Women's health groups to improve perinatal care in rural Nepal

BACKGROUND: Neonatal mortality rates are high in rural Nepal where more than 90% of deliveries are in the home. Evidence suggests that death rates can be reduced by interventions at community level. We describe an intervention which aimed to harness the power of community planning and decision making to improve maternal and newborn care in rural Nepal. METHODS: The development of 111 women's groups in a population of 86 704 in Makwanpur district, Nepal is described. The groups, facilitated by local women, were the intervention component of a randomized controlled trial to reduce perinatal and neonatal mortality rates. Through participant observation and analysis of reports, we describe the implementation of this intervention: the community entry process, the facilitation of monthly meetings through a participatory action cycle of problem identification, community planning, and implementation and evaluation of strategies to tackle the identified problems. RESULTS: In response to the needs of the group, participatory health education was added to the intervention and the women's groups developed varied strategies to tackle problems of maternal and newborn care: establishing mother and child health funds, producing clean home delivery kits and operating stretcher schemes. Close linkages with community leaders and community health workers improved strategy implementation. There were also indications of positive effects on group members and health services, and most groups remained active after 30 months. CONCLUSION: A large scale and potentially sustainable participatory intervention with women's groups, which focused on pregnancy, childbirth and the newborn period, resulted in innovative strategies identified by local communities to tackle perinatal care problems.     

Labor risk assessment in a rural community hospital

Unanticipated perinatal catastrophe in a rural community hospital is responsible for the deaths of many potentially salvageable infants. An intrapartum risk scoring system was designed to help anticipate infants needing skilled resuscitation at the rural community hospital. Thirty-three percent of infants whose mothers scored as high risk (greater than or equal to 10) required resuscitation while only 6% of infants whose mothers scored less than 10 required resuscitation. Sequential Apgar scores of infants in need of resuscitation attended by a skilled resuscitator showed significant improvement compared with Apgar scores of infants not attended by a skilled resuscitator, suggesting at least a short-term benefit for early identification of the infant at risk.     

Systemic control in rural perinatal health care ("Triple Ten Management")

Using "Triple Ten Management" as the basic method, we conducted research on a standard model of rural perinatal health care in our province. The "Triple Ten Management" includes: (1) controlling ten commonest high risk pregnancies; (2) application of ten perinatal monitoring techniques; (3) ten concerted managing regimes of rural perinatal care. Being verified in test points of 38 townships in 13 counties for one year, the model has been proved to be suitable for rural status and effective. The maternal mortality of the test points was reduced from 6.11/10,000 to 3.58/10,000; the perinatal mortality from 22.18% to 18.44% and the incidences of eclampsia and neonatal tetanus were also significantly reduced.     

Maternal death reviews at a rural hospital in Malawi

ObjectiveTo analyze maternal deaths at Nkhoma Church of Central Africa Presbyterian (CCAP) Hospital and identify factors causing delays in care.MethodsMaternal death audits are performed after every maternal death at Nkhoma CCAP Hospital. Information regarding the care provided at the health facility, the referral process, and any delays in the community was collected by an audit team using a structured approach. Data from August 2007 to September 2011 were analyzed retrospectively.ResultsIn total, 61 maternal deaths occurred during the study period, of which 58 were analyzed. Most deaths were categorized as indirect (n = 34 [58.6%]). Non-pregnancy-related infections were the leading cause of indirect death (n = 22), with meningitis the most common (n = 13). Most patients experienced a delay in seeking care (n = 37 [63.8%]), a transport delay (n = 43 [74.1%]), or a delay in receiving adequate care (n = 34 [58.6%]).ConclusionMost maternal deaths had indirect causes and were associated with delays in all phases. An audit makes clear which part of the referral chain needs to be strengthened. Nkhoma CCAP Hospital has taken steps to address all phases of delay.     

Prospective labor risk assessment in a rural community hospital

This prospective study investigates the utility of a labor risk assessment instrument for the prediction and management of the low Apgar infant in the community hospital setting. Two hundred and fifty patients in labor were managed with a protocol involving initial and ongoing risk assessment throughout the course of labor and delivery. Patients scored as high risk were independently assessed to determine the need for the presence of the resuscitation team at delivery. Twenty-one percent of infants of high-risk mothers required resuscitation, whereas only 8% of infants whose mothers scored as low or moderate risk required resuscitation. A modified ten factor list was developed using multiple logistic regression analysis and clinical experience. This was found to improve predictive power for low Apgar score infants in need of resuscitation within a risk group comprising only 27% of the population. We conclude that this intrapartum scoring system can be readily implemented in a community hospital and is effective in identifying high-risk infants so that resources can be mobilized for appropriate intervention.     

Use of intrathecal analgesia in a rural hospital Case studies

A woman's experience of unrelenting back pain with a fetus in an occipitoposterior position and the escalating interventions culminating in a cesarean birth is every midwife's nightmare. Intrathecal analgesia is a relatively simple and rapid method to provide maternal relaxation and relief from severe back labor. This article describes the use of intrathecal opioid analgesia in labor complicated by failure to progress in first-stage labor due to persistent occipitoposterior position of the fetus. Intrathecal analgesia has the advantage of being inexpensive and providing rapid onset of adequate pain relief for the first stage of labor. It does not cause motor blockade, so it allows the mother to be mobile and feel the urge to push. Consequently, there is no associated risk of an increased need for forceps or vacuum-assisted delivery. The authors note a decreased incidence of operative delivery for fetal occipitoposterior position with the use of intrathecal narcotics.     

Quality of hysterectomy care in rural Gujarat: the role of community-based health insurance

Community-based health insurance (CBHI) may be a mechanism for improving the quality of health care available to people outside the formal sector in developing countries. The purpose of this paper is to identify problems associated with the quality of hysterectomy care accessed by members of SEWA (Self-Employed Women’s Association), an Indian CBHI scheme, and discuss mechanisms that would optimize quality of care. Data on hysterectomy care were collected through a review of 63 insurance claims and semi-structured interviews with 12 providers. Quality of hysterectomy care accessed by SEWA’s members varied from potentially dangerous to excellent. Dangerous conditions included operating theatres without separate hand-washing facilities or proper lighting, the absence of qualified nursing staff, performing hysterectomy on demand, removing both ovaries without consulting or notifying the patient, and failing to send the excised organs for histopathology, even when signs were suggestive of disease. Women paid substantial amounts of money, even for poor and potentially dangerous care. In order to improve the quality of care for its members, a CBHI scheme can: (1) gather data on the costs and complications for each provider, and investigate where these are excessive; (2) use incentives to encourage providers to make efficient and equitable resource allocations; (3) contract with providers giving a high standard of care or who agree to certain conditions; and (4) inform and advise doctors and the insured about the costs and benefits of different interventions. In the case of SEWA, it is most feasible to identify a limited number of hospitals providing better quality care and contract directly with them.     

Antenatal and delivery care in rural western Kenya: the effect of training health care workers to provide focused antenatal care

Background  

Maternal mortality remains high in developing countries and data to monitor indicators of progress in maternal care is needed. We examined the status of maternal care before and after health care worker (HCW) training in WHO recommended Focused Antenatal Care.     

Availability and use of services for maternal and child health care in rural Nigeria.

A personal in-home interview was conducted in four rural towns in Nigeria. The aims of the interview were to describe the content of Maternal and Child Health (MCH) care in these rural towns and to assess how patterns of prenatal, delivery and postnatal service use are related to a variety of demographic and socioeconomic variables in the population. Findings from data analysis indicate that services available are deficient in terms of the number of centers and content of care. Variables found to be statistically significant (P less than 0.01) for use of services are maternal education, occupation, distance and previous use of a physician. Husband's occupation was significant only for prenatal registration, but not for subsequent use of services. Recommendations include a reorganization of rural MCH services and an introduction of female literacy programs, especially at the rural level.     

Late entry into prenatal care in a rural setting

Social support, behavioral risk, and structural or demographic variables as well as acceptance of pregnancy were tested as determinants of late entry into prenatal care in a sample of 176 women in a rural county in California. The respondents were all those over age 18 served by four obstetric practices during a 4-month period ending in February 2000. One nurse-midwifery practice was included. Late entry into prenatal care during the first trimester occurred in 27.3% of the cases overall. Statistically significant independent variables in bivariate analyses were modeled in multivariate logistic regression. Stress, lack of family and friend support. Medicaid enrollment, age under 20 or over 34, low acceptance of pregnancy, and lack of a high school diploma were all predictors of late entry. Lack of family and friend support modified the effects of stress and Medicaid as payer. Although the determinants of late entry were remarkably complex in this sample, they have potential for public health intervention.     

Utilisation of antenatal care in a Nigerian teaching hospital

Records of 300 antenatal clinic attendees of a Nigerian teaching hospital were analysed. Results show that many of them obtained care only late in pregnancy and inadequately. Reasons for the delay in seeking antenatal care should be further investigated.