Paying the price: The cost and consequences of emergency obstetric care in Burkina Faso

Metasynthesis: Experiences of Women with Severe Maternal Morbidity and Their Perception of the Quality of Health Care

Aim

To explore the experiences of women with severe maternal morbidity and their perception of the quality of health care.

Background

The exploration of factors associated with severe maternal morbidity has emerged as an alternative strategy in reducing maternal mortality. This approach is useful for the evaluation and improvement of maternal health services.

Design

Included a comprehensive search, appraisal of reports of qualitative studies, the classification of studies and the synthesis of findings.

Data Sources

A literature search was conducted through nine databases for articles published between January 1980 and August 2013.

Review Methods

The quality of included studies was assessed with a modified Critical Appraisal Skills Program tool. The synthesis applied a meta-ethnographic approach. It involved (1) identifying and comparing the findings; (2) creating a parsimonious thematic structure and (3) searching for disconfirming data.

Results

Nine studies published between 2005 and 2012, involving 292 women with severe maternal morbidity, were included. Three key themes were identified: 'provision of care', 'severe maternal morbidity' and 'health care seeking behavior'. Barriers to the access and utilization of heath care services were identified.

Conclusion

The findings appear to suggest that mental and physical health outcomes of women who experienced severe maternal morbidity were poor. There is a need to identify the persistence and severity of these outcomes over a longer period of time. More realistic and less biased information may be obtained in community-based interviews. The impact of potential negative fetal outcomes would be a strong influencing factor for the women. These findings may help to increase awareness of the non-physical components of severe maternal morbidity and provide guidance for professionals regarding preventive measures.

Continuing with "…a heavy heart" - consequences of maternal death in rural Kenya

BACKGROUND

This study analyzes the consequences of maternal death to households in Western Kenya, specifically, neonatal and infant survival, childcare and schooling, disruption of daily household activities, the emotional burden on household members, and coping mechanisms.

METHODS

The study is a combination of qualitative analysis with matched and unmatched quantitative analysis using surveillance and survey data. Between September 2011 and March 2013 all households in the study area with a maternal death were surveyed. Data were collected on the demographic characteristics of the deceased woman; household socio-economic status; a history of the pregnancy that led to the death; schooling experiences of surviving school-age children; and disruption to household functioning due to the maternal death. These data were supplemented by in-depth and focus group discussions. Quantitative data on neonatal and infant survival from a demographic surveillance system in the study area were also used. Descriptive and bivariate analyses were conducted with the quantitative data, and qualitative data were analyzed through text analysis using NVivo.

RESULTS

More than three-quarters of deceased women performed most household tasks when healthy. After the maternal death, the responsibility for these tasks fell primarily on the deceased's husbands, mothers, and mothers-in-law. Two-thirds of the individuals from households that suffered a maternal death had to shift into another household. Most children had to move away, mostly to their grandmother's home. About 37% of live births to women who died of maternal causes survived till age 1 year, compared to 65% of live births to a matched sample of women who died of non-maternal causes and 93% of live births to surviving women. Older, surviving children missed school or did not have enough time for schoolwork, because of increased housework or because the loss of household income due to the maternal death meant school fees could not be paid. Respondents expressed grief, frustration, anger and a sense of loss. Generous family and community support during the funeral and mourning periods was followed by little support thereafter.

CONCLUSION

The detrimental consequences of a maternal death ripple out from the woman's spouse and children to the entire household, and across generations.

Consequences of maternal mortality on infant and child survival: a 25-year longitudinal analysis in Butajira Ethiopia (1987-2011)

Background

Maternal mortality remains the leading cause of death and disability for reproductive-age women in resource-poor countries. The impact of a mother’s death on child outcomes is likely severe but has not been well quantified. This analysis examines survival outcomes for children whose mothers die during or shortly after childbirth in Butajira, Ethiopia.

Methods

This study uses data from the Butajira Health and Demographic Surveillance System (HDSS) site. Child outcomes were assessed using statistical tests to compare survival trajectories and age-specific mortality rates for children who did and did not experience a maternal death. The analyses leveraged the advantages of a large, long-term longitudinal dataset with a high frequency of data collection; but used a strict date-based method to code maternal deaths (as occurring within 42 or 365 days of childbirth), which may be subject to misclassification or recall bias.

Results

Between 1987 and 2011, there were 18189 live births to 5119 mothers; and 73 mothers of 78 children died within the first year of their child’s life, with 45% of these (n=30) classified as maternal deaths due to women dying within 42 days of childbirth. Among the maternal deaths, 81% of these infants also died. Children who experienced a maternal death within 42 days of their birth faced 46 times greater risk of dying within one month when compared to babies whose mothers survived (95% confidence interval 25.84-81.92; or adjusted ratio, 57.24 with confidence interval 25.31-129.49).

Conclusions

When a woman in this study population experienced a maternal death, her infant was much more likely to die than to survive—and the survival trajectory of these children is far worse than those of mothers who do not die postpartum. This highlights the importance of investigating how clinical care and socio-economic support programs can better address the needs of orphans, both throughout the intra- and post-partum periods as well as over the life course.

Male partners' perceptions of maternal near miss obstetric morbidity experienced by their spouses

BACKGROUND

Severe obstetric complications have potential negative impact on the family and household of the survivors, with potential negative effects during (and in the aftermath of) the traumatic obstetric events. The objective was to gain deeper understanding of how severe obstetric complications are perceived by male partners, and their impact on the livelihoods of the family and community.

METHODS

Data was collected through 25 in-depth narrative interviews with male partners of women with severe obstetric morbidity. The interviews occurred 4-12 months after the traumatic childbirth events. To gain a deeper understanding of the meanings and spouses attach to the experiences, we employed the notions of social capital and resilience.

RESULTS

Male partners' perceptions and experiences were mostly characterized by losses, dreams and dilemmas, disempowerment and alienation, seclusion and self isolation or reliance on the social networks. During the aftermath of the events, there was disruption of the livelihoods of the partners and the whole family.

CONCLUSION

While a maternal near miss obstetric event might appear as a positive outcome for the survivors, partners and caregivers of women who experience severe obstetric morbidity are deeply affected by the experiences of this life-threatening episode.

Cost to households in treating maternal complications in northern Ghana: a cross sectional study

Background

The cost of treating maternal complications has serious economic consequences to households and can hinder the utilization of maternal health care services at the health facilities. This study estimated the cost of maternal complications to women and their households in the Kassena-Nankana district of northern Ghana.

Methods

We carried out a cross-sectional study between February and April 2014 in the Kassena-Nankana district. Out of a total of 296 women who were referred to the hospital for maternal complications from the health centre level, sixty of them were involved in the study. Socio-demographic data of respondents as well as direct and indirect costs involved in the management of the complications at the hospital were collected from the patient’s perspective. Analysis was performed using STATA 11.

Results

Out of the 60 respondents, 60% (36) of them suffered complications due to prolonged labour, 17% (10) due to severe abdominal pain, 10% (6) due to anaemia/malaria and 7% (4) due to pre-eclampsia. Most of the women who had complications were primiparous and were between 21–25 years old. Transportation cost accounted for the largest cost, representing 32% of total cost of treatment. The median direct medical cost was US$8.68 per treatment, representing 44% of the total cost of treatment. Indirect costs accounted for the largest proportion of total cost (79%). Overall, the median expenditure by households on both direct and indirect costs per complication was US$32.03. Disaggregating costs by type of complication, costs ranged from a median of US$58.33 for pre-eclampsia to US$6.84 for haemorrrhage. The median number of days spent in the hospital was 2 days - five days for pre-eclampsia. About 33% (6) of households spent more than 5% of annual household expenditure and therefore faced catastrophic payments.

Conclusion

Although maternal health services are free in Ghana, women still incur substantial costs when complications occur and face the risk of incurring catastrophic health expenditure.

Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care

In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of women's views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen women's capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.

Natural calamities and 'the Big Migration': challenges to the Mongolian health system in 'the Age of the Market'

Beginning with the demise of the socialist state system in 1990, Mongolia embarked on a process of neoliberal economic reform, initiating what is known among the Mongols as 'the Age of the Market'. The socialist health system has been replaced by a series of reforms initiated and substantiated by foreign donor organisations. This paper critically examines Mongolia's health system and discusses the extent to which this 'system', despite its provision of universal, accessible and essential primary health care services, is unable to accommodate the health needs of poor urban in-migrants and nomadic herders in remote provinces. With a particular focus on recurrent natural winter disasters (dzud) and an escalating rural to urban migration, the paper argues that the issues of access to health services and health system strengthening must be understood in relation to factors external to the health system. Ethnographic research highlights that despite a growing economy, considerable external aid and an established primary health care model, weak rural politics, environmental challenges and economic constraints create escalating health vulnerability among the poorest in Mongolia.

Fear, guilt, and debt: an exploration of women's experience and perception of cesarean birth in Burkina Faso, West Africa

Background

This paper explores women’s experience and perception of cesarean birth in Burkina Faso and its social and economic implications within the household.

Methods

Five focus groups comprising mothers or pregnant women were conducted among residents of Bogodogo Health District in Ouagadougou to assess the perceptions of cesarean section (CS) by women in the community. In addition, 35 individual semistructured interviews were held at the homes of women who had just undergone CS in the referral hospital, and were conducted by an anthropologist and a midwife.

Results

Home visits to women with CS identified common fears about the procedure, such as “once you have had a CS, you will always have to deliver by CS”. The central and recurring theme in the interviews was communication between patients and care providers, ie, women were often not informed of the imminence of CS in the delivery room. Information given by health care professionals was often either not explicit enough or not understood. The women received insufficient information about postoperative personal hygiene, diet, resumption of sexual activity, and contraception. Overall, analysis of the experiences of women who had undergone CS highlighted feelings of guilt in the aftermath of CS. Other concerns included the feeling of not being a “good mother” who can give birth normally, alongside concerns about needing a CS in future pregnancies, the high costs that this might incur for their households, general fatigue, and possible medical complications after surgery.

Conclusion

Poor quality of care and the economic burden of CS place women in a multifaceted situation of vulnerability within the family. CS has a medical, emotional, social, and economic impact on poor African women that cannot be ignored. Managers of maternal health programs need to understand women’s perceptions of CS so as to overcome existing barriers to this life-saving procedure.

Partner experiences of "near-miss" events in pregnancy and childbirth in the UK: a qualitative study

Objective

Severe life-threatening complications in pregnancy that require urgent medical intervention are commonly known as “near-miss” events. Although these complications are rare (1 in 100 births), there are potentially 8,000 women and their families in the UK each year who live through a life-threatening emergency and its aftermath. Near-miss obstetric emergencies can be traumatic and frightening for women, and their impact can last for years. There is little research that has explored how these events impact on partners. The objective of this interview study was to explore the impact of a near-miss obstetric emergency, focusing particularly on partners.

Design

Qualitative study based on narrative interviews, video and audio recorded and transcribed for analysis. A qualitative interpretative approach was taken, combining thematic analysis with constant comparison. The analysis presented here focuses on the experiences of partners.

Participants

Maximum variation sample included 35 women, 10 male partners, and one lesbian partner who had experienced a life-threatening obstetric emergency.

Setting

Interviews were conducted in participants’ own homes.

Results

In the hospital, partner experiences were characterized by powerlessness and exclusion. Partners often found witnessing the emergency shocking and distressing. Support (from family or staff) was very important, and clear, honest communication from medical staff highly valued. The long-term emotional effects for some were profound; some experienced depression, flashbacks and post-traumatic stress disorder months and years after the emergency. These, in turn, affected the whole family. Little support was felt to be available, nor acknowledgement of their ongoing distress.

Conclusion

Partners, as well as women giving birth, can be shocked to experience a life-threatening illness in childbirth. While medical staff may view a near-miss as a positive outcome for a woman and her baby, there can be long-term mental health consequences that can have profound impacts on the individual, but also their families.

Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review

BACKGROUND

Demand-side financing, where funds for specific services are channelled through, or to, prospective users, is now employed in health and education sectors in many low- and middle-income countries. This systematic review aimed to critically examine the evidence on application of this approach to promote maternal health in these settings. Five modes were considered: unconditional cash transfers, conditional cash transfers, short-term payments to offset costs of accessing maternity services, vouchers for maternity services, and vouchers for merit goods. We sought to assess the effects of these interventions on utilisation of maternity services and on maternal health outcomes and infant health, the situation of underprivileged women and the healthcare system.

METHODS

The protocol aimed for collection and synthesis of a broad range of evidence from quantitative, qualitative and economic studies. Nineteen health and social policy databases, seven unpublished research databases and 27 websites were searched; with additional searches of Indian journals and websites. Studies were included if they examined demand-side financing interventions to increase consumption of services or goods intended to impact on maternal health, and met relevant quality criteria. Quality assessment, data extraction and analysis used Joanna Briggs Institute standardised tools and software. Outcomes of interest included maternal and infant mortality and morbidity, service utilisation, factors required for successful implementation, recipient and provider experiences, ethical issues, and cost-effectiveness. Findings on Effectiveness, Feasibility, Appropriateness and Meaningfulness were presented by narrative synthesis.

RESULTS

Thirty-three quantitative studies, 46 qualitative studies, and four economic studies from 17 countries met the inclusion criteria. Evidence on unconditional cash transfers was scanty. Other demand-side financing modes were found to increase utilisation of maternal healthcare in the index pregnancy or uptake of related merit goods. Evidence of effects on maternal and infant mortality and morbidity outcomes was insufficient. Important implementation aspects include targeting and eligibility criteria, monitoring, respectful treatment of beneficiaries, suitable incentives for providers, quality of care and affordable referral systems.

CONCLUSIONS

Demand-side financing schemes can increase utilisation of maternity services, but attention must be paid to supply-side conditions, the fine-grain of implementation and sustainability. Comparative studies and research on health impact and cost-effectiveness are required.

A qualitative evaluation of the choice of traditional birth attendants for maternity care in 2008 Sierra Leone: implications for universal skilled attendance at delivery

Maternal and newborn death is common in Sierra Leone; significant reductions in both maternal and newborn mortality require universal access to a skilled attendant during labor and delivery. When too few women use health facilities MDGs 4 and 5 targets will not be met. Our objectives were to identify why women use services provided by TBAs as compared to health facilities; and to suggest strategies to improve utilization of health facilities for maternity and newborn care services. Qualitative data from focus group discussions in communities adjacent to health facilities collected during the 2008 Emergency Obstetric and Newborn Care Needs Assessment were analyzed for themes relating to decision-making on the utilization of TBAs or health facilities. The prohibitive cost of services, and the geographic inaccessibility of health facilities discouraged women from using them while trust in the vast experience of TBAs as well as their compassionate care drew patients to them. Poor facility infrastructure, often absent staff, and the perception that facilities were poorly stocked and could not provide continuum of care services were barriers to facility utilization for maternity and newborn care. Improvements in infrastructure and the 24-hour provision of free, quality, comprehensive, and respectful care will minimize TBA preference in Sierra Leone.

The long term economic impact of severe obstetric complications for women and their children in Burkina Faso

This study investigates the long term economic impact of severe obstetric complications for women and their children in Burkina Faso, focusing on measures of food security, expenditures and related quality of life measures. It uses a hospital based cohort, first visited in 2004/2005 and followed up four years later. This cohort of 1014 women consisted of two main groups of comparison: 677 women who had an uncomplicated delivery and 337 women who experienced a severe obstetric complication which would have almost certainly caused death had they not received hospital care (labelled a “near miss” event). To analyze the impact of such near miss events as well as the possible interaction with the pregnancy outcome, we compared household and individual level indicators between women without a near miss event and women with a near miss event who either had a live birth, a perinatal death or an early pregnancy loss. We used propensity score matching to remove initial selection bias. Although we found limited effects for the whole group of near miss women, the results indicated negative impacts: a) for near miss women with a live birth, on child development and education, on relatively expensive food consumption and on women’s quality of life; b) for near miss women with perinatal death, on relatively expensive foods consumption and children’s education and c) for near miss women who had an early pregnancy loss, on overall food security. Our results showed that severe obstetric complications have long lasting consequences for different groups of women and their children and highlighted the need for carefully targeted interventions.

Economic impact of maternal death on households in rural china: a prospective cohort study

Objective

To assess the economic impact of maternal death on rural Chinese households during the year after maternal death.

Methods

A prospective cohort study matched 183 households who had suffered a maternal death to 346 households that experienced childbirth without maternal death in rural areas of three provinces in China. Surveys were conducted at baseline (1–3 months after maternal death or childbirth) and one year after baseline using the quantitative questionnaire. We investigated household income, expenditure, accumulated debts, and self-reported household economic status. Difference-in-Difference (DID), linear regression, and logistic regression analyses were used to compare the economic status between households with and without maternal death.

Findings

The households with maternal death had a higher risk of self-reported “household economy became worse” during the follow-up period (adjusted OR = 6.04, p<0.001). During the follow-up period, at the household level, DID estimator of income and expenditure showed that households with maternal death had a significant relative reduction of US$ 869 and US$ 650, compared to those households that experienced childbirth with no adverse event (p<0.001). Converted to proportions of change, an average of 32.0% reduction of annual income and 24.9% reduction of annual expenditure were observed in households with a maternal death. The mean increase of accumulated debts in households with a maternal death was 3.2 times as high as that in households without maternal death (p = 0.024). Expenditure pattern of households with maternal death changed, with lower consumption on food (p = 0.037), clothes and commodity (p = 0.003), traffic and communication (p = 0.022) and higher consumption on cigarette or alcohol (p = 0.014).

Conclusion

Compared with childbirth, maternal death had adverse impact on household economy, including higher risk of self-reported “household economy became worse”, decreased income and expenditure, increased debts and changed expenditure pattern.

Too poor to live? A case study of vulnerability and maternal mortality in Burkina Faso

This paper examines the concept of vulnerability in the context of maternal morbidity and mortality in Burkina Faso, an impoverished country in West Africa. Drawing on a longitudinal cohort study into the consequences of life-threatening or ‘near miss’ obstetric complications, we provide an in-depth case study of one woman’s experience of such morbidity and its aftermath. We follow Kalizeta’s trajectory from her near miss and the stillbirth of her child to her death from pregnancy-related hypertension after a subsequent delivery less than two years later, in order to examine the impact of severe and persistent illness and catastrophic health expenditure on her health and on her family’s everyday life. Kalizeta’s case illustrates how vulnerability in health emerges and is maintained or exacerbated over time. Even where social arrangements are supportive, structural impediments, including unaffordable and inadequate healthcare, can severely limit individual resilience to mitigate the negative social and economic consequences of ill health.

Removal of user fees no guarantee of universal health coverage: observations from Burkina Faso

In theory, the removal of user fees puts health services within reach of everyone, including the very poor. When Burkina Faso adopted the DOTS strategy for the control of tuberculosis, the intention was to provide free tuberculosis care. In 2007-2008, interviews were used to collect information from 242 smear-positive patients with pulmonary tuberculosis who were enrolled in the national tuberculosis control programme in six rural districts. The median direct costs associated with tuberculosis were estimated at 101 United States dollars (US$) per patient. These costs represented 23% of the mean annual income of a patient's household. During the course of their care, three quarters of the interviewed patients apparently faced "catastrophic" health expenditure. Inadequacies in the health system and policies appeared to be responsible for nearly half of the direct costs (US$ 45 per patient). Although the households of patients developed coping strategies, these had far-reaching, adverse effects on the quality of lives of the households' members and the socioeconomic stability of the households. Each tuberculosis patient lost a median of 45 days of work as a result of the illness. For a population living on or below the poverty line, every failure in health-care delivery increases the risk of "catastrophic" health expenditure, exacerbates socioeconomic inequalities, and reduces the probability of adequate treatment and cure. In Burkina Faso, a policy of "free" care for tuberculosis patients has not met with complete success. These observations should help define post-2015 global strategies for tuberculosis care, prevention and control.

Emergency obstetric care in Mali: catastrophic spending and its impoverishing effects on households

OBJECTIVE

To investigate the frequency of catastrophic expenditures for emergency obstetric care, explore its risk factors, and assess the effect of these expenditures on households in the Kayes region, Mali.

METHODS

Data on 484 obstetric emergencies (242 deaths and 242 near-misses) were collected in 2008-2011. Catastrophic expenditure for emergency obstetric care was assessed at different thresholds and its associated factors were explored through logistic regression. A survey was subsequently administered in a nested sample of 56 households to determine how the catastrophic expenditure had affected them.

FINDINGS

Despite the fee exemption policy for Caesareans and the maternity referral-system, designed to reduce the financial burden of emergency obstetric care, average expenses were 152 United States dollars (equivalent to 71 535 Communauté Financière Africaine francs) and 20.7 to 53.5% of households incurred catastrophic expenditures. High expenditure for emergency obstetric care forced 44.6% of the households to reduce their food consumption and 23.2% were still indebted 10 months to two and a half years later. Living in remote rural areas was associated with the risk of catastrophic spending, which shows the referral system's inability to eliminate financial obstacles for remote households. Women who underwent Caesareans continued to incur catastrophic expenses, especially when prescribed drugs not included in the government-provided Caesarean kits.

CONCLUSION

The poor accessibility and affordability of emergency obstetric care has consequences beyond maternal deaths. Providing drugs free of charge and moving to a more sustainable, nationally-funded referral system would reduce catastrophic expenses for households during obstetric emergencies.

Toward a typology of health-related informal credit: an exploration of borrowing practices for paying for health care by the poor in Cambodia

Background

Borrowing money is a common strategy to cope with health care costs. The impact of borrowing on households can be severe, leading to indebtedness and further impoverishment. However, the available literature on borrowing practices for health is limited. We explore borrowing practices for paying for health care by the poor in Cambodia and provide a typology, associated conditions, and the extent of the phenomenon.

Methods

In addition to a semi-structured literature review, in-depth interviews were conducted with representatives of 47 households with health-related debt and 19 managers of formal or informal credit schemes.

Results

A large proportion of Cambodians, especially the poor, resort to borrowing to meet the cost of health care. Because of limited cash flow and access to formal creditors, the majority take out loans with high interest rates from informal money lenders. The most common type of informal credit is locally known as Changkar and consists of five kinds of loans: short-term loans, medium-term loans, seasonal loans, loans for an unspecified period, and loans with repayment in labour, each with different lending and repayment conditions and interest rates.

Conclusion

This study suggests the importance of informal credit for coping with the cost of treatment and its potentially negative impact on the livelihood of Cambodian people. We provide directions for further studies on financial protection interventions to mitigate harmful borrowing practices to pay for health care in Cambodia.

Capitals diminished, denied, mustered and deployed. A qualitative longitudinal study of women's four year trajectories after acute health crisis, Burkina Faso

Accumulating evidence indicates that health crises can play a key role in precipitating or exacerbating poverty. For women of reproductive age in low-income countries, the complications of pregnancy are a common cause of acute health crisis, yet investigation of longer-term dynamics set in motion by such events, and their interactions with other aspects of social life, is rare. This article presents findings from longitudinal qualitative research conducted in Burkina Faso over 2004–2010. Guided by an analytic focus on patterns of continuity and change, and drawing on recent discussions on the notion of ‘resilience’, and the concepts of ‘social capital’ and ‘bodily capital’, we explore the trajectories of 16 women in the aftermath of costly acute healthcare episodes. The synthesis of case studies shows that, in conditions of structural inequity and great insecurity, an individual's social capital ebbs and flow over time, resulting in a trajectory of multiple adaptations. Women's capacity to harness or exploit bodily capital in its various forms (beauty, youthfulness, physical strength, fertility) to some extent determines their ability to confront and overcome adversities. With this, they are able to further mobilise social capital without incurring excessive debt, or to access and accumulate significant new social capital. Temporary self-displacement, often to the parental home, is also used as a weapon of negotiation in intra-household conflict and to remind others of the value of one's productive and domestic labour. Conversely, diminished bodily capital due to the physiological impact of an obstetric event or its complications can lead to reduced opportunities, and to further disadvantage.

'This year I will not put her to work': the production/reproduction nexus in Burkina Faso

Global advocacy campaigns increasingly highlight the negative impact of reproductive morbidity on economic productivity and development in order to justify donor investment in maternal health. Anthropological approaches nuance such narrow economic estimations of reproductive health. Drawing on ethnographic fieldwork from Burkina Faso in West Africa, this paper analyses the dynamic, and sometimes contradictory, relationship between women's work and reproductive health in impoverished communities. Specifically, it examines the consequences of life-threatening ‘near-miss’ obstetric complications for women's work across domestic, agricultural and economic spheres over a four-year period. Such events provide a window onto the diverse ways in which production and reproduction are intimately linked within women's everyday lives. Reproduction and production entail sources of potential empowerment and enhancement, as well as potential threats, to health and well-being. In the aftermath of ‘near-miss’ events, the realms of reproduction and production sometimes jeopardise each other and at other times reinforce each other, while strength in one domain can compensate for weakness in the other. Women's experiences thus reveal how ‘production’ and ‘reproduction’ are mutually constituted, challenging the purely instrumental accounts of pregnancy-related ‘productivity loss’ that dominate current global health discourse.

Relating the construction and maintenance of maternal ill-health in rural Indonesia

Estimates suggest that over 350,000 deaths and more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. Death and disability occur predominately among disadvantaged women in resource-poor settings and are largely preventable with adequate delivery care. This paper presents the substantive findings and policy implications from a programme of PhD research, of which the overarching objective was to assess quality of, and access to, care in obstetric emergencies. Three critical incident audits were conducted in two rural districts on Java, Indonesia: a confidential enquiry, a verbal autopsy survey, and a community-based review. The studies examined cases of maternal mortality and severe morbidity from the perspectives of local service users and health providers. A range of inter-related determining factors was identified. When unexpected delivery complications occurred, women and families were often uninformed, unprepared, found care unavailable, unaffordable, and many relied on traditional providers. Midwives in villages made important contributions by stabilising women and facilitating referrals but were often scarce in remote areas and lacked sufficient clinical competencies and payment incentives to treat the poor. Emergency transport was often unavailable and private transport was unreliable and incurred costs. In facilities, there was a reluctance to admit poorer women and those accepted were often admitted to ill-equipped, under-staffed wards. As a result, referrals between hospitals were also common. Otherwise, social health insurance, designed to reduce financial barriers, was particularly problematic, constraining quality and access within and outside facilities. Health workers and service users provided rich and explicit assessments of care and outcomes. These were used to develop a conceptual model in which quality and access are conceived of as social processes, observable through experience and reflective of the broader relationships between individuals and health systems. According to this model, differential quality and access can become both socially legitimate (imposed by structural arrangements) and socially legitimised (reciprocally maintained through the actions of individuals). This interpretation suggests that in a context of commodified care provision, adverse obstetric outcomes will occur and recur for disadvantaged women. Health system reform should focus on the unintended effects of market-based service provision to exclude those without the ability to pay for delivery care directly.

Overcoming phase 1 delays: the critical component of obstetric fistula prevention programs in resource-poor countries

BACKGROUND

An obstetric fistula is a traumatic childbirth injury that occurs when labor is obstructed and delivery is delayed. Prolonged obstructed labor leads to the destruction of the tissues that normally separate the bladder from the vagina and creates a passageway (fistula) through which urine leaks continuously. Women with a fistula become social outcasts. Universal high-quality maternity care has eliminated the obstetric fistula in wealthy countries, but millions of women in resource-poor nations still experience prolonged labor and tens of thousands of new fistula sufferers are added to the millions of pre-existing cases each year. This article discusses fistula prevention in developing countries, focusing on the factors which delay treatment of prolonged labor.

DISCUSSION

Obstetric fistulas can be prevented through contraception, avoiding obstructed labor, or improving outcomes for women who develop obstructed labor. Contraception is of little use to women who are already pregnant and there is no reliable screening test to predict obstruction in advance of labor. Improving the outcome of obstructed labor depends on prompt diagnosis and timely intervention (usually by cesarean section). Because obstetric fistulas are caused by tissue compression, the time interval from obstruction to delivery is critical. This time interval is often extended by delays in deciding to seek care, delays in arriving at a hospital, and delays in accessing treatment after arrival. Communities can reasonably demand that governments and healthcare institutions improve the second (transportation) and third (treatment) phases of delay. Initial delays in seeking hospital care are caused by failure to recognize that labor is prolonged, confusion concerning what should be done (often the result of competing therapeutic pathways), lack of women's agency, unfamiliarity with and fear of hospitals and the treatments they offer (especially surgery), and economic constraints on access to care.

SUMMARY

Women in resource-poor countries will use institutional obstetric care when the services provided are valued more than the competing choices offered by a pluralistic medical system. The key to obstetric fistula prevention is competent obstetrical care delivered respectfully, promptly, and at affordable cost. The utilization of these services is driven largely by trust.

Economic consequences of maternal illness in rural Bangladesh

We use panel data on household consumption combined with information taken from the medical records of women who gave birth in health facilities to explore the economic consequences of maternal ill health, in the context of a rural population in Bangladesh. The findings suggest that there is a large reduction in household resources associated with maternal illness, driven almost entirely by spending on health care. In spite of this loss of resources, we find that households are able to fully insure consumption against maternal ill health, although confidence intervals are unable to rule out a small effect. Households in our study area are shown to have good access to informal credit (whether it be from local money lenders or family relatives), and this appears critical in helping to smooth consumption in response to these health shocks, at least in the short term.

The immediate economic impact of maternal deaths on rural Chinese households

OBJECTIVE

To identify the immediate economic impact of maternal death on rural Chinese households.

METHODS

Results are reported from a study that matched 195 households who had suffered a maternal death to 384 households that experienced a childbirth without maternal death in rural areas of three provinces in China, using quantitative questionnaire to compare differences of direct and indirect costs between two groups.

FINDINGS

The direct costs of a maternal death were significantly higher than the costs of a childbirth without a maternal death (US$4,119 vs. $370, p<0.001). More than 40% of the direct costs were attributed to funeral expenses. Hospitalization and emergency care expenses were the largest proportion of non-funeral direct costs and were higher in households with maternal death than the comparison group (US$2,248 vs. $305, p<0.001). To cover most of the high direct costs, 44.1% of affected households utilized compensation from hospitals, and the rest affected households (55.9%) utilized borrowing money or taking loans as major source of money to offset direct costs. The median economic burden of the direct (and non-reimbursed) costs of a maternal death was quite high--37.0% of the household's annual income, which was approximately 4 times as high as the threshold for an expense being considered catastrophic.

CONCLUSION

The immediate direct costs of maternal deaths are extremely catastrophic for the rural Chinese households in three provinces studied.

Mortality after near-miss obstetric complications in Burkina Faso: medical, social and health-care factors

OBJECTIVE

To investigate mortality in women in Burkina Faso in the 4 years following a life-threatening near-miss obstetric complication and to identify the medical, social and health-care-related causes of death.

METHODS

In total, 1014 women were recruited after hospital discharge and followed for up to 4 years: 337 had near-miss complications and 677 had uncomplicated pregnancies. Significant differences in mortality between the groups were assessed using Fisher's exact test. The medical causes of death were identified from medical records and verbal autopsy data; social and health-care-related factors associated with death were identified from interviews with the deceased women's relatives.

FINDINGS

In the 4 years, 15 (5.3%) women died in the near-miss group and 5 (0.9%) died after uncomplicated pregnancies (P < 0.001). More than half the deaths after a near miss, but none after an uncomplicated delivery, were pregnancy-related. Indirect factors contributed to many of these deaths, particularly human immunodeficiency virus infection. Relatives' accounts suggested that the high cost and poor quality of health care, a lack of follow-up care and an unmet need for contraception contributed to the excess mortality in the near-miss group.

CONCLUSION

Women in Burkina Faso who initially survived a near-miss obstetric complication had an increased risk of all-cause and pregnancy-related death in the ensuing 4 years. The likelihood of survival over the longer term could be increased by offering a continuum of care that addresses the indirect and social causes of death and supplements the emergency intrapartum obstetric care provided by current safe motherhood programmes.

Barriers to emergency obstetric care services in perinatal deaths in rural gambia: a qualitative in-depth interview study

Objective. The Gambia has one of the world's highest perinatal mortality rates. We explored barriers of timely access to emergency obstetric care services resulting in perinatal deaths and in survivors of severe obstetric complications in rural Gambia. Method. We applied the “three delays” model as a framework for assessing contributing factors to perinatal deaths and obstetric complications. Qualitative in-depth interviews were conducted with 20 survivors of severe obstetric complications at home settings within three to four weeks after hospital discharge. Family members and traditional birth attendants were also interviewed. The interviews were translated into English and transcribed verbatim. We used content analysis to identify barriers of care. Results. Transport/cost-related delays are the major contributors of perinatal deaths in this study. A delay in recognising danger signs of pregnancy/labour or decision to seek care outside the home was the second important contributor of perinatal deaths. Decision to seek care may be timely, but impaired access precluded utilization of EmOC services. Obtaining blood for transfusion was also identified as a deterrent to appropriate care. Conclusion. Delays in accessing EmOC are critical in perinatal deaths. Thus, timely availability of emergency transport services and prompt decision-making are warranted for improved perinatal outcomes in rural Gambia.

Borrowing and selling to pay for health care in low- and middle-income countries

Many families around the world make sizable out-of-pocket payments for health care. We calculated the frequency of borrowing money or selling assets to buy health services in forty low- and middle-income countries and estimated how various factors are associated with these coping strategies. The data represented a combined population of 3.66 billion, or 58 percent of the world's population. On average, 25.9 percent of households borrowed money or sold items to pay for health care. The risk was higher among the poorest households and in countries with less health insurance. Health systems in developing countries are failing to protect families from the financial risks of seeking health care.

Innovative approaches to reducing financial barriers to obstetric care in low-income countries

Lack of access to quality care is the main obstacle to reducing maternal mortality in low-income countries. In many settings, women must pay out-of-pocket fees, resulting in delays, some of them fatal, and catastrophic expenditure that push households into poverty. Various innovative approaches have targeted the poor or exempted specific services, such as cesarean deliveries. We analyzed 8 case studies to better understand current experiments in reducing financial barriers to maternal care. Although service utilization increased in most of the settings, concerns remain about quality of care, equity between rich and poor patients and between urban and rural residents, and financial sustainability to support these new strategies.

Women's sexual health and contraceptive needs after a severe obstetric complication ("near-miss"): a cohort study in Burkina Faso

BACKGROUND

Little is known about the reproductive health of women who survive obstetric complications in poor countries. Our aim was to determine how severe obstetric complications in Burkina Faso affect reproductive events in the first year postpartum.

METHODS

Data were collected from a prospective cohort of women who either experienced life threatening (near-miss) pregnancy-related complications or an uncomplicated childbirth, followed from the end of pregnancy to one year postpartum or post-abortum. Documented outcomes include menses resumption, sexual activity resumption, dyspareunia, uptake of contraceptives, unmet needs for contraception and women's reproductive intentions.Participants were recruited in seven hospitals between December 2004 and March 2005 in six towns in Burkina Faso.

RESULTS

Reproductive events were associated with pregnancy outcome. The frequency of contraceptive use was low in all groups and the method used varied according to the presence or not of a live baby. The proportion with unmet need for contraception was high and varied according to the time since end of pregnancy. Desire for another pregnancy was highest among near-miss women with perinatal death or natural abortion. Women in the near-miss group with induced abortion, perinatal death and natural abortion had significantly higher odds of subsequent pregnancy. Unintended pregnancies were observed mainly in women in the near-miss group with live birth and the uncomplicated delivery group.

CONCLUSIONS

Considering the potential deleterious impact (on health and socio-economic life) of new pregnancies in near-miss women, it is important to ensure family planning coverage includes those who survive a severe complication.

Women's experiences of seeking reproductive health care in rural Ghana: challenges for maternal health service utilization

AIM

This paper is a report of part of a larger study exploring rural Ghanaian women's experiences of seeking reproductive health care. The aim of this part of the study was to describe rural women's perspectives on their experiences in seeking reproductive care from professional nurses.

BACKGROUND

Nurses' relationships with childbearing women have been linked to women's reproductive healthcare-seeking behaviour and service utilization. However, few researchers have studied women's perspectives on their relationships with nurses when seeking health care. In Ghana, the high rates of maternal mortality raise concerns about a number of factors, including nurses' relational practices.

METHODS

Data were collected in 2007 with a convenience sample of 27 Ghanaian women via in-depth interviews, focus groups and participant observation. Women's ages ranged from 15 to 49 years. The translated and transcribed data were thematically analyzed.

FINDINGS

Healthcare providers' relational practice influenced women's healthcare-seeking behaviours. Major themes from women's stories were: (a) experiences of intimidation and being scolded, (b) experiences of limited choices, (c) receiving silent treatment, and experiences of lack of privacy. Women emphasized the importance of their relationships with nurses and the impact of these relationships on their healthcare-seeking.

CONCLUSION

Nursing education in Ghana must place emphasis on basic relational practices. Structural changes to health clinics and routine nursing practices are necessary to create conditions for privacy to address women's health concerns. Women's perspectives must be considered for service improvement. Further research is needed to examine nurses' perspectives on relational care.

A lost cause? Extending verbal autopsy to investigate biomedical and socio-cultural causes of maternal death in Burkina Faso and Indonesia

Maternal mortality in developing countries is characterised by disadvantage and exclusion. Women who die whilst pregnant are typically poor and live in low-income and rural settings where access to quality care is constrained and where deaths, within and outside hospitals, often go unrecorded and unexamined. Verbal autopsy (VA) is an established method of determining cause(s) of death for people who die outside health facilities or without proper registration. This study extended VA to investigate socio-cultural factors relevant to outcomes. Interviews were conducted with relatives of 104 women who died during pregnancy, childbirth or postpartum in two rural districts in Indonesia and for 70 women in a rural district in Burkina Faso. Information was collected on medical signs and symptoms of the women prior to death and an extended section collected accounts of care pathways and opinions on preventability and cause of death. Illustrative quantitative and qualitative analyses were performed and the implications for health surveillance and planning were considered. The cause of death profiles were similar in both settings with infectious diseases, haemorrhage and malaria accounting for half the deaths. In both settings, delays in seeking, reaching and receiving care were reported by more than two-thirds of respondents. Relatives also provided information on their experiences of the emergencies revealing culturally-derived systems of explanation, causation and behaviour. Comparison of the qualitative and quantitative results suggested that the quantified delays may have been underestimated. The analysis suggests that broader empirical frameworks can inform more complete health planning by situating medical conditions within the socio-economic and cultural landscapes in which healthcare is situated and sought. Utilising local knowledge, extended VA has potential to inform the relative prioritisation of interventions that improve technical aspects of life-saving services with those that address the conditions that underlie health, for those whom services typically fail to reach.

Effects of severe obstetric complications on women's health and infant mortality in Benin

OBJECTIVE

To document the impact of severe obstetric complications on post-partum health in mothers and mortality in babies over 12 months in Benin and to assess whether severe complications associated with perinatal death are particularly likely to lead to adverse health consequences.

METHODS

Cohort study which followed women and their babies after a severe complication or an uncomplicated childbirth. Women were selected in hospitals and interviewed at home at discharge, and at 6 and 12 months post-partum. Women were invited for a medical check-up at 6 months and 12 months.

RESULTS

The cohort includes 205 women with severe complications and a live birth, 64 women with severe complications and perinatal death and 440 women with uncomplicated delivery. Women with severe complications and a live birth were not dissimilar to women with a normal delivery in terms of post-partum health, except for hypertension [adjusted OR = 5.8 (1.9-17.0)], fever [adjusted OR = 1.71 (1.1-2.8)] and infant mortality [adjusted OR = 11.0 (0.8-158.2)]. Women with complications and perinatal death were at increased risk of depression [adjusted OR = 3.4 (1.3-9.0)], urine leakages [adjusted OR = 2.7 (1.2-5.8)], and to report poor health [adjusted OR = 5.27 (2.2-12.4)] and pregnancy's negative effects on their life [adjusted OR = 4.11 (1.9-9.0)]. Uptake of post-natal services was poor in all groups.

CONCLUSION

Women in developing countries face a high risk of severe complications during pregnancy and delivery. These can lead to adverse consequences for their own health and that of their offspring. Resources are needed to ensure that pregnant women receive adequate care before, during and after discharge from hospital. Near-miss women with a perinatal death appear a particularly high-risk group.

Beyond body counts: a qualitative study of lives and loss in Burkina Faso after 'near-miss' obstetric complications

Averting women's pregnancy-related death is today recognised as an international health and development priority. Maternal survival is, in this sense, a success story. There is, however, little research into what happens to the women who survive the severe obstetric complications that are the main causes of maternal mortality. This paper examines findings from repeated in-depth interviews with 64 women who survived a clinically defined 'near-miss.' These interviews were conducted as part of a prospective longitudinal study of women who 'nearly died' of pregnancy-related complications in Burkina Faso, a poor country in West Africa. Drawing on sociological and anthropological perspectives that consider the defining characteristics of 'loss' to be social as much as biomedical, the paper seeks to understand loss as disruption of familiar forms and patterns of life. Women's accounts of their lives in the year following the near-miss event show that such events are not only about blood loss, seizures or infections, but also about a household crisis for which all available resources were mobilised, with a train of physical, economic and social consequences. The paper argues that near-miss events are characterised by the near-loss of a woman's life, but also frequently by the loss of the baby and by further significant disruptions in three overlapping dimensions of women's lives. These include disruption of bodily integrity through injury, ongoing illness and loss of strength and stamina; disruption of the household economy through high expenditure, debts and loss of productive capacity; and disruption of social identity and social stability. Maternal health policy needs to be concerned not only with averting the loss of life, but also with preventing or ameliorating others losses set in motion by an obstetric crisis.

Ensuring effective Essential Obstetric Care in resource poor settings

Although Emergency Obstetric Care (EOC) is globally accepted as a key strategy to improve maternal health and reduce maternal mortality, there is still a lot of debate surrounding its use--What is EOC? Is it evidence-based? How can we measure it? How can we improve access to EOC? This paper attempts to answer these questions. Although there are no randomized controlled trials, there is strong evidence from quasi-experimental, observational and ecological studies that EOC should be a critical component of any programme to reduce maternal mortality. This paper also identifies the barriers to accessing EOC and proposes strategies to overcome them which could contribute to achieving Millennium Development Goal 5.

Evaluating quality of obstetric care in low-resource settings: building on the literature to design tailor-made evaluation instruments--an illustration in Burkina Faso

Background

There are many instruments available freely for evaluating obstetric care quality in low-resource settings. However, this profusion can be confusing; moreover, evaluation instruments need to be adapted to local issues. In this article, we present tools we developed to guide the choice of instruments and describe how we used them in Burkina Faso to facilitate the participative development of a locally adapted instrument.

Methods

Based on a literature review, we developed two tools: a conceptual framework and an analysis grid of existing evaluation instruments. Subsequently, we facilitated several sessions with evaluation stakeholders in Burkina Faso. They used the tools to develop a locally adapted evaluation instrument that was subsequently tested in six healthcare facilities.

Results

Three outputs emerged from this process:

1) A comprehensive conceptual framework for the quality of obstetric care, each component of which is a potential criterion for evaluation.

2) A grid analyzing 37 instruments for evaluating the quality of obstetric care in low-resource settings. We highlight their key characteristics and describe how the grid can be used to prepare a new evaluation.

3) An evaluation instrument adapted to Burkina Faso. We describe the experience of the Burkinabé stakeholders in developing this instrument using the conceptual framework and the analysis grid, while taking into account local realities.

Conclusions

This experience demonstrates how drawing upon existing instruments can inspire and rationalize the process of developing a new, tailor-made instrument. Two tools that came out of this experience can be useful to other teams: a conceptual framework for the quality of obstetric care and an analysis grid of existing evaluation instruments. These provide an easily accessible synthesis of the literature and are useful in integrating it with the context-specific knowledge of local actors, resulting in evaluation instruments that have both scientific and local legitimacy.

Risk of psychological distress following severe obstetric complications in Benin: the role of economics, physical health and spousal abuse

BACKGROUND

Little is known about the impact of life-threatening obstetric complications ('near miss') on women's mental health in low- and middle-income countries.

AIMS

To examine the relationships between near miss and postpartum psychological distress in the Republic of Benin.

METHOD

One-year prospective cohort using epidemiological and ethnographic techniques in a population of women delivering at health facilities.

RESULTS

In total 694 women contributed to the study. Except when associated with perinatal death, near-miss events were not associated with greater risk of psychological distress in the 12 months postpartum compared with uncomplicated childbirth. Much of the direct effect of near miss with perinatal death on increased risk of psychological distress was shown to be mediated through wider consequences of traumatic childbirth.

CONCLUSIONS

A live baby protects near-miss women from increased vulnerability by giving a positive element in their lives that helps them cope and reduces their risk of psychological distress. Near-miss women with perinatal death should be targeted early postpartum to prevent or treat the development of depressive symptoms.

Identifying practices and ideas to improve the implementation of maternal mortality reduction programmes: findings from five South Asian countries

OBJECTIVE

The successful implementation of programmes to reduce maternal mortality is constrained by a 'know-do' gap: the disparity between what is known and the application of that knowledge in policy and practice. This study identified innovations, practices and ideas aimed to improve project and programme implementation.

DESIGN

Cross-sectional.

SETTING

Five South Asian countries: Afghanistan, Bangladesh, India, Nepal and Pakistan.

SAMPLE

Sixteen projects and programmes, and 100 key informants.

METHODS

In-depth review of documents, key informant interviews and focus-group discussions.

MAIN OUTCOME MEASURES

Innovations and ideas to improve programme implementation, and their perceived effects.

RESULTS

Delegation of duties to intermediate-level health workers, incentivisation of health workers, providing the means to overcome financial barriers for accessing care, quality improvements and knowledge transfer were examples of ideas put into practice to improve programme implementation. There was a perception that these improved service use and availability, but objective evidence was lacking.

CONCLUSIONS

Some innovations, practices and ideas are supported by evidence of effect, and could be replicated, whereas others have not been formally evaluated. Testing of these innovations is required before more widespread adoption can be recommended, although experiences should be shared to narrow the 'know-do' gap, even though the evidence on beneficial effects remains unclear.