Reduction of maternal and perinatal mortality in rural and peri-urban settings: what works?

Scoping review of maternal and newborn health interventions and programmes in Nigeria

OBJECTIVE

To systematically scope and map research regarding interventions, programmes or strategies to improve maternal and newborn health (MNH) in Nigeria.

DESIGN

Scoping review.

DATA SOURCES AND ELIGIBILITY CRITERIA

Systematic searches were conducted from 1 June to 22 July 2020 in PubMed, Embase, Scopus, together with a search of the grey literature. Publications presenting interventions and programmes to improve maternal or newborn health or both in Nigeria were included.

DATA EXTRACTION AND ANALYSIS

The data extracted included source and year of publication, geographical setting, study design, target population(s), type of intervention/programme, reported outcomes and any reported facilitators or barriers. Data analysis involved descriptive numerical summaries and qualitative content analysis. We summarised the evidence using a framework combining WHO recommendations for MNH, the continuum of care and the social determinants of health frameworks to identify gaps where further research and action may be needed.

RESULTS

A total of 80 publications were included in this review. Most interventions (71%) were aligned with WHO recommendations, and half (n=40) targeted the pregnancy and childbirth stages of the continuum of care. Most of the programmes (n=74) examined the intermediate social determinants of maternal health related to health system factors within health facilities, with only a few interventions aimed at structural social determinants. An integrated approach to implementation and funding constraints were among factors reported as facilitators and barriers, respectively.

CONCLUSION

Using an integrated framework, we found most MNH interventions in Nigeria were aligned with the WHO recommendations and focused on the intermediate social determinants of health within health facilities. We determined a paucity of research on interventions targeting the structural social determinants and community-based approaches, and limited attention to pre-pregnancy interventions. To accelerate progress towards the sustainable development goal MNH targets, greater focus on implementing interventions and measuring context-specific challenges beyond the health facility is required.

Making effective referrals happen: a theory-informed policy analysis

Effective referral is a critical element of a well-functioning health system. While having a good referral policy in place is important, equally important is its effective implementation. Using the implementation of a policy on referral of obstetric emergencies in Shanghai as a case, we illustrate the application of the 'Inhabited Institutions' analytical approach for studying policy implementation. In doing so, our study highlights how 'referral' is a quintessential systems process embedded in institutional, social and historical contexts. We show that multiple institutional logics, in the form of explicit and tacit organizing principles and assumptions, intersect to influence and shape actors' actions, sometimes with good outcomes and sometimes with poor outcomes. We reveal the embedded agency of frontline healthcare managers and providers across different levels of care. We show how frontline managers and providers, operating under conditions of uncertainties and ambiguities in organizational processes, actively draw upon their experience and network capital to creatively adapt to get referrals done in a timely manner to save lives of critically ill pregnant women. From our findings, two sets of linked implications emerge for strengthening referral systems. Given that referral often involves ill and complicated cases, getting referrals right depends on the exercise of discretion and judgement by those at the frontline to arrive at timely and workable solutions-health systems need to recognize this. We also conclude that to get referrals right, while one needs clearly defined policies and implementation processes that are locally appropriate, well understood by all concerned and easy to follow, this is not enough. In addition, explicit measures that enable the exercise of discretion and judgement at the frontline need to be locally identified and adopted.

Antenatal Care Practices Among Hard-to-Reach Fishing Communities on Lake Victoria: A Community-Based Cross-Sectional Survey

Background: Uganda has one of the highest maternal deaths in sub-Saharan Africa, with a mortality ratio of 336 per 100 000 live births. Early regular antenatal care (ANC) helps prevent adverse outcomes, including deaths, through prevention, identification, treatment, and/or referral of at-risk women. We explored ANC practices and associated factors among women from hard-to-reach Lake Victoria islands fishing communities in Kalangala district, Uganda. Methods: A cross-sectional survey among 486 consenting women aged 15 to 49 years, who were pregnant or had a birth or abortion in the past 6 months was conducted in 6 island fishing communities of Kalangala district, Uganda, during January to May 2018. ODK software interviewer-administered questionnaires were used to collect data on sociodemographics and ANC practices. Regression modeling using STATA version 15 was used to determine factors associated with ANC visits. Results: Women’s median (range) age was 26 (15-45) years, 63% (304/486) had up to primary level education, 45% (219/486) were housewives (stay home mums), 87% (423/486) were married. ANC visits ranged from 0 to 10, with over three-fifths of women having their first visit late after 3 months of being pregnant (63%, 198/316). Women without a history of pregnancy loss (adjusted odds ratio [AOR] = 1.8, 95% CI 1.1-3.0), those not staying with their partners (AOR = 2.5, 95% CI 1.1-6.0), and those whose partners were working in fishing-related activities (AOR = 1.8, 95% CI 1.0-3.0) were likely to have started care late. Women from communities with a public health facility and those with partners working in none fishing-related activities had the highest predicted number of visits. Conclusion: Antenatal practices among these communities are characterized by late start of care. Community-led early ANC awareness interventions are needed. Targeted health policies need to consider public ANC facilities for each island for improved antenatal outcomes and maternal health.

The effect of the community midwifery model on maternal and newborn health service utilization and outcomes in Busia County of Kenya: a quasi-experimental study

BACKGROUND

Poor women in hard-to-reach areas are least likely to receive healthcare and thus carry the burden of maternal and perinatal mortality from complications of childbirth. This study evaluated the effect of an enhanced community midwifery model on skilled attendance during pregnancy/childbirth as well as on maternal and perinatal outcomes against the backdrop of protracted healthcare workers' strikes in rural Kenya.

METHODS

The study used a quasi-experimental (one-group pretest-posttest) design. The study spanned three time periods: December 2016-February 2017 when doctors were on strike (P1), March-May 2017 when no healthcare providers were on strike (P2), and June-October 2017 when nurses/midwives were on strike (P3), which was also the period when the project enhanced the capacity of community midwives (CMs) to provide services at the community level. Analysis entailed comparison of frequencies/means of maternal and newborn health service utilization data across the three periods.

RESULTS

The monthly average number of clients obtaining services from CMs across the three time periods was: first antenatal care (ANC) (P1-1.8, P2-2.3, P3-9.9), fourth ANC (P1-1.4, P2-1.0, P3-7.1), skilled birth (P1-1.5, P2-1.7, P3-13.1) and the differences in means were statistically significant (p < 0.05). Over the period, the monthly average number of clients obtaining services from health facilities was: first ANC (P1-55.7, P2-70.8, P3-4.0), fourth ANC (P1-29.6, P2-38.1, P3-1.2) and skilled birth (P1-63.1, P2-87.4, P3-5.6), p < 0.05. There were no statistically significant differences in the average number of clients obtaining services from CMs or health facilities between P1 and P2 (p > 0.05). There was, however, a statistically significant increase in the average number of clients obtaining services from CMs in P3 accompanied by a statistically significant decline in the average number of clients obtaining services from health facilities (p < 0.05). First ANC increased by 68%, fourth ANC by 75%, skilled births by 68%, and postnatal care by 33% in P3 (p < 0.0001). There was a non-significant decline in macerated stillbirths and neonatal deaths in P3.

CONCLUSIONS

The findings underscore the importance of integrating community-level health service providers (CMs and health volunteers) into the primary health care system to complement service delivery according to their level of expertise, especially in low-resource settings.

Healthcare providers' perception of the referral system in maternal care facilities in Aceh, Indonesia: a cross-sectional study

OBJECTIVES

Our study investigates the barriers perceived by staff in the referral systems in maternal healthcare facilities across Aceh province in Indonesia.

DESIGN

With a cross-sectional approach, two sets of surveys were administered during September to October 2016 in 32 sampling units of our study. We also collected referral data in the form of the frequency of ingoing and outgoing referral cases per facility.

SETTING

In three districts, Aceh Besar, Banda Aceh and Bireuen, a total of 32 facilities including hospitals, community health centres, and private midwife clinics that met the criteria of providing at least basic emergency obstetric and neonatal care (BEonC) were covered.

PARTICIPANTS

Across the 32 healthcare centres, 149 members of staff (mainly midwives) agreed to participate in our surveys.

PRIMARY AND SECONDARY OUTCOME MEASURES

The first survey consisted of 65 items focusing on organisational measures as well as case numbers for example, patient counts, mortality rate and complications. The second survey with 68 items asked healthcare providers about a range of factors including attitudes towards the referral process in their facility and potential barriers to a well-functioning system in their district.

RESULTS

Overall, mothers'/families' consent as well as the complex administration process were found to be the main barriers (36% and 12%, respectively). Healthcare providers noted that information about other facilities has the biggest room for improvement (37%) rather than transport, timely referral of mothers and babies, or the availability of referral facilities.

CONCLUSIONS

The largest barrier perceived by healthcare providers in our study was noted to be family consent and administrative burden. Moreover, lack of information about the referral system itself and other facilities seemed to be affecting healthcare providers and mothers/families alike and improvements perhaps through a shared information system is needed.

Perinatal and newborn care in a two years retrospective study in a first level peripheral hospital in Sicily (Italy)

BACKGROUND

Two hundred seventy-five thousand maternal deaths, 2.7 million neonatal deaths, and 2.6 million stillbirths have been estimated in 2015 worldwide, almost all in low-income countries (LICs). Moreover, more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. A significant decrease of mortality/morbidity rates could be achieved by providing effective perinatal and newborn care also in high-income countries (HICs), especially in peripheral hospitals and/or rural areas, where the number of childbirths per year is often under the minimal threshold recognized by the reference legislation. We report on a 2 years retrospective cohort study, conducted in a first level peripheral hospital in Cefalù, a small city in Sicily (Italy), to evaluate care provided and mortality/morbidity rates. The proposed goal is to improve the quality of care, and the services that peripheral centers can offer.

METHODS

We collected data from maternity and neonatal records, over a 2-year period from January 2017 to December 2018. The informations analyzed were related to demographic features (age, ethnicity/origin area, residence, educational level, marital status), diagnosis at admission (attendance of birth training courses, parity, type of pregnancy, gestational age, fetal presentation), mode of delivery, obstetric complications, the weight of the newborns, their feeding and eventual transfer to II level hospitals, also through the Neonatal Emergency Transport Service, if the established criteria were present.

RESULTS

Eight hundred sixteen women were included (age 18-48 years). 179 (22%) attended birth training courses. 763 (93%) were Italian, 53 foreign (7%). 175 (21%) came from outside the province of Palermo. Eight hundred ten were single pregnancies, 6 bigeminal; 783 were at term (96%), 33 preterm (4%, GA 30-41 WG); 434 vaginal deliveries (53%), 382 caesarean sections (47%). One maternal death and 28 (3%) obstetric complications occurred during the study period. The total number of children born to these women was 822, 3 of which stillbirths (3.6‰). 787 (96%) were born at term (>37WG), 35 preterm (4%), 31 of which late preterm. Twenty-one newborns (2.5%) were transferred to II level hospitals. Among them, 3 for moderate/severe prematurity, 18 for mild prematurity/other pathology. The outcome was favorable for all women (except 1 hysterectomy) and the newborns transferred, and no neonatal deaths occurred in the biennium under investigation. Of the remaining 798 newborns, 440 were breastfed at discharge (55%), 337 had a mixed feeding (breastfed/formula fed, 42%) and 21 were formula fed (3%).

CONCLUSIONS

Although the minimal standard of adequate perinatal care in Italy is >500 childbirths/year, the aims of the Italian legislation concern the rationalization of birth centers as well as the structural, technological and organizational improvement of health facilities. Therefore, specific contexts and critical areas need to be identified and managed. Adequate resources and intervention strategies should be addressed not only to perinatal emergencies, but also to the management of mild prematurity/pathology, especially in vulnerable populations for social or orographic reasons. The increasing availability and spread of health care offers, even in HICs, cannot be separated from the goal of quality of care, which is an ethic and public health imperative.

The significant association between maternity waiting homes utilization and perinatal mortality in Africa: systematic review and meta-analysis

OBJECTIVE

A proper uptake of maternity waiting homes (MWHs) is important to improve maternal and child health (MCH). The aim of this review is to generate the best existing evidences concerning the MWHs utilization and its impact on perinatal mortality (PNM) among pregnant mothers in Africa. Both relevant quantitative and qualitative studies, investigated and reported from databases were explored. Meta-analysis of the studies was displayed by tables and forest plots. The Stata version 14 was used with the fixed effect model and 95% confidence interval.

RESULTS

In this review, a total of 68,805 births were recorded in this review. About 1.6% and 7.2% PNM occurred among non-exposed and exposed mothers respectively. Fifty percent of the studies showed there is a significant association between MWHs use and PNM. Meta-analysis revealed that utilizing MWHs have a significant effect in a reducing PNM by 82.5% (80.4%-84.5%), I2 = 96.5%. Therefore, use of MWHs has a potential to reduce PNM among pregnant mothers. The review revealed that MWHs relevance to achieving sustainable development goals (SDGs) concerning reducing newborn mortality. Therefore, the utilization rate of MWHs must be enhanced to achieve SDGs.

Who do the women trust for maternity care: A knowledge network-based study in rural India

BACKGROUND

Knowledge about the causes of critical ailments and risks during a maternity episode is crucial for women's health. Although maternity-care knowledge is present both in explicit and tacit forms, there is a lack of requisite knowledge among women. Rural women rely on their community for such knowledge.

OBJECTIVE

This article sought to analyse knowledge-sharing practices of rural women in India in relation to critical decisions during a maternity episode.

METHOD

Primary data were gathered through interview of 306 married women, who had had at least one childbirth during the previous 5 years, and were collected using structured interviews conducted in 10 villages of two districts in West Bengal, India. Their knowledge level of risks and networks of communication was examined for four critical decisions: (i) general health, (ii) choice of delivery method, (iii) antenatal check-up visits and (iv) nutrition.

RESULTS

This empirical study using degree-centrality method demonstrated that the pattern of knowledge flow is not uniform for different types of decisions. Many women were not aware of critical danger signs during pregnancy episodes. Only 28% of participants could mention at least three danger signs during pregnancy episodes. For the purposes of this study, these women were considered "knowledgeable."

DISCUSSION

Maternal health in the community could be improved by redesigning the knowledge network for sharing the maternity-care knowledge of risks and danger signs. This research highlights the influence of culture on maternity-related knowledge-sharing in rural India and uncovers structural holes in the knowledge network.

IMPLICATIONS

Results of this research could be used to design policies and programs to create community-based knowledge networks for maternity care.

Illness recognition, decision-making, and care-seeking for maternal and newborn complications: a qualitative study in Sarlahi District, Nepal

BACKGROUND

Identification of maternal and newborn illness and the decision-making and subsequent care-seeking patterns are poorly understood in Nepal. We aimed to characterize the process and factors influencing recognition of complications, the decision-making process, and care-seeking behavior among families and communities who experienced a maternal complication, death, neonatal illness, or death in a rural setting of Nepal.

METHODS

Thirty-two event narratives (six maternal/newborn deaths each and 10 maternal/newborn illnesses each) were collected using in-depth interviews and small group interviews. We purposively sampled across specific illness and complication definitions, using data collected prospectively from a cohort of women and newborns followed from pregnancy through the first 28 days postpartum. The event narratives were coded and analyzed for common themes corresponding to three main domains of illness recognition, decision-making, and care-seeking; detailed event timelines were created for each.

RESULTS

While signs were typically recognized early, delays in perceiving the severity of illness compromised prompt care-seeking in both maternal and newborn cases. Further, care was often sought initially from informal health providers such as traditional birth attendants, traditional healers, and village doctors. Key decision-makers were usually female family members; husbands played limited roles in decisions related to care-seeking, with broader family involvement in decision-making for newborns. Barriers to seeking care at any type of health facility included transport problems, lack of money, night-time illness events, low perceived severity, and distance to facility. Facility care was often sought only after referral or following treatment failure from an informal provider and private facilities were sought for newborn care. Respondents characterized government facility-based care as low quality and reported staff rudeness and drug type and/or supply stock shortages.

CONCLUSION

Delaying the decision to seek skilled care was common in both newborn and maternal cases. Among maternal cases, delays in receiving appropriate care when at a facility were also seen. Improved recognition of danger signs and increased demand for skilled care, motivated through community level interventions and health worker mobilization, needs to be encouraged. Engaging informal providers through training in improved danger sign identification and prompt referral, especially for newborn illnesses, is recommended.

Experiences of 6 years quality assurance in obstetrics in Nigeria - a critical review of results and obstacles

OBJECTIVE

The objective of this study was to monitor the maternal mortality ratio (MMR) in 19 general hospitals after introducing quality assurance in four states in Nigeria.

METHODS

Data collection with a structured maternity record book started in 2008 in ten rural hospitals in Kano and Kaduna State. In 2011, five hospitals from Federal Capital Territory Abuja were added, whilst in 2013 four hospitals were added from Ondo State. The routine data collection was conducted by experienced midwives and supervised by obstetricians from each of the states. However, the data from all four states were collated centrally at Aminu Kano Teaching Hospital for analysis.

RESULTS

From 2008 to 2013, 121,808 deliveries were evaluated; MMR fell from 1380 to 360/100,000 in Kaduna State, whilst for Kano State there was a gradual reduction of MMR from 2100/100,000 in 2008 to 1070/100,000 in 2011, and then it increased to 2150/100,000 in 2013. Ondo state had the lowest MMR of 180/100,000 in 2013 followed by Abuja with 240/100,000. The median cesarean section rate was 8.19%, (range 0.97-22.53%), eclampsia/preeclampsia was 4.43% (range 0-56.55%), and postpartum hemorrhage was 3.36% (range 0.81-11.4%).

CONCLUSIONS

Quality assurance in rural hospitals generates the awareness necessary to improve maternal health and lead to reduction of MMR.

Primary health care research in Bolivia: systematic review and analysis

Bolivia is currently undergoing a series of healthcare reforms centred around the Unified Family, Community and Intercultural Health System (SAFCI), established in 2008 and Law 475 for Provision of Comprehensive Health Services enacted in 2014 as a first step towards universal health coverage. The SAFCI model aims to establish an intercultural, intersectoral and integrated primary health care (PHC) system, but there has not been a comprehensive analysis of effective strategies towards such an end. In this systematic review, we analyse research into developing PHC in Bolivia utilizing MEDLINE, the Virtual Health Library and grey literature from Pan American Health Organization/World Health Organization's internal database. We find that although progress has been made towards implementation of a healthcare system incorporating principles of PHC, further refining the system and targeting improvements effectively will require increased research and evaluation. Particularly in the 7 years since establishment of SAFCI, there has been a dearth of PHC research that makes evaluation of such key national policies impossible. The quantity and quality of PHC research must be improved, especially quasi-experimental studies with adequate control groups. The infrastructure for such studies must be strengthened through improved financing mechanisms, expanded institutional capacity and setting national research priorities. Important for future progress are improved tracking of health indicators, which in Bolivia are often out-of-date or incomplete, and prioritization of focused national research priorities on relevant policy issues. This study aims to serve as an aid towards PHC development efforts at the national level, as well as provide lessons for countries globally attempting to build effective health systems accommodating of a multi-national population in the midst of development.

Maternal and child health interventions in Nigeria: a systematic review of published studies from 1990 to 2014

BACKGROUND

Poor maternal and child health indicators have been reported in Nigeria since the 1990s. Many interventions have been instituted to reverse the trend and ensure that Nigeria is on track to achieve the Millennium Development Goals. This systematic review aims at describing and indirectly measuring the effect of the Maternal, Newborn, and Child Health (MNCH) interventions implemented in Nigeria from 1990 to 2014.

METHODS

PubMed and ISI Web of Knowledge were searched from 1990 to April 2014 whereas POPLINE® was searched until 16 February 2015 to identify reports of interventions targeting Maternal, Newborn, and Child Health in Nigeria. Narrative and graphical synthesis was done by integrating the results of extracted studies with trends of maternal mortality ratio (MMR) and under five mortality (U5MR) derived from a joint point regression analysis using Nigeria Demographic and Health Survey data (1990-2013). This was supplemented by document analysis of policies, guidelines and strategies of the Federal Ministry of Health developed for Nigeria during the same period.

RESULTS

We identified 66 eligible studies from 2,662 studies. Three interventions were deployed nationwide and the remainder at the regional level. Multiple study designs were employed in the enrolled studies: pre- and post-intervention or quasi-experimental (n = 40; 61%); clinical trials (n = 6;9%); cohort study or longitudinal evaluation (n = 3;5%); process/output/outcome evaluation (n = 17;26%). The national MMR shows a consistent reduction (Annual Percentage Change (APC) = -3.10%, 95% CI: -5.20 to -1.00 %) with marked decrease in the slope observed in the period with a cluster of published studies (2004-2014). Fifteen intervention studies specifically targeting under-five children were published during the 24 years of observation. A statistically insignificant downward trend in the U5MR was observed (APC = -1.25%, 95% CI: -4.70 to 2.40%) coinciding with publication of most of the studies and development of MNCH policies.

CONCLUSIONS

The development of MNCH policies, implementation and publication of interventions corresponds with the downward trend of maternal and child mortality in Nigeria. This systematic review has also shown that more MNCH intervention research and publications of findings is required to generate local and relevant evidence.

A scoping review of training and deployment policies for human resources for health for maternal, newborn, and child health in rural Africa

BACKGROUND

Most African countries are facing a human resources for health (HRH) crisis, lacking the required workforce to deliver basic health care, including care for mothers and children. This is especially acute in rural areas and has limited countries' abilities to meet maternal, newborn, and child health (MNCH) targets outlined by Millennium Development Goals 4 and 5. To address the HRH challenges, evidence-based deployment and training policies are required. However, the resources available to country-level policy makers to create such policies are limited. To inform future HRH planning, a scoping review was conducted to identify the type, extent, and quality of evidence that exists on HRH policies for rural MNCH in Africa.

METHODS

Fourteen electronic health and health education databases were searched for peer-reviewed papers specific to training and deployment policies for doctors, nurses, and midwives for rural MNCH in African countries with English, Portuguese, or French as official languages. Non-peer reviewed literature and policy documents were also identified through systematic searches of selected international organizations and government websites. Documents were included based on pre-determined criteria.

RESULTS

There was an overall paucity of information on training and deployment policies for HRH for MNCH in rural Africa; 37 articles met the inclusion criteria. Of these, the majority of primary research studies employed a variety of qualitative and quantitative methods. Doctors, nurses, and midwives were equally represented in the selected policy literature. Policies focusing exclusively on training or deployment were limited; most documents focused on both training and deployment or were broader with embedded implications for the management of HRH or MNCH. Relevant government websites varied in functionality and in the availability of policy documents.

CONCLUSIONS

The lack of available documentation and an apparent bias towards HRH research in developed areas suggest a need for strengthened capacity for HRH policy research in Africa. This will result in enhanced potential for evidence uptake into policy. Enhanced alignment between policy-makers' information needs and the independent research agenda could further assist knowledge development and uptake. The results of this scoping review informed an in-depth analysis of relevant policies in a sub-set of African countries.

Newborn care in Indonesia, Lao People's Democratic Republic and the Philippines: a comprehensive needs assessment

Background

Between 1990 and 2011, global neonatal mortality decline was slower than that of under-five mortality. As a result, the proportion of under-five deaths due to neonatal mortality increased. This increase is primarily a consequence of decreasing post-neonatal and child under-five mortality as a result of the typical focus of child survival programmes of the past two decades on diseases affecting children over four weeks of age. Newborns are lagging behind in improved child health outcomes. The aim of this study was to conduct a comprehensive, equity-focussed newborn care assessment and to explore options to improve newborn survival in Indonesia, Lao People’s Democratic Republic (PDR) and the Philippines.

Methods

We assessed newborn health policies, services and care in the three countries through document review, interviews and health facility visits. Findings were triangulated to describe newborns’ health status, the health policy and the health system context for newborn care and the equity situation regarding newborn survival.

Results

Main findings: (1) In the three countries, decline of neonatal mortality is lagging behind compared to that of under-five mortality. (2) Comprehensive newborn policies in line with international standards exist, although implementation remains poor. An important factor hampering implementation is decentralisation of the health sector, which created confusion regarding roles and responsibilities. Management capacity and skills at decentralised level were often found to be limited. (3) Quality of newborn care provided at primary healthcare and referral level is generally substandard. Limited knowledge and skills among providers of newborn care are contributing to poor quality of care. (4) Socio-economic and geographic inequities in newborn care are considerable.

Conclusions

Similar important challenges for newborn care have been identified in Indonesia, Lao PDR and the Philippines. There is an urgent need to address weak leadership and governance regarding newborn care, quality of newborn care provided and inequities in newborn care. Child survival programmes focussed on children over four weeks of age have shown to have positive outcomes. Similar efforts as those used in these programmes should be considered in newborn care.

Head of household education level as a factor influencing whether delivery takes place in the presence of a skilled birth attendant in Busia, Uganda: a cross-sectional household study

Background

Assistance during delivery by a skilled attendant is recommended as a means to reduce child and maternal mortality. Globally, higher levels of maternal education have been associated with better health behaviours at delivery. However, given that heads of households tend to be the decision makers regarding accessing healthcare, some educated mothers may find themselves prevented from accessing healthcare at the point of delivery.

Methods

We examined the association between head of household education level and health seeking behaviours at delivery across a sample of 392 households. Chi-squared analysis and odds ratios were calculated to measure the strength of the relationship between no, some primary, or some secondary or higher education attained by the head of household and the presence or absence of a skilled birth attendant at that child’s birth, and whether the birth took place at a health facility.

Results

Heads of household (n = 392) were predominantly male (93.4% [(90.9%, 95.8%), a = 0.05]). We found a significant difference in skilled birth attendance between heads of households with some primary education and heads of household with some secondary education or higher (χ² (1) = 6.231, p <0.05) whereby those with secondary or higher education were significantly more likely to seek a skilled birth attendant (OR = 1.5,[1.1,2.1]). The difference in health centre delivery between heads of household with a primary education and heads of household with a secondary or higher education was also significant (χ² (1) = 7.519, p <0.05). Those with secondary or higher education were significantly more likely to deliver in a health facility (OR = 1.6,[1.2,2.1]).

Conclusions

The results of our analysis, which identified the vast majority of heads of households as men, suggests that education, or rather limited or a lack of education for the head of household, may be a barrier to women’s use of health care in Uganda and therefore reinforces the need to increase educational access among male heads of households. Improving the rates of health centre deliveries and utilization of services provided by skilled health workers might lie, in part, in increasing overall education levels of heads of households, specifically the education of male heads of households.

Barriers to neonatal care in developing countries: parents' and providers' perceptions

AIM

Hospital care and advanced medical technologies for sick neonates are increasingly available, but not always readily accessible, in many countries. We characterised parents' and providers' perceptions of barriers to neonatal care in developing countries.

METHODS

We interviewed parents whose infant was hospitalised within the first month of life in Cambodia, Malaysia, Laos and Vietnam, asking about perceived barriers to obtaining newborn care. We also surveyed health-care providers about perceived barriers to providing care.

RESULTS

We interviewed 198 parents and 212 newborn care providers (physicians, nurses, midwives, paediatric and nursing trainees). Most families paid all costs of newborn care, which they reported as a hardship. Although newborn care is accessible, 39% reported that hospitals are too distant; almost 20% did not know where to obtain care. Parents cited lack of cleanliness (46%), poor availability of medications (42%) or services (36%), staff friendliness (42%), poor infant outcome (45%), poor communications with staff (44%) and costs of care (34%) as significant problems during prior newborn care. Providers cited lack of equipment (74%), lack of staff training (61%) and poor infrastructure (51%) as barriers to providing neonatal care. Providers identified distance to hospital, lack of transportation, care costs and low parental education as barriers for families.

CONCLUSIONS

Improving cleanliness, staff friendliness and communication with parents may diminish some barriers to neonatal care in developing countries. Costs of newborn care, hospital infrastructure, distance to hospital, staffing shortages, limited staff training and limited access to medications pose more difficult barriers to remedy.

Patient-Held Maternal and/or Child Health Records: Meeting the Information Needs of Patients and Healthcare Providers in Developing Countries?

Though improvements in infant and maternal mortality rates have occurred over time, women and children still die every hour from preventable causes. Various regional, social and economic factors are involved in the ability of women and children to receive adequate care and prevention services. Patient-held maternal and/or child health records have been used for a number of years in many countries to help track health risks, vaccinations and other preventative health measures performed. Though these records are primarily designed to record patient histories and healthcare information and guide healthcare workers providing care, because the records are patient-held, they also allow families a greater ability to track their own health and prevention strategies. A LITERATURE SEARCH WAS PERFORMED TO ANSWER THESE QUESTIONS: (1) What are maternal information needs regarding pregnancy, post-natal and infant healthcare, especially in developing countries? (2) What is known about maternal information seeking behavior in developing countries? (3) What is the history and current state of maternal and/or child patient-held healthcare records, do they provide for the information needs of the healthcare provider and what are the effects and outcomes of patient-held records in general and for maternal and/or child health in particular? Specific information needs of pregnant women and mothers are rarely studied. The small numbers of maternal information behavior results available indicate that mothers, in general, prefer to receive health information directly from their healthcare provider as opposed to from other sources (written, etc.) Overall, in developing countries, patient-held maternal and/or child healthcare records have a mostly positive effect for both patient and care provider. Mothers and children with records tend to have better outcomes in healthcare and preventative measures. Further research into the information behaviors of pregnant women and mothers to determine the extent of reliance on interpersonal information seeking is recommended before expending significant resources on enhanced patient-held maternal and/or child healthcare records including storage on mobile devices. In particular, research is needed to explore the utility of providing targeted health messages to mothers regarding their own health and that of their children; this might best be accomplished through mobile technologies.

Implementing knowledge into practice for improved neonatal survival; a cluster-randomised, community-based trial in Quang Ninh province, Vietnam

BACKGROUND

Globally, almost 4 million newborns die during the first 4 weeks of life every year. By increased use of evidence-based knowledge in the healthcare system a large proportion of these neonatal deaths could be prevented. But there is a severe lack of knowledge on effective methods for successful implementation of evidence into practice, particularly in low- and middle-income countries. Recent studies have demonstrated promising results with increased survival among both mothers and newborns using community-based approaches. In Vietnam evidence-based guidelines on reproductive health were launched in 2003 and revised in 2009. The overall objective of the current project is to evaluate if a facilitation intervention on the community level, with a problem-solving approach involving local representatives if the healthcare system and the community, results in improvements of neonatal health and survival.

METHODS/DESIGN

The study, which has been given the acronym NeoKIP (Neonatal Health - Knowledge Into Practice), took place in 8 districts composed by 90 communes in a province in northern Vietnam, where neonatal mortality rate was 24/1000 in 2005. A cluster randomised design was used, allocating clusters, as defined as a commune and its correponding Commune Health Center (CHC) to either intervention or control arm. The facilitation intervention targeted staff at healthcare centres and key persons in the communes. The facilitator role was performed by lay women (Women's Union representatives) using quality improvement techniques to initiate and sustain improvement processes targeting identified problem areas. The intervention has been running over 3 years and data were collected on the facilitation process, healthcare staff knowledge in neonatal care and their behaviour in clinical practice, and reproductive and perinatal health indicators. Primary outcome is neonatal mortality.

DISCUSSION

The intervention is participatory and dynamic, focused on developing a learning process and a problem-solving cycle. The study recognises the vital role of the local community as actors in improving their own and their newborns' health, and applies a bottom-up approach where change will be accomplished by an increasing awareness at and demand from grass root level. By utilising the existing healthcare structure this intervention may, if proven successful, be well suited for scaling up.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN44599712.

Organizações Não Governamentais na área da Saúde da Criança - revisão da literatura

A segunda metade do século vinte assistiu ao crescimento de entidades que refletiam a mobilização da sociedade civil para uma participação mais efetiva nas questões de interesse público e de cunho social. Desta forma surgiram as organizações não governamentais (ONG) que ganharam espaço como parceiros dos setores públicos e privados para a atuação em diferentes áreas, entre elas a saúde. Baseado em uma revisão da literatura, este trabalho teve como objetivo conhecer o status do conhecimento científico sobre a participação das ONG na saúde da criança e a partir da identificação e classificação de suas atividades, observar se esta atuação tem se compatibilizado com a agenda desse campo. A análise das publicações considerou a procedência dos autores, o periódico, os objetivos, a origem e o local de atuação das ONG e a procedência dos recursos aplicados nos projetos desenvolvidos. A natureza das atividades variou de acordo com o grau de desenvolvimento da região onde as ONG atuavam e os temas, parceria entre órgãos de governo e terceiro setor, sustentabilidade e impacto das ações nas comunidades beneficiárias foram os principais tópicos destacados pelos autores. Concluiu-se que as questões estão apenas se esboçando e que o impacto das intervenções das ONG na área da saúde da criança é um campo de conhecimento a ser explorado.

Maternal health interventions in resource limited countries: a systematic review of packages, impacts and factors for change

Background

The burden of maternal mortality in resource limited countries is still huge despite being at the top of the global public health agenda for over the last 20 years. We systematically reviewed the impacts of interventions on maternal health and factors for change in these countries.

Methods

A systematic review was carried out using the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles published in the English language reporting on implementation of interventions, their impacts and underlying factors for maternal health in resource limited countries in the past 23 years were searched from PubMed, Popline, African Index Medicus, internet sources including reproductive health gateway and Google, hand-searching, reference lists and grey literature.

Results

Out of a total of 5084 articles resulting from the search only 58 qualified for systematic review. Programs integrating multiple interventions were more likely to have significant positive impacts on maternal outcomes. Training in emergency obstetric care (EmOC), placement of care providers, refurbishment of existing health facility infrastructure and improved supply of drugs, consumables and equipment for obstetric care were the most frequent interventions integrated in 52% - 65% of all 54 reviewed programs. Statistically significant reduction of maternal mortality ratio and case fatality rate were reported in 55% and 40% of the programs respectively. Births in EmOC facilities and caesarean section rates increased significantly in 71% - 75% of programs using these indicators. Insufficient implementation of evidence-based interventions in resources limited countries was closely linked to a lack of national resources, leadership skills and end-users factors.

Conclusions

This article presents a list of evidenced-based packages of interventions for maternal health, their impacts and factors for change in resource limited countries. It indicates that no single magic bullet intervention exists for reduction of maternal mortality and that all interventional programs should be integrated in order to bring significant changes. State leaders and key actors in the health sectors in these countries and the international community are proposed to translate the lessons learnt into actions and intensify efforts in order to achieve the goals set for maternal health.

The effect of providing skilled birth attendance and emergency obstetric care in preventing stillbirths

Background

Of the global burden of 2.6 million stillbirths, around 1.2 million occur during labour i.e. are intrapartum deaths. In low-/middle-income countries, a significant proportion of women give birth at home, usually in the absence of a skilled birth attendant. This review discusses the impact of skilled birth attendance (SBA) and the provision of Emergency Obstetric Care (EOC) on stillbirths and perinatal mortality.

Methods

A systematic literature search was performed on PubMed/MEDLINE, Cochrane Database and the WHO regional libraries. Data of all eligible studies were extracted into a standardized Excel sheet containing variables such as participants’ characteristics, sample size, location, setting, blinding, allocation concealment, intervention and control details and limitations. We undertook a meta-analysis of the impact of SBA on stillbirths. Given the paucity of data from randomized trials or robust quasi-experimental designs, we undertook an expert Delphi consultation to determine impact estimates of provision of Basic and Comprehensive EOC on reducing stillbirths if there would be universal coverage (99%).

Results

The literature search yielded 871 hits. A total of 21 studies were selected for data abstraction. Our meta-analysis on community-based skilled birth attendance based on two before-after studies showed a 23% significant reduction in stillbirths (RR = 0.77; 95% CI: 0.69 – 0.85). The overall quality grade of available evidence for this intervention on stillbirths was ‘moderate’. The Delphi process supported the estimated reduction in stillbirths by skilled attendance and experts further suggested that the provision of Basic EOC had the potential to avert intrapartum stillbirths by 45% and with provision of Comprehensive EOC this could be reduced by 75%. These estimates are conservative, consistent with historical trends in maternal and perinatal mortality from both developed and developing countries, and are recommended for inclusion in the Lives Saved Tool (LiST) model.

Conclusions

Both Skilled Birth Attendance and Emergency/or Essential Obstetric Care have the potential to reduce the number of stillbirths seen globally. Further evidence is needed to be able to calculate an effect size.

Determinants of utilisation of maternal care services after the reduction of user fees: a case study from rural Burkina Faso

OBJECTIVE

To identify determinants of utilisation for antenatal care (ANC) and skilled attendance at birth after a substantial reduction in user fees.

METHODS

The study was conducted in the Nouna Health District in north-western Burkina Faso in early 2009. Data was collected by means of a representative survey on a sample of 435 women who reported a pregnancy in the prior 12 months. Two independent logit models were used to assess the determinants of (a) ANC utilisation (defined as having attended at least 3 visits) and (b) skilled assistance at birth (defined as having delivered in a health facility).

RESULTS

76% of women had attended at least 3 ANC visits and 72% had delivered in a facility. Living within 5 km from a facility was positively associated, while animist religion, some ethnicities, and household wealth were negatively associated with ANC utilisation. Some ethnicities, living within 5 km from a health facility, and having attended at least 3 ANC visits were positively associated with delivering in a facility.

CONCLUSIONS

User fee alleviation secured equitable access to care across socio-economic groups, but alone did not ensure that all women benefited from ANC and from skilled attendance at birth. Investments in policies to address barriers beyond financial ones are urgently needed.

Intrauterine rectovaginal tear during a manual attempt to rotate a neonate

Intrauterine rectovaginal tears in neonates are a rare and life-threatening complication of abnormal presentation during labor. Two previous cases have been presented in the literature, of which one had a fatal outcome. The authors present a third case of a severe rectovaginal intrauterine tear that had a favorable outcome.

Referral of high-risk pregnant mothers by trained traditional birth attendants in Buikwe County, Mukono District, Uganda

Traditional birth attendants (TBAs) represent an important component of the healthcare system in resource-limited settings, and are present at 50% of deliveries in developing countries. While several studies have been carried out on the effectiveness of TBAs in reducing maternal morbidity and mortality, very little attention has been given to the needs assessment of TBAs within the environment they practice. We conducted a cross-sectional study among trained TBAs (TTBAs) in the Mukono District of Uganda with needs assessment as one of the aims of the survey. A total of 48 TTBAs within the age range of 19-80 years were interviewed. Knowledge of the TTBAs regarding obstetric cases requiring referral and years of experience gathered were satisfactory. Among the 38 referred mothers, one maternal and fetal death intra-partum were recorded, yielding a case fatality rate of 2.6%. The single most important need of TTBAs was transportation. On average, the distance between the residence and the workplace of a TTBA was 7 km, and lack of transportation hampered the actual transfer of cases to a higher level of care. To remedy this, we recommend the introduction of a practical, cheap and sustainable single-ambulance-multiple-cellular phone system to facilitate prompt referral of complicated obstetric cases within the entire Health District.

Delivering interventions to reduce the global burden of stillbirths: improving service supply and community demand

BACKGROUND

Although a number of antenatal and intrapartum interventions have shown some evidence of impact on stillbirth incidence, much confusion surrounds ideal strategies for delivering these interventions within health systems, particularly in low-/middle-income countries where 98% of the world's stillbirths occur. Improving the uptake of quality antenatal and intrapartum care is critical for evidence-based interventions to generate an impact at the population level. This concluding paper of a series of papers reviewing the evidence for stillbirth interventions examines the evidence for community and health systems approaches to improve uptake and quality of antenatal and intrapartum care, and synthesises programme and policy recommendations for how best to deliver evidence-based interventions at community and facility levels, across the continuum of care, to reduce stillbirths.

METHODS

We systematically searched PubMed and the Cochrane Library for abstracts pertaining to community-based and health-systems strategies to increase uptake and quality of antenatal and intrapartum care services. We also sought abstracts which reported impact on stillbirths or perinatal mortality. Searches used multiple combinations of broad and specific search terms and prioritised rigorous randomised controlled trials and meta-analyses where available. Wherever eligible randomised controlled trials were identified after a Cochrane review had been published, we conducted new meta-analyses based on the original Cochrane criteria.

RESULTS

In low-resource settings, cost, distance and the time needed to access care are major barriers for effective uptake of antenatal and particularly intrapartum services. A number of innovative strategies to surmount cost, distance, and time barriers to accessing care were identified and evaluated; of these, community financial incentives, loan/insurance schemes, and maternity waiting homes seem promising, but few studies have reported or evaluated the impact of the wide-scale implementation of these strategies on stillbirth rates. Strategies to improve quality of care by upgrading the skills of community cadres have shown demonstrable impact on perinatal mortality, particularly in conjunction with health systems strengthening and facilitation of referrals. Neonatal resuscitation training for physicians and other health workers shows potential to prevent many neonatal deaths currently misclassified as stillbirths. Perinatal audit systems, which aim to improve quality of care by identifying deficiencies in care, are a quality improvement measure that shows some evidence of benefit for changes in clinical practice that prevent stillbirths, and are strongly recommended wherever practical, whether as hospital case review or as confidential enquiry at district or national level.

CONCLUSION

Delivering interventions to reduce the global burden of stillbirths requires action at all levels of the health system. Packages of interventions should be tailored to local conditions, including local levels and causes of stillbirth, accessibility of care and health system resources and provider skill. Antenatal care can potentially serve as a platform to deliver interventions to improve maternal nutrition, promote behaviour change to reduce harmful exposures and risk of infections, screen for and treat risk factors, and encourage skilled attendance at birth. Following the example of high-income countries, improving intrapartum monitoring for fetal distress and access to Caesarean section in low-/middle-income countries appears to be key to reducing intrapartum stillbirth. In remote or low-resource settings, families and communities can be galvanised to demand and seek quality care through financial incentives and health promotion efforts of local cadres of health workers, though these interventions often require simultaneous health systems strengthening. Perinatal audit can aid in the development of better standards of care, improving quality in health systems. Effective strategies to prevent stillbirth are known; gaps remain in the data, the evidence and perhaps most significantly, the political will to implement these strategies at scale.

Remaking the Guatemalan midwife: health care reform and midwifery training programs in Highland Guatemala

Midwifery practice and identity in Guatemala is constantly being transformed because midwives must negotiate their practices in response to changing international and national health care agendas and processes. Recently, the Guatemalan government implemented the Sistema Integral de Atención en Salud (SIAS). Framed by neoliberal processes and global reproductive health paradigms, SIAS is designed to attain the reproductive health goals outlined in the 1996 Peace Accords by reducing maternal and infant mortality rates. As the primary birthing specialists in rural areas, midwives are essential to this task. A central focus of SIAS is incorporating midwives into the national health care system through midwifery training programs. Drawing on observations of midwifery training programs and interviews with midwives in the municipality of San Martín Jilotepeque, I argue that the incorporation of midwives into SIAS is redefining the position by establishing a new model of recruitment to the role, education, and practice and authority.

Management of post-partum hemorrhage in low-income countries

The provision of safe and effective delivery care for all women in poor countries remains elusive, resulting in a continuing burden of mortality in general and mortality from post-partum haemorrhage in particular. Deployment of a functional health system and effective linkage of the health system to communities are the necessary prerequisites for the provision of the life-saving technical interventions that will make a difference in individual cases. Sadly, two factors militate against progress: the mantra that 'we know what works' (resulting in some serious gaps in evidence for best practice in resource-poor settings) and a lack of large-scale investment in maternity services to counteract the degradation of infrastructure and depletion of human resources evident in many countries.

Mainstreaming nutrition in maternal, newborn and child health: barriers to seeking services from existing maternal, newborn, child health programmes

In the light of mainstreaming nutrition programs into health services, this review article approaches the issue of barriers to existing maternal child health programs from both theoretical and applied perspectives. It begins with a discussion of salient literature on models of health service utilization. The mid-section of the paper presents the results of a review of research studies that illuminate the barriers to care. Categorical themes emerged from the review of studies in the form of barriers based on geographic factors, temporal factors, a myriad of socio-cultural factors, financial factors and quality of care. The discussion focuses on the need to overcome existing restrictions to health services in order to facilitate initiatives to mainstream nutrition and achieve Millennium Development Goal #1.

Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets

Background

Almost two decades since the initiation of the Safe motherhood Initiative, Maternal Mortality is still soaring high in most developing countries. In 2000 WHO estimated a life time risk of a maternal death of 1 in 16 in Sub- Saharan Africa while it was only 1 in 2800 in developed countries. This huge discrepancy in the rate of maternal deaths is due to differences in access and use of maternal health care services. It is known that having a skilled attendant at every delivery can lead to marked reductions in maternal mortality. For this reason, the proportion of births attended by skilled health personnel is one of the indicators used to monitor progress towards the achievement of the MDG-5 of improving maternal health.

Methods

Cross sectional study which employed quantitative research methods.

Results

We interviewed 974 women who gave birth within one year prior to the survey. Although almost all (99.8%) attended ANC at least once during their last pregnancy, only 46.7% reported to deliver in a health facility and only 44.5% were assisted during delivery by a skilled attendant. Distance to the health facility (OR = 4.09 (2.72–6.16)), discussion with the male partner on place of delivery (OR = 2.37(1.75–3.22)), advise to deliver in a health facility during ANC (OR = 1.43 (1.25–2.63)) and knowledge of pregnancy risk factors (OR 2.95 (1.65–5.25)) showed significant association with use of skilled care at delivery even after controlling for confounding factors.

Conclusion

Use of skilled care during delivery in this district is below the target set by ICPD + of attaining 80% of deliveries attended by skilled personnel by 2005. We recommend the following in order to increase the pace towards achieving the MDG targets: to improve coverage of health facilities, raising awareness for both men and women on danger signs during pregnancy/delivery and strengthening counseling on facility delivery and individual birth preparedness.

Complicated deliveries, critical care and quality in Emergency Obstetric Care in Northern Tanzania

Our objective was to determine the availability and quality of obstetric care to improve resource allocation in northern Tanzania. We surveyed all facilities providing delivery services (n=129) in six districts in northern Tanzania using the UN Guidelines for monitoring emergency obstetric care (EmOC). The three last questions in this audit outline are examined: Are the right women (those with obstetric complications) using emergency obstetric care facilities (Met Need)? Are sufficient quantities of critical services being provided (cesarean section rate (CSR))? Is the quality of the services adequate (case fatality rate (CFR))? Complications are calculated using Plan 3 of the UN Guidelines to assess the value of routine data for EmOC indicator monitoring. Nearly 60% of the expected complicated deliveries in the study population were conducted at EmOC qualified health facilities. 81.2% of the expected complicated deliveries are conducted in any facility (including facilities not qualifying as EmOC facilities). There is an inadequate level of critical services provided (CSR 4.6). Voluntary agencies provide most of these services in rural settings. All indicators show large variations with the setting (urban/rural location, level and ownership of facilities). Finally, there is large variation in the CFR with only one facility meeting the minimum accepted level. Utilization and quality of critical obstetric services at lower levels and in rural districts must be improved. The potential for improving the resource allocation within lower levels of the health care system is discussed. Given the small number of qualified facilities yet relatively high Met Need, we argue that it is neither the mothers' ignorance nor their lack of ability to get to a facility that is the main barrier to receiving quality care when needed, but rather the lack of quality care at the facility. Little can be concluded using the CFR to describe the quality of services provided.

Home deliveries in Indonesia: who provides assistance?

Indonesia has set an ambitious target of reducing its maternal mortality rate to 125 maternal deaths per 100,000 live births by the year 2010. This poses formidable challenges in a geographically diverse country where the majority of births occur at home. One option for the Indonesian government in order to reduce its maternal mortality would be to increase rates of skilled assistance for home deliveries. In order to design appropriate policies to achieve this, it is imperative to understand the determinants of use of birth attendants by mothers delivering at home. We use the Andersen Behavioral Model as a theoretical framework to understand the determinants of the use of a trained provider, traditional birth attendant, or no trained assistance during home deliveries in Indonesia. The 1997 Indonesia Demographic and Health Survey (IDHS) was used, and data from the most recent home delivery was abstracted for analysis. Out of a total sample of 10,692 home deliveries, a majority (53%) used the services of a TBA, 40% had a doctor, nurse or midwife in attendance, and only 7% delivered with the help of family and/or friends. A multinomial logit model was used to predict determinants of use. Our results indicate that maternal education, religion, asset index quartile and number of antenatal visits are significant determinants among all choice sets.

[Impact of delivery care type on perinatal mortality in Tapachula, Chiapas, southern border of Mexico]

PURPOSE

To know and to explain the effects of the obstetrical assistance on the rate of perinatal mortality in a municipality of the state of Chiapas, Mexico which is distinguished by having a marginal rural zone, another one presenting an important agroindustrial and fishery development and the urban area.

DESIGN

Transversal, epidemiological study. Some localities representing the three different geopolitic areas of the municipality were selected by probabilistic sampling. Field work was done from october 1996 to march 1997.

PARTICIPANTS

Information was obtained by a probabilistic sampling survey of 1,382 pregnancies occurring from 1987 to 1996 in 670 women whose age range was between 15 to 49 years old. The unit of analysis was the set of alive newborns as well as dead newborns (stillbirth) from the 28th week of the gestation period until the first week of extrauterin life.

RESULTS

The analysis showed a rate of perinatal mortality of 36.2 per 1000 alive newborns, the percentage of birth assistance by a midwife is of 40 percent while assistance by a relative of the pregnant, her husband or herself is that of 3.8%. The higher risks of increasing the mortality rate were found to be during the gestation period prior to or up to the 7th month (OR = 23.0, p < 0.05), for the lack of prenatal control (OR = 3.44, p < 0.05) and when birth assistance is provided by the woman's husband or a relative (OR = 3.31, p < 0.01).

CONCLUSION

Empirical midwives are currently assisting up to the 43% of the pregnancies as far as prenatal control is concerned while they assist up to 40% of the actual deliveries, the later varying when moving to the core of the municipality. Statistically important differences in the rate of perinatal mortality were not found regardless of the type of assistance received prior to and during the actual delivery, by a midwife or a physician.