services at a large urban hospital; some women traveled from rural areas for delivery. Inductive data analysis was conducted on the transcribed audiotapes of the interviews and groups. Results : Barriers to family‐centered maternity care were categorized as issues in coordination of services among health caregivers, patient‐health caregiver relationships and systems, and access to services. Facilitators of family‐centered maternity care were identified as perceived response to high‐risk patients, health‐related support outside the hospital, and special resources. Narratives, or personal stories told by the women, were used to illustrate barriers and facilitators. Conclusions : Education about family‐centered maternity care is vitally important for health caregivers. In clinical situations, each childbearing woman and her family should be treated as if they are extraordinary. In this way, practitioners can alter routines that cause the woman and her family to lose individualized care. (BIRTH 31:1 March 2004)     

Evaluation of a community intervention for promotion of safe motherhood in Eritrea

Introduction: We evaluated a community‐based intervention to promote safe motherhood, focusing on knowledge and behaviors that may reduce maternal mortality and birth complications. The intervention aimed to increase women's birth preparedness, knowledge of birth danger signs, use of antenatal care services, and birth at a health care facility. Methods: Volunteers from a remote rural community in Northern Eritrea were trained to lead participatory educational sessions on safe motherhood with women and men. The evaluation used a quasiexperimental design (nonequivalent group pretest‐posttest) including cross‐sectional surveys with postpartum women (pretest n = 466, posttest n = 378) in the intervention area and in a similar remote rural comparison area. Results: Women's knowledge of birth danger signs increased significantly in the intervention area but not in the comparison area. There was a significant increase in the proportion of women who had the recommended 4 or more antenatal care visits during pregnancy in the intervention area (from 18% to 80%, P < .001), although this proportion did not change significantly in the comparison area (from 53% to 47%, P= .194). There was a greater increase in birth in a health care facility in the intervention area. Discussion: Participatory sessions led by community volunteers can increase safe motherhood knowledge and encourage use of essential maternity services.     

Canadian Maternity Experiences Survey Pilot Study

Abstract: Background : The Maternity Experiences Survey is a project of the Canadian Perinatal Surveillance System. Its primary objective is to provide insight into Canadian women's maternity experiences. A pilot study was conducted in 2002/2003 to determine to what extent women's reports could be used to assess Canadian perinatal health policies and practices, and to test the procedures proposed for a national maternity experiences survey. Methods : A nonrepresentative sample of 291 mothers was drawn from Canadian birth registration records. Mothers whose children had died or were no longer in their care were excluded. Participants were interviewed 9 to 11 months postpartum about prenatal, labor, and birth and postpartum experiences. Results : The response rate was 86 percent. Respondents were generally comfortable answering all questions and identified areas of potential strength and weakness in the Canadian maternity care system. They had difficulty recalling information on some prenatal tests, and labor and birth procedures. The use of birth registrations to draw the pilot sample worked well. However, some regions may not be able to provide timely access to birth registrations for the purposes of a national survey. Conclusions : The high response rate and women's ability to provide information on a wide range of topics demonstrates that a national maternity survey would be an effective method of providing important maternal health information. The data collected would allow Health Canada to carry out more effective national perinatal health surveillance with a view to influencing perinatal health policy and practice.     

Willingness to Pay for a Maternity Waiting Home Stay in Zambia

Introduction

Complications of pregnancy and childbirth can pose serious risks to the health of women, especially in resource‐poor settings. Zambia has been implementing a program to improve access to emergency obstetric and neonatal care, including expansion of maternity waiting homes‐residential facilities located near a qualified medical facility where a pregnant woman can wait to give birth. Yet it is unclear how much support communities and women would be willing to provide to help fund the homes and increase sustainability.

Methods

We conducted a mixed‐methods study to estimate willingness to pay for maternity waiting home services based on a survey of 167 women, men, and community elders. We also collected qualitative data from 16 focus group discussions to help interpret our findings in context.

Results

The maximum willingness to pay was 5.0 Zambian kwacha or $0.92 US dollars per night of stay. Focus group discussions showed that willingness to pay is dependent on higher quality of services such as food service and suggested that the pricing policy (by stay or by night) could influence affordability and use.

Discussion

While Zambians seem to value and be willing to contribute a modest amount for maternity waiting home services, planners must still address potential barriers that may prevent women from staying at the shelters. These include cash availability and affordability for the poorest households.     

Childbearing in U.S. Military Hospitals: Dimensions of Care Affecting Women's Perceptions of Quality and Satisfaction

Abstract: Background : The U.S. Department of Defense provides medical services for approximately 9.1 million beneficiaries, one‐half of whom are women. Information is lacking about how well the military health system has adopted patient‐centered approaches for promoting individual choice and preference in a bureaucratically structured military hospital. The purpose of this study was to examine women's evaluations of maternity care with respect to decision‐making, confidence, trust in health care providers, and treatment within the military hospital. Methods : The Department of Defense Inpatient Childbirth Survey was mailed to a simple stratified random sample of beneficiaries who received maternity care at a military hospital between July 1 and September 30, 2001. Data for 11 dimensions of women's care and experiences were examined from self‐reported assessments of 2,124 respondents who gave birth at one of 44 military hospitals. A multiple logistic regression model was estimated to determine which dimensions of care predicted beneficiaries’ likelihood to recommend the military hospital to family and friends. Result : Less than 50 percent of respondents would recommend the military hospital to family and friends. Significantly associated with women's willingness to recommend their specific military hospital to others were courtesy and availability of staff, confidence and trust in provider, treatment with respect and dignity, information and education, physical comfort, involvement of friends and family, continuity and transition, and involvement in decision‐making. Conclusions : In a military population, obstetric patients who are treated with respect, courtesy, and dignity, are involved in decisions about their care, and have established trusting relationships with their practitioners are significantly more likely to recommend the military hospital to others. It is important for military health care leaders to establish a proactive program of patient‐centered maternity care. Continuous care, education, support services, and a multidisciplinary approach should be integrated to retain and recapture obstetric patients who are served in military hospitals in the United States.     

Maternal health outcomes two years after term breech delivery

Objective. To evaluate maternal health outcomes two years after term breech delivery.

Design. This was a non-randomized single-center prospective cohort study. Mothers were asked to fill out questionnaires at two years postpartum to judge their health in the previous three to six months. Outcomes of the planned cesarean section group were compared with outcomes of the planned vaginal delivery group, whether or not a vaginal birth was realized or an emergency cesarean section was performed.

Results. One hundred and eighty-three women completed a follow-up questionnaire at two years postpartum. Outcomes of the planned cesarean section group were compared with her partner were found between the two groups. Also, no differences were found in all investigated maternal health items, or in sexual activity and fertility.

Conclusion. Maternal health outcomes two years after term breech delivery were similar after planned cesarean section and planned vaginal delivery.     

User fees and maternity services in Ethiopia

Objectives

To examine user fees for maternity services and how they relate to provision, quality, and use of maternity services in Ethiopia.

Methods

The national assessment of emergency obstetric and newborn care (EmONC) examined user fees for maternity services in 751 health facilities that provided childbirth services in 2008.

Results

Overall, only about 6.6% of women gave birth in health facilities. Among facilities that provided delivery care, 68% charged a fee in cash or kind for normal delivery. Health centers should be providing maternity services free of charge (the healthcare financing proclamation), yet 65% still charge for some aspect of care, including drugs and supplies. The average cost for normal and cesarean delivery was US $7.70 and US $51.80, respectively. Nineteen percent of these facilities required payment in advance for treatment of an obstetric emergency. The health facilities that charged user fees had, on average, more delivery beds, deliveries (normal and cesarean), direct obstetric complications treated, and a higher ratio of skilled birth attendants per 1000 deliveries than those that did not charge. The case fatality rate was 3.8% and 7.1% in hospitals that did and did not charge user fees, respectively.

Conclusion

Utilization of maternal health services is extremely low in Ethiopia and, although there is a government decree against charging for maternity service, 65% of health centers do charge for some aspects of maternal care. As health facilities are not reimbursed by the government for the costs of maternity services, this loss of revenue may account for the more and better services offered in facilities that continue to charge user fees. User fees are not the only factor that determines utilization in settings where the coverage of maternity services is extremely low. Additional factors include other out-of-pocket payments such as cost of transport and food and lodging for accompanying relatives. It is important to keep quality of care in mind when user fees are under discussion.     

The misleading choice for safer births in Brazilian’s most developed region: a cross-sectional study

Purpose: To analyze the Cesarean Section (CS) rate in Brazilian women according to category of health insurance and individual characteristics associated with the mode of delivery.

Materials and methods: A cross-sectional study was performed in three maternity services (one public tertiary referral center, one maternity service for both public and private care, and one private maternity service) in Campinas city, Brazil. Eligibility criteria were: inpatient during the immediate postpartum period, hospital birth, single pregnancy, and live newborn. Sociodemographic and anthropometric data, reproductive history, pregnancy planning, and prenatal care information was obtained from participants. Comorbidities, type of birth, and newborn data were collected from medical records. The mode of delivery was categorized as either CS or vaginal delivery.

Results: A total of 1276 women were included in this study. The overall CS rate was 57.5%. CS rates were 41.6, 54.8, and 90.1% for public, mixed (public and private), and private maternity services, respectively. Mean age was higher in women who had a CS (28.0?±?6.0 years versus 25.9?±?6.5 years, p?2 versus 23.8?±?4.5?kg/m², p?Conclusions: The overall CS rate was high (greater than 50%); in the private service, almost all participants had a CS delivery (90.1%). Better socioeconomic conditions and primiparity were associated with higher CS rates in Brazil. Political pressure for the management of unnecessary CSs is vital in Brazil. Together with the provision of real incentives for normal deliveries in public and, most importantly, private services.     

Catastrophizing labor pain compromises later maternity adjustments

OBJECTIVE: The purpose of this study was to evaluate the impact of labor pain intensity and labor pain catastrophizing on maternity blues and postpartum social functioning. STUDY DESIGN: Pain intensity and pain catastrophizing were assessed in 89 women in active labor before the administration of analgesia. Both these measures were assessed again retrospectively 2 days after delivery in 82 women who had a spontaneous vaginal delivery. Women also filled out the Edinburgh Postnatal Depression Scale. Six weeks later women completed the social functioning domain of the short form SF36 health survey. RESULTS: Pain catastrophizing during labor significantly predicted both maternity blues (P = .001) and postpartum social functioning (P = .001) when being controlled for maternal age and education, parity, type of analgesia, and labor pain intensity. Low level of education and younger age also contributed to the prediction of maternity blues and social functioning. CONCLUSION: Labor pain catastrophizing rather than labor pain intensity predicts postpartum maternal adjustments.     

Temporal trends and morbidities of vacuum,forceps, and combined use of both

Abstract

Objective: To assess trends over time of operative vaginal delivery and compare delivery-related morbidity between vacuum delivery, forceps delivery, or combined use of both in California.

Methods: California ICD-9 discharge data from 2001 to 2007 were used to identify cases of forceps and vacuum delivery.

Results: There was a decline in all operative delivery types (9.0% in 2001 to 7.6% in 2007), with the decline in the use of forceps most pronounced (7.26/1000 deliveries in 2001 to 3.85/1000 in 2007). Higher rates of third/fourth degree lacerations, postpartum hemorrhage, manual extraction of placenta, pelvic hematoma requiring evacuation, cervical laceration repair, and thromboembolic events were noted in forceps compared to vacuum deliveries. When both instruments were used, rates of third/fourth degree lacerations and postpartum hemorrhage were increased. Operative delivery failure was highest in combined use compared to forceps or vacuum alone.

Conclusion: The incidence of operative vaginal delivery in California is declining, with decreasing use of forceps most notable. Several maternal morbidities are increased in forceps and combined deliveries compared to vacuum deliveries. There is a significantly higher risk of failure when two operative delivery methods are employed. These findings may be contributing to the declining willingness of providers to perform operative vaginal delivery.     

Maternal expectations and postpartum emotional adjustment in first-time mothers: results of a questionnaire survey

Abstract

Objective: Several predictors of postpartum mood have been identified in the literature, but the role of maternal expectations in postpartum mental health remains unclear. The aim of this study was to identify whether maternal expectations during the postpartum hospital stay predict adjustment and depressive symptoms at 6 weeks postpartum.

Methods: The sample included 233 first-time mothers recruited from the postpartum unit of a Midwestern hospital. Participants completed measures of maternal expectations and depressive symptoms (EPDS) at Time 1 (2?d postpartum) and completed EPDS and an Emotional Adjustment Scale (BaM-13) at Time 2 (6 weeks postpartum).

Results: A conditional relationship between the expectation that an infant’s behavior will reflect maternal skill and Time 2 outcomes (BaM-13 and EPDS) was found, such that endorsing this belief predicted increased depression and poorer adjustment in those with higher (but not lower) Time 1 EPDS scores. Time 2 BaM-13 scores were also negatively predicted by expectations of self-sacrifice and positively predicted by expectations that parenthood would be naturally fulfilling.

Conclusions: The expectations that new mothers hold about parenting soon after delivery are predictive of emotional adjustment in the early postpartum period, suggesting a role for discussion of expectations in future preventive strategies.     

Postpartum Depression Help‐Seeking Barriers and Maternal Treatment Preferences: A Qualitative Systematic Review

ABSTRACT: Background: Despite the well‐documented risk factors and health consequences of postpartum depression, it often remains undetected and untreated. No study has comprehensively examined postpartum depression help‐seeking barriers, and very few studies have specifically examined the acceptability of postpartum depression treatment approaches. The objective of this study was to examine systematically the literature to identify postpartum depression help‐seeking barriers and maternal treatment preferences. Methods: Medline, CINAHL, and EMBASE databases were searched using specific key words, and published peer‐reviewed articles from 1966 to 2005 were scanned for inclusion criteria. Results: Of the 40 articles included in this qualitative systematic review, most studies focused on women’s experiences of postpartum depression where help seeking emerged as a theme. A common help‐seeking barrier was women’s inability to disclose their feelings, which was often reinforced by family members and health professionals’ reluctance to respond to the mothers’ emotional and practical needs. The lack of knowledge about postpartum depression or the acceptance of myths was a significant help‐seeking barrier and rendered mothers unable to recognize the symptoms of depression. Significant health service barriers were identified. Women preferred to have “talking therapies” with someone who was nonjudgmental rather than receive pharmacological interventions. Conclusions: These results suggest that women did not proactively seek help, and the barriers involved both maternal and health professional factors. Common themes related to specific treatment preferences emerged from women of diverse cultural backgrounds. The clinical implications outlined in this review will assist health professionals in addressing these barriers and in developing preventive and treatment interventions that are in accord with maternal preferences. (BIRTH 33:4 December 2006)     

Profile of Mood States and Parental Attitudes in Motherhood: Comparing Women with Planned and Unplanned Pregnancies

Abstract: Background: Despite the availability of various contraceptive options, in some Western countries most pregnancies are unplanned. The objective of this longitudinal study was to assess the influence of planned and unplanned pregnancy on women's psychological well‐being and on maternal attitude toward parenting in the first years after giving birth. Methods: A sample of 119 primiparous women (88 planned and 31 unplanned pregnancies) with normal pregnancy, uncomplicated vaginal delivery, and a healthy living baby completed the Profile of Mood States (POMS) instrument in the ninth month of pregnancy, and at 1, 6, and 12 months after birth, and the Parental Attitude Research Instrument (PARI) 2 years after the birth. The POMS evaluates mood disturbance and the PARI assesses maternal attitudes toward parenthood in general. Results: Women with unplanned pregnancies demonstrated a significantly more disturbed mood, both in pregnancy and in the first year after the birth. However, at approximately 2 years after childbirth there was no difference between the two groups of women in their rejection of the maternal role, and repressive and punitive maternal attitudes. Conclusions : In primiparas of middle socioeconomic levels, unplanned pregnancy is a risk factor for moderate mood disturbances rather than for an inadequate parental educational role. The study findings demonstrate the need to prevent unplanned pregnancies, and to offer immediate health assistance when particular conditions arise. (BIRTH 32:2 June 2005)     

Syrian Women's Preferences for Birth Attendant and Birth Place

Abstract: Background : Women's preferences for type of maternity caregiver and birth place have gained importance and have been documented in studies reported from the developed world. The purpose of our study was to identify Syrian women's preferences for birth attendant and place of delivery. Methods : Interviews with 500 women living in Damascus and its suburbs were conducted using a pretested structured questionnaire. Women were asked about their preferences for the birth attendant and place of delivery, and an open‐ended question asked them to give an explanation for their preferences. We analyzed preferences and their determinants, and also agreement between actual and preferred place of delivery and birth attendant. Results : Only a small minority of women (5–10%) had no preference. Most (65.8%) preferred to give birth at the hospital, and 60.4 percent preferred to be attended by doctors compared with midwives (21.2%). More than 85 percent of women preferred the obstetrician to be a female. The actual place of delivery and type of birth attendant did not match the preferred place of delivery and type of birth attendant. Women's reasons for preferences were a perception of safety and competence, and communication style of caregiver. Conclusions : Most women preferred to be delivered by female doctors at a hospital in this population sample in Syria. The findings suggest that proper understanding of women's preferences is needed, and steps should be taken to enable women to make good choices. Policies about maternity education and services should take into account women's preferences.     

Introduction of misoprostol for prevention of postpartum hemorrhage at the community level in Senegal

Objective

To demonstrate that training ensures correct administration of oral misoprostol by auxiliary midwives for prevention of postpartum hemorrhage (PPH) among women giving birth at the community level in Senegal.

Methods

A 6-day training program for auxiliary midwives and supervisors, including 1 day of PPH prevention training and a practicum of 10 deliveries at health centers and 3 deliveries at maternity huts, was conducted in 2 Senegalese districts in June–July 2009. Data were collected between July and December 2009 on the administration of oral misoprostol by trained auxiliary midwives among 245 women giving birth at health centers, health posts, and maternity huts.

Results

All participating women received the correct administration of oral misoprostol; however, few women delivering in the community-based maternity huts received the supervision that is locally required to administer misoprostol. Women were willing to pay for some or all of the costs of misoprostol for PPH prevention.

Conclusion

Timely management of PPH is essential to reduce maternal mortality. With limited training, auxiliary midwives achieved the correct administration of oral misoprostol that can attain this goal. Community delivery supervised by a skilled attendant limits access to, and need not be a requirement for, PPH prevention.     

Relationships Among Infant Sleep Patterns,Maternal Fatigue,and Development of Depressive Symptomatology

ABSTRACT: Background: Postpartum depression is a serious condition for women after childbirth. Although its etiology is unclear, one potentially important predictive variable that has received little attention is maternal sleep deprivation. The objective of this study was to examine relationships among infant sleep patterns, maternal fatigue, and the development of postpartum depression in women with no major depressive symptomatology at 1 week postpartum. Methods: As part of a population‐based postpartum depression study, 505 women who had an Edinburgh Postnatal Depression Scale (EPDS) score < 13 at 1 week postpartum completed questionnaires at 4 and 8 weeks postpartum. Results: Mothers exhibiting major depressive symptomatology (EPDS > 12) at 4 and 8 weeks were significantly more likely to report that their baby cried often, be woken up 3 times or more between 10 pm and 6 am , have received less than 6 hours of sleep in a 24‐hour period over the past week, indicate that their baby did not sleep well, and think that their baby's sleep pattern did not allow them to get a reasonable amount of sleep. Consistent with these findings, mothers with an EPDS score > 12 were significantly more likely to respond that they often felt tired. Conclusions: These results suggest that infant sleep patterns and maternal fatigue are strongly associated with a new onset of depressive symptoms in the postpartum period, and provide support for the development of postpartum depression preventive interventions designed to reduce sleep deprivation in the early weeks postpartum.     

New mothers’ feelings of disappointment and failure after cesarean delivery

Background

Childbirth is an important life event and how women feel in retrospect about their first childbirth may have long‐term effects on the mother, child, and family. In this study, we investigated the association between mode of delivery at first childbirth and birth experience, using a new scale developed specifically to measure women's affective response.

Methods

This was a prospective cohort study of 3006 women who were interviewed during pregnancy and 1‐month postpartum. The First Baby Study Birth Experience Scale was used to measure the association between mode of delivery and women's postpartum feelings about their childbirth, taking into account relevant confounders, including maternal age, race, education, pregnancy intendedness, depression, social support, and maternal and newborn complications by way of linear and logistic regression models.

Results

Women who had unplanned cesarean delivery had the least positive feelings overall about their first childbirth, in comparison to those whose deliveries were spontaneous vaginal (P < .001), instrumental vaginal (P = .001), and planned cesarean (P < .001). In addition, those who delivered by unplanned cesarean were more likely to feel disappointed (adjusted odds ratio [OR] 6.21 [95% confidence interval (CI) 4.62‐8.35]) and like a failure (adjusted OR 5.09 [95% CI 3.65‐7.09]) in comparison to women who had spontaneous vaginal delivery; and less likely to feel extremely or quite a bit proud of themselves (adjusted OR 2.70 [95% CI 2.20‐3.30]).

Conclusions

Delivering by unplanned cesarean delivery adversely affects how women feel about their first childbirth in retrospect, and their self‐esteem.     

Factors associated with maternal near miss in childbirth and the postpartum period: findings from the birth in Brazil National Survey, 2011–2012

Background

Maternal near-miss (MNM) audits are considered a useful approach to improving maternal healthcare. The aim of this study was to evaluate the factors associated with maternal near-miss cases in childbirth and the postpartum period in Brazil.

Methods

The study is based on data from a nationwide hospital-based survey of 23,894 women conducted in 2011–2012. The data are from interviews with mothers during the postpartum period and from hospital medical files. Univariate and multivariable logistic regressions were performed to analyze factors associated with MNM, including estimation of crude and adjusted odds ratios and their respective 95 % confidence intervals (95 % CI).

Results

The estimated incidence of MNM was 10.2/1,000 live births (95 % CI: 7.5–13.7). In the adjusted analyses, MNM was associated with the absence of antenatal care (OR: 4.65; 95 % CI: 1.51–14.31), search for two or more services before admission to delivery care (OR: 4.49; 95 % CI: 2.12–9.52), obstetric complications (OR: 9.29; 95 % CI: 6.69–12.90), and type of birth: elective C-section (OR: 2.54; 95 % CI: 1.67–3.88) and forceps (OR: 9.37; 95 % CI: 4.01–21.91). Social and demographic maternal characteristics were not associated with MNM, although women who self-reported as white and women with higher schooling had better access to antenatal and maternity care services.

Conclusion

The high proportion of elective C-sections performed among women in better social and economic situations in Brazil is likely attenuating the benefits that could be realized from improved prenatal care and greater access to maternity services. Strategies for reducing the rate of MNM in Brazil should focus on: 1) increasing access to prenatal care and delivery care, particularly among women who are at greater social and economic risk and 2) reducing the rate of elective cesarean section, particularly among women who receive services at private maternity facilities, where C-section rates reach 90 % of births.