Household knowledge and practices of newborn and maternal health in Haripur district, Pakistan.

OBJECTIVE: To learn about household maternal and newborn health knowledge and practices to aid the design of newborn programming within Save the Children's Haripur Program. STUDY DESIGN: In April, we conducted 43 semi-structured interviews (SSIs) and 34 focus group discussions among men, women of reproductive age and health service providers; in September, we added 21 SSIs among new mothers, new fathers and dais. Two investigators analyzed the findings according to themes within six care types: antenatal, delivery, immediate newborn, routine postpartum, special maternal and special newborn. RESULT: Findings indicated poor maternal diet and antenatal care-seeking. Home delivery with an untrained dai was the norm. Respondents knew about benefits of clean delivery, but rarely put knowledge into practice. Knowledge and practices for maintaining the newborn's warmth were good. Delayed initiation of breastfeeding, avoidance of colostrum and prelacteal feeding were almost universal. Unhygienic cord care, including an unclean cut and application of ghee on the cord-stump, was the norm. After delivery, mothers often maintained low fluid intake but otherwise reported healthy nutritional practices. Knowledge of some danger signs in newborns was common, but timely action upon recognition was not. CONCLUSION: Although the findings illustrate some beneficial practices, many reported practices are harmful to the newborn. These findings, consistent with the sparse existing data in Pakistan, inform program interventions for household-level behavioral change.     

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.     

An evaluation of a community-based approach to safe motherhood in northwestern Tanzania.

OBJECTIVES: We present an evaluation of the Community Capacity Building and Empowerment initiative, undertaken by the Community-Based Reproductive Health Project (CBRHP), designed to address high maternal morbidity and mortality. METHODS: Qualitative data from group interviews and program data from CBRHP were used to assess progress in development and use of community level transport systems and support for the village health workers (VHWs). RESULTS: Project activities increased community participation in maternal health. An increase was seen in knowledge of danger signs, birth planning, timely referrals, and transport of pregnant women to hospitals, as well as in support and retention of VHWs. More women with obstetrical problems are using the community-based transport system to get to hospitals. CONCLUSIONS: Community participation and support for VHW activities and the transport systems have led to better care for pregnant women and sustained links between the communities and health facilities, which may reduce maternal and infant morbidity and mortality.     

A survey of knowledge, attitude and practice of malaria management among pregnant women from two health care facilities in Nigeria

BACKGROUND: Malaria remains one of the most important causes of maternal and child morbidity and mortality in sub-Saharan Africa, despite the availability of effective interventions. The objective of this study was to assess the knowledge, attitude and practice of malaria management among pregnant women attending antenatal clinics in Nigeria. METHODS: A cross-sectional study was undertaken on a sample of 867 pregnant women attending antenatal clinics in 2 health care facilities in Edo State, Nigeria, using a self-administered questionnaire. RESULTS: Of the respondents, 87% said that they had undergone at least 1 episode of malaria during their current pregnancy. Most respondents (89%) attributed malaria to bites from infected mosquitoes, while 75% consider malaria an important health risk during pregnancy. However, knowledge of the consequences of malaria during pregnancy was poor, especially the risk posed to the fetus. Overall, the mean knowledge score on a scale of '0-7' was 3.5 (median 4.0). Respondents had poor belief in the effectiveness and use of insecticide-treated bed nets and intermittent preventive therapy, in preventing malaria during pregnancy. CONCLUSIONS: This study has revealed that malaria is perceived as a common health problem among pregnant women attending these 2 health care facilities, and that knowledge, attitude and practice of its management is poor. Efforts should be made to improve anti-malarial intervention during pregnancy, to ensure that the goals of the Roll Back Malaria Initiative are achieved in Nigeria.     

Community-driven impact of a newborn-focused behavioral intervention on maternal health in Shivgarh, India

ObjectiveTo assess the effect on maternal health outcomes of a community-based behavior change management intervention for essential newborn care leading to a reduction in neonatal mortality.MethodsA cluster-randomized controlled trial involving 1 control and 2 intervention arms was conducted in Shivgarh, India, between January 2004 and May 2005. Risk-enhancing domiciliary newborn care behaviors, including those posing a concomitant risk to maternal health, were targeted through home visits and community meetings. Secondary outcomes included knowledge of maternal danger signs, self-reported complications, maternal care practices, care-seeking from trained providers, and maternal mortality ratio (MMR). The intervention arms were combined for analysis, which was done by intention to treat.ResultsSignificant improvements were observed in maternal health equity and outcomes including knowledge of danger signs, care practices, self-reported complications, and timely care-seeking from trained providers. The difference in adjusted MMR was not significant (relative risk 0.44; 95% confidence interval, 0.14–1.43; P = 0.11) owing to the inadequate sample size for this outcome, but may suggest a decline in MMR given improvements in other outcomes in the causal pathway to mortality.ConclusionCommunity-based strategies focused on prevention and care-seeking effectively complemented facility-based strategies toward improving maternal health, while synergizing with newborn care interventions.     

HIV-INFECTED WOMEN AND INFANTS

The utilization of health care by HIV-seropositive pregnant women and their infants was studied in an indigent urban population. Ninety HIV-seropositive women delivered 99 HIV-exposed infants at the Johns Hopkins Hospital from August 1, 1988, to April 1, 1991. Repeat pregnancies occurred in 17 (18.9%) women during the study period. Completion of the primary immunization series by age nine months was the criteria for infant adherence to medical care. Of all infants, 72.9% achieved adequate immunization status by nine months. However, only 41 (45.6%) women reported ever seeking HIV-related health care. Factors associated with maternal adherence with HIV-related health care included HIV status of her infant, maternal drug use, and incarceration. Number of living children, maternal age, educational level, marital status, and repeat pregnancy were not associated with mothers seeking HIV-related health care. Despite low adherence to HIV-related health care in this sample of HIV-seropositive women, the majority of their infants did receive adequate immunizations, one proxy measure of adequate infant health care.     

HIV-infected women and infants: Social and health factors impeding utilization of health care

The utilization of health care by HIV-seropositive pregnant women and their infants was studied in an indigent urban population. Ninety HIV-seropositive women delivered 99 HIV-exposed infants at the Johns Hopkins Hospital from August 1, 1988, to April 1, 1991. Repeat pregnancies occurred in 17 (18.9%) women during the study period. Completion of the primary immunization series by age nine months was the criteria for infant adherence to medical care. Of all infants, 72.9% achieved adequate immunization status by nine months. However, only 41 (45.6%) women reported ever seeking HIV-related health care. Factors associated with maternal adherence with HIV-related health care included HIV status of her infant, maternal drug use, and incarceration. Number of living children, maternal age, educational level, marital status, and repeat pregnancy were not associated with mothers seeking HIV-related health care. Despite low adherence to HIV-related health care in this sample of HIV-seropositive women, the majority of their infants did receive adequate immunizations, one proxy measure of adequate infant health care.     

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)     

Causes and characteristics of maternal deaths in rural northern Tanzania

BACKGROUND: To assess causes and characteristics of maternal deaths in a poorly characterized area. METHODS: A health facility- and population-based study, with an audit of case series on maternal deaths, was done in two divisions with 42 villages (population 143 000), in Mbulu and Hanang districts, Arusha region, Tanzania. In 1995, all known deaths of women between 15 and 50 years, who were residents of the study area, were recorded from all the health facilities and villages in the study area. Supplementary data from the health facilities were collected in 1996. Verbal autopsies, health facility and antenatal records, and additional oral information were used to assess each maternal death. RESULTS: Forty-five maternal deaths were identified, 26 in 1995 and 19 in 1996. Thirteen of the deaths were direct, while 32 were indirect. Hemorrhage was the main cause of direct obstetric deaths and cerebral malaria of indirect death, accounting for 20 cases, with most of them occurring during an epidemic season. Twenty-four of the women, including 10 of those dying of malaria, died postpartum. Most of the deceased women sought help at a health facility as the first place of seeking help, and used the hospital ambulance. Fourteen of the deaths (31%) were considered possibly avoidable under the prevailing circumstances, with delay in seeking help being most common. CONCLUSIONS: Addressing malaria as a major cause of maternal death, both in pregnancy and postpartum, in epidemic-prone areas, and increased community and family awareness of when to seek help could be important factors in reducing maternal deaths.     

Community attitudes to pregnancy, anaemia, iron and folate supplementation in urban and rural Lagos, south-western Nigeria

OBJECTIVE: To identify community perspectives and attitudes to pregnancy, anaemia, iron and folate supplements during pregnancy in Lagos, south-western Nigeria. DESIGN: Qualitative using focus group discussions, observational data and in-depth interviews. SETTING: Amukoko, a peri-urban slum area and Ibese a rural coastal area in Lagos, south-western Nigeria. PARTICIPANTS: 23 pregnant women and two health-care providers. FINDINGS: Maternal anaemia is not perceived as a priority health problem by pregnant women. Knowledge of the signs and symptoms of anaemia is limited among rural pregnant women. The recognition of maternal complications associated with anaemia is low among pregnant women and some health-care providers. Severe blood loss at or after delivery is sometimes attributed to the excessive use of iron and folate supplements. Sustaining the motivation to continue taking iron tablets and communicating the benefits of iron supplementation which could encourage compliance was also lacking. IMPLICATIONS FOR PRACTICE: An understanding of the local beliefs, attitudes and practices regarding pregnancy is needed to design more effective methods of health education for pregnant women and to provide maternal services which are 'culturally acceptable'.     

Advancing newborn health and survival in developing countries: a conceptual framework.

Four million newborns die every year at home, often without skilled care at delivery or any other contact with the formal health system. Improved household practices and use of services, often in the community, should improve survival. We developed a conceptual framework for household and community newborn and maternal care that acknowledges the inseparability of the mother and neonate, yet stresses elements relating to the newborn, heretofore underemphasized in safe motherhood and child-survival programs. The framework identifies five paths that, if implemented well, would generally improve newborn outcomes: (1) use of routine maternal and newborn care and good-quality services; (2) response to maternal danger signs; (3) response to the nonbreathing newborn; (4) care for the low birth weight baby; and (5) response to newborn danger signs, particularly those of infection. This model, balancing preventive (19 routine behaviors) and curative care (14 special behaviors), is rooted in the community, bridges safe motherhood and child survival, and provides a framework for newborn health research, programmatic, and advocacy agendas for developing countries.     

Reducing maternal mortality among Afghan refugees in Pakistan

Objective

The International Rescue Committee (IRC) strove to reduce maternal mortality among Afghan refugees in Hangu district of Pakistan by improving access to emergency obstetric care (EmOC), community knowledge of danger signs of pregnancy, and the use of health information.

Methods

IRC established EmOC centers, trained community members on safe motherhood, linked primary health care with education on danger signs of pregnancy and the importance of skilled attendance, and improved the health information system.

Results

The maternal mortality ratio among Afghan refugees in the area improved from 291 per 100 000 live births in 2000 to 102 per 100 000 live births in 2004. The proportion of refugee births attended by skilled staff increased from 5% in 1996 to 67% in 2007. Complete prenatal care coverage increased from 49% in 2000 to 90% in 2006, and postnatal coverage more than trebled from 27% in 2000 to 85% in 2006.

Conclusion

Improved services, community involvement and education, good coordination, and effective systems succeeded in reducing maternal mortality in a traditionally conservative environment.     

Addressing disparities in maternal health care in Pakistan: gender, class and exclusion

ABSTRACT: BACKGROUND: After more than two decades of the Safe Motherhood Initiative and Millennium Development Goals aimed at reducing maternal mortality, women continue to die in childbirth at unacceptably high rates in Pakistan. While an extensive literature describes various programmatic strategies, it neglects the rigorous analysis of the reasons these strategies have been unsuccessful, especially for women living at the economic and social margins of society. A critical gap in current knowledge is a detailed understanding of the root causes of disparities in maternal health care, and in particular, how gender and class influence policy formulation and the design and delivery of maternal health care services. Taking Pakistan as a case study, this research builds upon two distinct yet interlinked conceptual approaches to understanding the phenomenon of inequity in access to maternal health care: social exclusion and health systems as social institutions. METHODS: This four year project consists of two interrelated modules that focus on two distinct groups of participants: (1) poor, disadvantaged women and men and (2) policy makers, program managers and health service providers. Module one will employ critical ethnography to understand the key axes of social exclusion as related to gender, class and zaat and how they affect women's experiences of using maternal health care. Through health care setting observations, interviews and document review, Module two will assess policy design and delivery of maternal health services. DISCUSSION: This research will provide theoretical advances to enhance understanding of the power dynamics of gender and class that may underlie poor women's marginalization from health care systems in Pakistan. It will also provide empirical evidence to support formulation of maternal health care policies and health care system practices aimed at reducing disparities in maternal health care in Pakistan. Lastly, it will enhance inter-disciplinary research capacity in the emerging field of social exclusion and maternal health and help reduce social inequities and achieve the Millennium Development Goal No. 5.     

Severe maternal morbidity among immigrant women in the Netherlands: patients' perspectives

This 2006 study investigated ethnicity-related factors contributing to sub-standard maternity care and the effects on severe maternal morbidity among immigrant women in the Netherlands. In-depth interviews were carried out with 40 immigrant and 10 native Dutch women. The immigrant women reported that health care providers often paid insufficient attention to their pregnancy-related complaints, especially in cases of pre-eclampsia. They also reported delays in receiving information about diagnosis and treatment. Obstetricians who reviewed 20 of these cases judged sub-standard care to have played a role in the development of complications in 16 of them. The women themselves had problems identifying medically significant complications, presenting their complaints to health care providers effectively, and taking an active role as patients. Even highly educated migrant women showed low health literacy skills in their interaction with doctors. Patients' perspectives are valuable as one of the tools to evaluate the quality of maternity care. Communication by maternal health professionals can be improved through more sensitivity to social factors that affect immigrant women's health problems. Women with limited health literacy should be empowered through education about danger signs in pregnancy and information about preferences and policies in obstetrics in the Netherlands. They should also be invited to participate in medical decision-making.     

Male involvement in the maternal health care system: implication towards decreasing the high burden of maternal mortality

Background

One of the essential components of antenatal care (ANC) is birth preparedness and complication readiness (BP/CR). Strengthening BP/CR measures is one of the principal strategies to reduce maternal mortality and morbidity. The current study aimed at determining the level of men’s knowledge about obstetric danger signs, and their involvement in BP/CR among community of Northwest Ethiopia.

Method

A cross-sectional community based survey was conducted in Northwest Ethiopia from May 2016 to July 2016. Data was analyzed by the Statistical Package for the Social Sciences software Version 21.0 for Windows. Participants’ socio-demographic characteristics, knowledge of obstetric danger signs, and level of involvement in BP/CR were described using frequencies and percentages. Bivariate and multivariable logistic regressions were employed to explore the associated factors and P-value of 0.05 was used as a cut-off point to declare significant association.

Result

From 856 men who were invited for the study, 824 men agreed for the interview giving a response rate of 96.2%. Half of the men stated one danger sign that may occur during pregnancy 407(49.4%); one third during delivery 271(32.9%); and 213(25.8%) during postpartum period. Among all participants, 256(31.1%) had not made any preparations; 363(44.1%) made one step; 116(14.1%) made two steps; 82(9.9%) made three steps; 5(0.6%) made four steps; 2(0.24%) made five steps; and no one made all the birth preparation steps during the birth of their last child. BP/CR was significantly association with knowledge of at least one danger sign during pregnancy (AOR?=?3.3, 95% CI: 3.1, 3.9); during delivery (AOR?=?2.2, 95% CI: 1.1, 2.8); and post partum period (AOR?=?1.8, 95% CI: 1.1, 2.4). Furthermore, BP/CR was found to be positively associated with being married, completing college education, escorting wife to antenatal care, and urban residence.

Conclusions

Men’s level of knowledge about obstetric danger signs, and their involvement in BP/CR was found to be very poor. Considering the importance of male involvement in the maternal health care, it is recommended to advocate policies and strategies that can improve awareness of men and enhance their engagement in the maternal care.

     

EXPLORING THE RECOGNITION OF AND INITIAL RESPONSE TO PROLONGED LABOR AND BIRTH ASPHYXIA IN DHAKA,DINAJPUR, AND MATLAB,BANGLADESH

Purpose: This study investigated the knowledge and behaviors of Bangladeshi women and their caregivers regarding the recognition of and initial response to prolonged labor (PL) and birth asphyxia (BA) in homebirth settings. Methods: Survey data on cultural knowledge about the causes, signs, and treatments for PL/BA were collected through structured interviews of 360 randomly‐selected respondents. Integrated illness history (IIH) narratives were conducted with women who experienced PL/BA and their caregivers (n=19 PL, 16 BA groups). Congruence was determined between structured interviews and IIH interviews. Results: PL: The highest rates of congruence (ie, agreement between knowledge and behavior) occurred when perceived cause was malnourishment of mother/baby, treatment was seeking professional care, and symptom was increasing pain strength. The highest rates of incongruence occurred when perceived cause was spirits. BA: The highest rates of congruence occurred when perceived cause was PL, treatments were stimulating the baby and seeking professional care, and symptom was baby's inability to move. The highest rates of incongruence occurred when perceived cause was spirits, treatments were covering and oil‐massaging the baby, and symptom was baby's inability to cry. Conclusions: During complications, inconsistency between knowledge and behavioral response may delay the seeking of appropriate care, adversely impacting outcomes. Causes, signs, symptoms, and treatments eliciting these responses should be addressed appropriately. Funding: Scholarly Inquiry and Research at Emory (SIRE), Global Health Institute, Emory University.     

Recognition of high risk pregnancies and referral practices among traditional birth attendants in Mkuranga District, Coast Region, Tanzania

A cross-sectional study was carried out in Mkuranga District of Tanzania with the aim of comparing the ability of trained and untrained traditional birth attendants (TBAs) in identifying women with danger signs for developing complications during pregnancy and childbirth as well as their referral practices. Study findings revealed that majority of the TBAs (86.5%) had not received any training. Trained TBAs were more knowledgeable on danger signs during pregnancy and childbirth and were more likely to refer women with complications to a health facility, compared to untrained TBAs. The authors recommend that in resource constrained countries like Tanzania and especially in remote rural areas, TBAs should be trained on early identification of mothers with obstetrical complications and on their prompt referral to health facilities that can provide emergency obstetric care.     

The 1988 National Maternal and Infant Health Survey: Design,Content, and Data Availability

ABSTRACT: The 1988 National Maternal and Infant Health Survey was conducted by the National Center for Health Statistics to study factors related to poor pregnancy outcome, such as adequacy of prenatal care; inadequate and excessive weight gain during pregnancy; maternal smoking, drinking, and drug use; and pregnancy and delivery complications. The survey is a nationally representative sample of 11,000 women who had live births, 4000 who had late fetal deaths, and 6000 who had infant deaths in 1988. Mothers were mailed questionnaires based on information from certificates of live birth, reports of fetal death, and certificates of infant death. Information supplied by the mother, prenatal care providers, and hospitals of delivery was linked with the vital records to expand knowledge of maternal and infant health in the United States. Data collection from the Longitudinal Followup of mothers in the survey began in January 1991. It provides information on health and development of low- and very low-birthweight babies, child care and safety, maternal health, maternal depression, and plans for adoption and foster care. Both surveys will provide useful data for clinicians in maternal and child health.     

Disabled women׳s maternal and newborn health care in rural Nepal: A qualitative study

Objective

there is little evidence about disabled women?s access to maternal and newborn health services in low-income countries and few studies consult disabled women themselves to understand their experience of care and care seeking. Our study explores disabled women?s experiences of maternal and newborn care in rural Nepal.

Design

we used a qualitative methodology, using semi-structured interviews.

Setting

rural Makwanpur District of central Nepal.

Participants

we purposively sampled married women with different impairments who had delivered a baby in the past 10 years from different topographical areas of the district. We also interviewed maternal health workers. We compared our findings with a recent qualitative study of non-disabled women in the same district to explore the differences between disabled and non-disabled women.

Findings

married disabled women considered pregnancy and childbirth to be normal and preferred to deliver at home. Issues of quality, cost and lack of family support were as pertinent for disabled women as they were for their non-disabled peers. Health workers felt unprepared to meet the maternal health needs of disabled women.

Key conclusions and implications for practice

integration of disability into existing Skilled Birth Attendant training curricula may improve maternal health care for disabled women. There is a need to monitor progress of interventions that encourage institutional delivery through the use of disaggregated data, to check that disabled women are benefiting equally in efforts to improve access to maternal health care.