Orthodox versus unorthodox care: A qualitative study on where rural women seek healthcare during pregnancy and childbirth in Southwest,Nigeria

Introduction

Utilization of orthodox health facilities for maternal health services is determined by factors operating at the individual, household, community and state level. The prevalence of small family norm is one of the identified variables operating within the community which influences the decision of where to access care (orthodox/traditional). The objective of the study was to determine the use of orthodox versus unorthodox maternity healthcare and determinants among rural women in southwest Nigeria.

Methods

A qualitative study was done and involved three focus group discussions. A semi-structured interview guide was used to collect information from women of reproductive age group within a rural Local Government Area in Lagos state.

Results

Most of the women access some form of healthcare during pregnancy, orthodox, unorthodox or both. Those who patronize both services concurrently do so to benefit from the two as each has some unique features such as herbal concoctions for traditional, ultrasound and immunization of babies for orthodox. Traditional belief exerts a strong influence on decision of where to access maternal healthcare services. Actual place of delivery is determined by individual and household factors including financial resources.

Conclusion

Rural women utilize one or both orthodox and unorthodox maternal health services for different reasons. Ward Development Committees should be strengthened so as to reach the communities, educate and convince women to dispel myths which limit their use of orthodox care. Training and monitoring of Traditional Birth Attendants (TBAs) are vital to eliminate harmful practices. We also recommend improved financial access to orthodox healthcare.     

Women's groups' perceptions of neonatal and infant health problems in rural Malawi

Aims

To present the perceptions of women in rural Malawi regarding the health problems affecting neonates and infants and to explore the relevance of these perceptions for child health policy and strategy in Malawi.

Methods

Women''s groups in Mchinji district identified newborn and infant health problems (204 groups, 3484 women), prioritised problems they considered most important (204 groups, 3338 women) and recorded these problems on monitoring forms. Qualitative data was obtained through 6 focus-group discussions with the women''s groups and 22 interviews with individuals living in women''s group communities but not attending groups.

Results

Women in Malawi do not define the neonatal period according to any epidemiological definition. In order of importance they identified and prioritised the following problems for newborns and infants: diarrhoea, infection, preterm birth, tetanus, malaria, asphyxia, respiratory tract infection, hypothermia, jaundice, convulsions and malnutrition.

Conclusion

This study suggests that women in rural Malawi collectively have a developed understanding of neonatal and infant health problems. This makes a strong argument for the involvement of lay people in policy and strategy development and also suggests that this capacity, harnessed and strengthened through community mobilisation approaches, has the potential to improve neonatal and infant health and reduce mortality.     

Perinatal mortality audit at Tikure Anbessa Teaching Hospital,Addis Ababa,Ethiopia: 1995 to 1996

Objectives

To determine the prevalence and causes of perinatal mortality rates at Tikure Anbessa hospital, Ethiopia, 1995–96

Design

A cross-sectional review of hospital records of all women who delivered at Tikure Anbessa Hospital. Data were collected prospectively.

Setting

Teaching Hospital of Tikure Anbessa, Addis Ababa, Ethiopia

Subjects

Women and neonates from 8986 deliveries. Deliveries exceeding 28 weeks of gestation or birth weight of 1000 grams were considered.

Materials and Methods

All deliveries were included for infants whose gestational age exceeded 28 completed weeks. When the gestational age was unknown, the birth weight of 1000 grams or more was considered. All perinatal deaths and obstetric complications were identified. Labour chart, mode of delivery and summary of delivery had been recorded by the responsible resident at a monthly combined obstetric and paediatric perinatal mortality meeting. Age of the mother, parity, booking status for antenatal care, obstetric complications, labour, mode of delivery, birth weight, gestational age, one and five minutes Apgar scores were collected.

Results

A total of 8986 deliveries were conducted during the study period. Of these 6933 (77.2%) were booked for antenatal care while the remaining 2053 (22.8%) were not booked in any health institution. The perinatal mortality rate of the hospital was 71.6 per 1000 live births. The risk of perinatal mortality was more than doubled among mothers who failed to book for antenatal care follow-up and no laboratory investigations was done were birth asphyxia followed by premature birth 15.4% and 12% respectively.

Conclusions

Perinatal mortality rates are high at Tikure Anbessa Hospital, Ethiopia. There is need to ensure that pregnant women are booked for antenatal care so as to provide adequate antenatal and perinatal health care.     

Caesarean section in Malawi: preventable factors in maternal and perinatal mortality

Objectives

To examine factors that may influence maternal and perinatal mortality associated with caesarean section in an African country.

Design

A prospective observational study, conducted between January 1998 and June 2000, of 8070 caesarean sections.

Setting

25 district and 2 central hospitals in Malawi.Main outcome measures. Association between hospital type, ward or operative care, training of surgical and anaesthesia personnel, preoperative complications, method of anaesthesia, blood loss and anaesthetic technique on maternal and perinatal mortality.

Results

Questionnaires were returned for 5236 caesarean sections in district and 2834 in central hospitals. 95% were emergencies, 65% for obstructed labour. Pre-operative haemorrhagic shock was present in 7.6% of women, anaemia in 6.2% and ruptured uterus in 4.1%. Previous caesarean section did not appear to predispose to ruptured uterus. There were 85 maternal deaths (1.05% mortality), 65 of which occurred postoperatively on the wards. Maternal mortality was increased with ruptured uterus (adjusted odds ratio 3.9, 95% CI 2.3–6.5), little anaesthetic training (2.3, 1.3 to 4.1) and blood loss requiring transfusion (19.3, 9–41). In mothers without preoperative haemorrhage spinal anaesthesia was associated with lower maternal mortality than general anaesthesia (0.23, 0.1–0.7). Perinatal mortality was 11.2% overall, and was significantly associated with ruptured uterus, halothane and ketamine anaesthesia.

Conclusion

Maternal and perinatal mortality rates among women undergoing caesarean section in Malawi are high. Improving resuscitation in postoperative wards might reduce maternal mortality. Blood loss and pre-operative complications are both strongly associated with mortality. Spinal anaesthesia was associated with good outcome.     

Awareness about postpartum insertion of intrauterine device among antenatal cases

Background

In spite of many available contraceptives numerous unwanted and unplanned pregnancies occur. Though the couples desire contraception but are not able to accept it due to their ignorance and misconceptions. Intrauterine Contraceptive Device (IUCD); an effective contraceptive is usually inserted six weeks after delivery. It can be inserted within 48 h of delivery called postpartum insertion for which government has started the program in many states. The study was undertaken to find out the choices about contraception after delivery and awareness about postpartum insertion.

Methods

The present observational study was conducted in one of the zonal service hospitals. 500 antenatal cases were included in the study. Their choice of contraception after delivery and awareness was determined through a questionnaire. Reasons for refusal of postpartum insertion were recorded. A small sample of staff also was included in the study.

Results

500 cases were included in the study, a large number had decided about contraception; mainly breast feeding supplemented by barrier contraceptive. 94 of 500 were willing for insertion of contraceptive device but not immediately after delivery due to apprehension in general and fear of side effects. Staff''s awareness about postpartum insertion was poor.

Conclusion

Knowledge and acceptance of postpartum insertion is very low among antenatal women; probably because the concept is new in the community. There is a strong need to increase the knowledge and awareness about this by health education and counseling.     

Health Professionals Expose TB Patients to Stigmatization in Society: Insights from Communities in an Urban District in Ghana

Objectives

To determine how the activities and attitudes of health professionals expose TB patients to stigmatization in the community.

Design

Qualitative research approach using individual interviews and focus groups

Setting

Shama Ahanta East Metropolitan district in the western region of Ghana

Participants

Members in nine communities in the district

Outcome measures

Words and statements that depict how activities and attitudes of health professionals may expose TB patients to stigmatization

Results

Five interrelated ways by which activities and attitudes of health professionals may expose TB patients to stigmatization in the community were identified in data: TB control practices; fear-based responses to TB; inappropriate health education messages; medical licensing for sellers; and prohibition of burial rites.

Conclusions

The findings may explain the diagnostic delay and low TB case detection rate in Ghana. This calls for intensification of education on TB and regular organization of refresher courses and possibly retraining of health professionals in TB control and management. When health professionals are seen to be treating TB patients as ‘normal’ individuals, it has the potential of changing the society''s perception about the disease.     

Performance factors of mobile rich media job aids for community health workers

Objective

To study and analyze the possible benefits on performance of community health workers using point-of-care clinical guidelines implemented as interactive rich media job aids on small-format mobile platforms.

Design

A crossover study with one intervention (rich media job aids) and one control (traditional job aids), two periods, with 50 community health workers, each subject solving a total 15 standardized cases per period per period (30 cases in total per subject).

Measurements

Error rate per case and task, protocol compliance.

Results

A total of 1394 cases were evaluated. Intervention reduces errors by an average of 33.15% (p=0.001) and increases protocol compliance 30.18% (p<0.001).

Limitations

Medical cases were presented on human patient simulators in a laboratory setting, not on real patients.

Conclusion

These results indicate encouraging prospects for mHealth technologies in general, and the use of rich media clinical guidelines on cell phones in particular, for the improvement of community health worker performance in developing countries.     

Contraceptive knowledge, beliefs and attitudes in rural Malawi: misinformation, misbeliefs and misperceptions

Introduction

The objective of the study was to find out factors that affect the intentions of men and women to use family planning methods.

Methods

The study was conducted in Mangochi district, the southern region of Malawi in 2006.About 60 Focus group discussions were conducted to identify the attitudes and beliefs of 30 male and 30 female participants regarding family planning methods. The data was then transcribed and analyzed manually identifying central themes and relationships across the cases and narratives.

Results

Most of the respondents knew the different types of family planning methods and reported that health facilities had adequate stock of family planning supplies. However, it was found that most of the women and men were not using any modern family planning methods. Reasons included: family planning methods were perceived side effects, such as prolonged menstruation, men''s concerns about impotence and genital sores, weight gain or loss, and subsequent infertility. Traditional family planning methods were mostly used for infertility problems.

Conclusion

Despite knowing about the different types of family planning methods, and awareness of their ready availability in health facilities, use of these methods is low because considerable misinformation still prevails regarding contraceptive methods'' side effects.     

Perinatal outcomes among children born by assisted reproductive techniques—a hospital-based case control study

Background

Widespread use of assisted reproductive techniques (ART) has raised major concern about the outcome of resulting pregnancies, as well as about the health of the newborn children. The ART conceived pregnancies have an increased risk for prematurity and low birth weight (LBW). The risk of congenital malformations among children conceived via ART is contemplated to be high. The present case control study was conducted with an aim of analysing perinatal outcomes of children born by ART in the Indian context.

Methods

The case control study was conducted in the Army Hospital (Research and Referral), New Delhi. It included 82 cases and 164 controls. The data was collected on maternal and newborn characteristics among cases and controls. Perinatal outcomes were compared between ART conceived and spontaneously pregnant women in terms of birth weight, preterm, multiple pregnancies, and neonatal complications.

Results

Significant difference was observed in terms of the preterm delivery, birth weight, neonatal complications between the cases and the controls. The adjusted odds ratio (OR) was 21.6 (95% confidence interval [CI] 4.3, 112.9) for preterm delivery; 6.0 (95% CI 1.1, 43.8) for multiple pregnancy and 3.2 (95% CI 1.5, 7.0) for caesarean section. The risk of LBW and neonatal complications was heavily confounded by preterm delivery and multiple pregnancies, the adjusted OR being 0.9 and 1.0, respectively.

Conclusion

Increased risk of preterm delivery, multiple pregnancies and caesarean section was associated with ART. The LBW was confounded by preterm delivery and multiple pregnancies.Key Words: assisted reproductive techniques, odds ratio, perinatal outcomes     

Incontinence,bladder neck mobility,and sphincter ruptures in primiparous women

Objective

To compare the function of the pelvic floor in primiparae before and during pregnancy with the status post partum concerning symptoms of incontinence, sphincter ruptures, bladder-neck mobility and the influence of the different modes of deliveries.

Methods

Questionnaire evaluating symptoms of urinary and anal incontinence in nulliparous women before and after delivery and correlating these symptoms with functional changes of the pelvic floor based on a careful gynaecologic examination as well as perineal and endoanal ultrasound.

Results

112 women were included in our study and came for the first visit, 99 women returned for follow-up 6 months after childbirth. Stress and flatus incontinence significantly increased from before pregnancy (3 and 12%) to after childbirth (21 and 28%) in women with spontaneous delivery or vacuum extraction. No new symptoms occurred after c-section. There was no significant difference between the bladder neck position before and after delivery. The mobility of the bladder neck was significantly higher after vaginal delivery using a vacuum extraction compared to spontaneous delivery or c-section.The bladder neck in women with post partum urinary stress incontinence was significantly more mobile than in continent controls. The endoanal ultrasound detected seven occult sphincter defects without any correlation to symptoms of anal incontinence.

Conclusion

Several statistically significant changes of the pelvic floor after delivery were demonstrated. Spontaneous vaginal delivery or vacuum extraction increases the risk for stress or anal incontinence, delivery with vacuum extraction leads to higher bladder neck mobility and stress incontinent women have more mobile bladder necks than continent women.     

Are Meaningful Use Stage 2 certified EHRs ready for interoperability? Findings from the SMART C-CDA Collaborative

Background and objective

Upgrades to electronic health record (EHR) systems scheduled to be introduced in the USA in 2014 will advance document interoperability between care providers. Specifically, the second stage of the federal incentive program for EHR adoption, known as Meaningful Use, requires use of the Consolidated Clinical Document Architecture (C-CDA) for document exchange. In an effort to examine and improve C-CDA based exchange, the SMART (Substitutable Medical Applications and Reusable Technology) C-CDA Collaborative brought together a group of certified EHR and other health information technology vendors.

Materials and methods

We examined the machine-readable content of collected samples for semantic correctness and consistency. This included parsing with the open-source BlueButton.js tool, testing with a validator used in EHR certification, scoring with an automated open-source tool, and manual inspection. We also conducted group and individual review sessions with participating vendors to understand their interpretation of C-CDA specifications and requirements.

Results

We contacted 107 health information technology organizations and collected 91 C-CDA sample documents from 21 distinct technologies. Manual and automated document inspection led to 615 observations of errors and data expression variation across represented technologies. Based upon our analysis and vendor discussions, we identified 11 specific areas that represent relevant barriers to the interoperability of C-CDA documents.

Conclusions

We identified errors and permissible heterogeneity in C-CDA documents that will limit semantic interoperability. Our findings also point to several practical opportunities to improve C-CDA document quality and exchange in the coming years.     

Abstracts of the 1st Annual Malawi Mental Health Research andPractice Development Conference, 7th & 8th February 2011, Blantyre,Malawi

Introduction

Contemporary mental services delivery is moving towards cost-effective community based as opposed to institutionalized care (Harrison, Alam & Mashall, 2001). Domiciliary mental health care is one example of such service that is being promoted in developed countries. Domiciliary mental health care refers to the delivery of mental health services in the home for purposes of restoring and maintaining the health of clients when they are in acute state (Campbell, 1996). This paper highlights successes and lessons learnt in the domiciliary mental health care approach that St. John of God Community Services is implementing in the northern city of Mzuzu.

Objectives of the program

The broad objective of domiciliary mental health care in Mzuzu service is to provide an alternative community based mental health care to clients with mental health problems in the city of Mzuzu and its environs through care delivery, family education, community participation and alleviation of stigma associated with psychiatric admission.

Strategies

Strategies used in the program include provision of nursing care to clients in their homes; mobile clinics and mental health education to family members and the entire community.

Successes

Some successes of this cost-effective initiative include attainment of optimum level of functioning by 275 clients since establishment in 2006; reduced recovery period when compared with those in residential unit; family/community involvement, reduced stigma associated with admission to a psychiatric hospital and the freedoms enjoyed whilst in the homes.

Challenges

The biggest challenge is that some carers do not cooperate and prefer that their client be managed in the hospital even when client is less problematic at home.

Conclusion

Domiciliary mental health care is cost-effective and feasible in Malawi provided families are given support within their communities.

• Malawi Med J. 2011 Sep; 23(3): 99–103.
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• Increasing the Capacity of Health Surveillance Assistants in Community Mental Health Care in Zomba District — Interim Findings of an Education Intervention

2011 Sep; 23(3): 99–103.

Increasing the Capacity of Health Surveillance Assistants in Community Mental Health Care in Zomba District — Interim Findings of an Education Intervention

Jerome Wright, Dr Stephanie Common, Dr Felix Kauye, and Mr Chikayiko ChiwandiraAuthor information Copyright and License information Disclaimer“Zomba Link”, Harrogate, UK and Zomba Mental Hospital, Zomba, MalawiCopyright notice     

Risk Factors for Suicide in Wives of Military Personnel

Background

An increasing trend in attempted and completed suicide amongst wives of serving personnel was observed.

Methods

A questionnaire designed to elicit the known risk-factors for suicide, suicide attempts and suicidal ideation by women in the Indian context was administered to 222 wives of Indian military personnel living in a garrison with their husbands.

Result

A large number (28%) of the sample were child-less. Alcoholism in husband was reported by 22 women and domestic violence by four. Six had been bereaved in the past year. Chronic illness was reported by 10 women and psychiatric illness by four.

Conclusion

Wives of military personnel may need targeted community interventions focusing on the risk factors for suicide.Key Words: Suicide: Community, Risk-factors, Wives of military personnel     

Preterm delivery and low maternal serum cholesterol level: Any correlation?

Background:

The study assessed whether low maternal serum cholesterol during early pregnancy is associated with preterm delivery.

Patients and Methods:

It was a prospective observational cohort study involving pregnant women at gestational age of 14-20 weeks over a period of 12 months. Blood samples were obtained to measure total serum cholesterol concentrations and the sera were then analysed enzymatically by the cholesterol oxidase: p-aminophenazone (CHOD PAP) method.

Results:

The study showed an incidence of 5.0% for preterm delivery in the low risk study patients. Preterm birth was 4.83-times more common with low total maternal cholesterol than with midrange total cholesterol (11.8% versus 2.2%, P = 0.024).

Conclusion:

Low maternal serum cholesterol (hypocholesterolaemia) is associated with preterm delivery. Optimal maternal serum cholesterol during pregnancy may have merit, therefore pregnant women should be encouraged to follow a healthy, balanced diet.     

Knowledge and perceptions of quality of obstetric and newborn care of local health providers: a cross-sectional study in three districts in Malawi

Aim

Quality of service delivery for maternal and newborn health in Malawi is influenced by human resource shortages and knowledge and care practices of the existing service providers. We assessed Malawian healthcare providers'' knowledge of management of routine labour, emergency obstetric care and emergency newborn care; correlated knowledge with reported confidence and previous study or training; and measured perception of the care they provided.

Methods

This study formed part of a large-scale quality of care assessment in three districts (Kasungu, Lilongwe and Salima) of Malawi. Subjects were selected purposively by their role as providers of obstetric and newborn care during routine visits to health facilities by a research assistant. Research assistants introduced and supervised the self-completed questionnaire by the service providers. Respondents included 42 nurse midwives, 1 clinical officer, 4 medical assistants and 5 other staff. Of these, 37 were staff working in facilities providing Basic Emergency Obstetric Care (BEMoC) and 15 were from staff working in facilities providing Comprehensive Emergency Obstetric Care (CEMoC).

Results

Knowledge regarding management of routine labour was good (80% correct responses), but knowledge of correct monitoring during routine labour (35% correct) was not in keeping with internationally recognized good practice. Questions regarding emergency obstetric care were answered correctly by 70% of respondents with significant variation depending on clinicians'' place of work. Knowledge of emergency newborn care was poor across all groups surveyed with 58% correct responses and high rates of potentially life-threatening responses from BEmOC facilities. Reported confidence and training had little impact on levels of knowledge. Staff in general reported perception of poor quality of care.

Conclusion

Serious deficiencies in providers'' knowledge regarding monitoring during routine labour and management of emergency newborn care were documented. These may contribute to maternal and neonatal deaths in Malawi. The knowledge gap cannot be overcome by simply providing more training.     

A view of maternal mortalities in women conceiving through assisted reproductive techniques: A nation-based study of Turkey

Background

Our aim was to evaluate maternal mortality causes among Turkish women giving birth after assisted reproductive techniques (ARTs).

What harm does a second delivery to the pelvic floor?

Objective

To compare the pelvic floor function of primiparous women to women after a second delivery regarding symptoms of urinary and anal incontinence, anal sphincter ruptures and bladder-neck mobility.

Methods

A questionnaire evaluating symptoms of urinary and anal incontinence was used in nulliparous women before and 27 months after childbirth. Furthermore these symptoms were correlated with functional changes of the pelvic floor based on a careful gynecologic examination as well as perineal and endoanal ultrasound.

Results

112 nulliparous women were included, 49 women returned for follow-up on average 27 months (SD 4.4 months) after the first delivery. 39 women (group A) had just one delivery, 10 women (group B - 10/49) had had a second delivery. Apart from levator ani muscle strength, no significant difference between pelvic floor function of group A vs group B was demonstrable. Furthermore, we could show no significant difference for symptoms of urinary (11 (28.2%) vs. 5 (50.0%)) and anal incontinence (14 (35.9%) vs. 4 (40.0%)) between both groups. However, we found a lasting increase of stress urinary and anal incontinence as well as overactive bladder symptoms after one or more deliveries. The position of the bladder neck at rest was lower in both groups compared to the position before the first delivery and bladder neck mobility increased after one or more deliveries.

Discussion

Our study shows several statistically significant changes of the pelvic floor function even on average 27 months after delivery, but a subsequent delivery did not compromise the pelvic floor any further.     

Walking Epidural : An Effective Method of Labour Pain Relief

Background

Labour pain can be deleterious for mother and baby. Epidural analgesia relieves labour pains effectively with minimal maternal and foetal side effects. A prospective open label study was undertaken to ascertain effective dosing regime for walking epidural in labour.

Methods

Fifty women with singleton foetus in vertex position were included. Epidural catheter was inserted in L2-3 / L3-4 interspinous space. Initial bolus of 10 ml (0.1% bupivacaine and 0.0002% fentanyl) solution was injected and after the efficacy of block was established, an epidural infusion of the same drug solution was started at the rate of 5 ml/hour.

Results

In first stage of labour 80% of the parturient had excellent to good pain relief (visual analogue scale 1 to 3) with standard protocol while 20% parturient required one or more additional boluses. For the second stage, pain relief was good to fair (VAS 4-6) for most of the parturient. The incidence of caesarian section was 4% and 6% needed assisted delivery. No major side effects were observed.

Conclusion

0.1% bupivacaine with 0.0002% fentanyl maximizes labour pain relief and minimizes side effects.Key Words: Labour analgesia, Walking epidural     

Sociotechnical challenges to developing technologies for patient access to health information exchange data

Background

Providing patients with access to their medical data is widely expected to help educate and empower them to manage their own health. Health information exchange (HIE) infrastructures could potentially help patients access records across multiple healthcare providers. We studied three HIE organizations as they developed portals to give consumers access to HIE data previously exchanged only among healthcare organizations.

Objective

To follow the development of new consumer portal technologies, and to identify barriers and facilitators to patient access to HIE data.

Methods

Semistructured interviews of 15 key informants over a 2-year period spanning the development and early implementation of three new projects, coded according to a sociotechnical framework.

Results

As the organizations tried to develop functionality that fully served the needs of both providers and patients, plans were altered by technical barriers (primarily related to data standardization) and cultural and legal issues surrounding data access. Organizational changes also played an important role in altering project plans. In all three cases, patient access to data was significantly scaled back from initial plans.

Conclusions

This prospective study revealed how sociotechnical factors previously identified as important in health information technology success and failure helped to shape the evolution of three novel consumer informatics projects. Barriers to providing patients with seamless access to their HIE data were multifactorial. Remedies will have to address technical, organizational, cultural, and other factors.