Giving birth in maternity hospitals in Benin: testimonies of women

Women attending antenatal care as a sentinel surveillance population for malaria in Geita region, Tanzania: feasibility and acceptability to women and providers

BACKGROUND

Measurement of malaria prevalence is conventionally estimated through infrequent cross-sectional household surveys that do not provide continuous information regarding malaria parasitaemia. Recent studies have suggested that malaria parasitaemia prevalence among women attending antenatal care (ANC) correlates with prevalence among children under 5 years old and that pregnant women could be a sentinel population for tracking malaria prevalence. In mainland Tanzania, 97% of women are tested for malaria parasitaemia during first ANC visits. However, acceptability among pregnant women and healthcare providers of collecting malaria risk factor data during ANC visits is limited.

METHODS

A tablet-based questionnaire including 15 questions on insecticide-treated net ownership and use and care-seeking for febrile children was introduced at 40 healthcare facilities in Geita Region, Tanzania. Facilities were randomly selected from among those with 15-120 first ANC visits per month. To assess perspectives regarding introduction of the questionnaire, 21 semi-structured interviews were held with providers and facility in-charges at 12 facilities. Thirty pregnant and recently delivered women participated in focus group discussions at seven facilities to assess the acceptability of spending additional time answering questions about malaria risk.

RESULTS

All pregnant women reported that introduction of ANC surveillance and spending 10 more minutes with providers answering questions about their health would be neutral or beneficial. They perceived being asked about their health as standard of care. Providers and in-charges reported that introduction of ANC surveillance was within their scope of practice. Nine of 21 indicated it could potentially benefit women's health. Six providers expressed concern about staffing shortages and need for reimbursement for extra time and noted that data management occurs after hours.

CONCLUSIONS

Pregnant women and providers generally perceived ANC surveillance for malaria as acceptable and positive. Pregnant and recently delivered women saw this as a reasonable and even helpful intervention. To be seen as a part of standard practice, efforts are needed to ensure providers perceive a benefit for ANC clients and that staffing concerns are addressed. In addition, staff should receive feedback related to data submissions regarding malaria prevalence and risk factors among women at their facility, with actions to take.

Can patients improve the quality of care they receive? Experimental evidence from Senegal

Providers in many low and middle-income countries (LMICs) often fail to correctly diagnose and treat their patients, even though they have the clinical knowledge to do so. Against the backdrop of many failed attempts to increase provider effort, this study examines whether quality of care can be improved by encouraging patients to be more active during consultations. We design a simple experiment with undercover standardised patients who randomly vary how much information they disclose about their symptoms. We find that providers are 27% more likely to correctly manage a patient who volunteers several key symptoms of their condition at the start of the consultation, compared to a typical patient who shares less information. Lower performance in the control group is not due to providers' lack of knowledge, an incapacity to ask the right questions, or a response to time or resource constraints. Instead, providers' low motivation seems to limit their ability to adapt their effort to patients' inputs in the consultation. Our findings provide proof-of-concept evidence that interventions making patients more active in their consultations could significantly improve the quality of care in LMICs.

Interventions to increase patient and family involvement in escalation of care for acute life-threatening illness in community health and hospital settings

BACKGROUND

There is now a rising commitment to acknowledge the role patients and families play in contributing to their safety. This review focuses on one type of involvement in safety - patient and family involvement in escalation of care for serious life-threatening conditions i.e. helping secure a step-up to urgent or emergency care - which has been receiving increasing policy and practice attention. This review was concerned with the negotiation work that patient and family members undertake across the emergency care escalation pathway, once contact has been made with healthcare staff. It includes interventions aiming to improve detection of symptoms, communication of concerns and staff response to these concerns.

OBJECTIVES

To assess the effects of interventions designed to increase patient and family involvement in escalation of care for acute life-threatening illness on patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP) ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform from 1 Jan 2000 to 24 August 2018. The search was updated on 21 October 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-randomised controlled trials where the intervention focused on patients and families working with healthcare professionals to ensure care received for acute deterioration was timely and appropriate. A key criterion was to include an interactive element of rehearsal, role play, modelling, shared language, group work etc. to the intervention to help patients and families have agency in the process of escalation of care. The interventions included components such as enabling patients and families to detect changes in patients' conditions and to speak up about these changes to staff. We also included studies where the intervention included a component targeted at enabling staff response.

DATA COLLECTION AND ANALYSIS

Seven of the eight authors were involved in screening; two review authors independently extracted data and assessed the risk of bias of included studies, with any disagreements resolved by discussion to reach consensus. Primary outcomes included patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. Our advisory group (four users and four providers) ensured that the review was of relevance and could inform policy and practice.

MAIN RESULTS

We included nine studies involving 436,684 patients and family members and one ongoing study. The published studies focused on patients with specific conditions such as coronary artery disease, ischaemic stroke, and asthma, as well as pregnant women, inpatients on medical surgical wards, older adults and high-risk patients with a history of poor self-management. While all studies tested interventions versus usual care, for four studies the usual care group also received educational or information strategies. Seven of the interventions involved face-to-face, interactional education/coaching sessions aimed at patients/families while two provided multi-component education programmes which included components targeted at staff as well as patients/families. All of the interventions included: (1) an educational component about the acute condition and preparedness for future events such as stroke or change in fetal movements: (2) an engagement element (self-monitoring, action plans); while two additionally focused on shared language or communication skills. We had concerns about risk of bias for all but one of the included studies in respect of one or more criteria, particularly regarding blinding of participants and personnel. Our confidence in results regarding the effectiveness of interventions was moderate to low. Low-certainty evidence suggests that there may be moderate improvement in patients' knowledge of acute life-threatening conditions, danger signs, appropriate care-seeking responses, and preparedness capacity between interactional patient-facing interventions and multi-component programmes and usual care at 12 months (MD 4.20, 95% CI 2.44 to 5.97, 2 studies, 687 participants). Four studies in total assessed knowledge (3,086 participants) but we were unable to include two other studies in the pooled analysis due to differences in the way outcome measures were reported. One found no improvement in knowledge but higher symptom preparedness at 12 months. The other study found an improvement in patients' knowledge about symptoms and appropriate care-seeking responses in the intervention group at 18 months compared with usual care. Low-certainty evidence from two studies, each using a different measure, meant that we were unable to determine the effects of patient-based interventions on self-efficacy. Self-efficacy was higher in the intervention group in one study but there was no difference in the other compared with usual care. We are uncertain whether interactional patient-facing and multi-component programmes improve time from the start of patient symptoms to treatment due to low-certainty evidence for this outcome. We were unable to combine the data due to differences in outcome measures. Three studies found that arrival times or prehospital delay time was no different between groups. One found that delay time was shorter in the intervention group. Moderate-certainty evidence suggests that multi-component interventions probably have little or no impact on mortality rates. Only one study on a pregnant population was eligible for inclusion in the review, which found no difference between groups in rates of stillbirth. In terms of unintended events, we found that interactional patient-facing interventions to increase patient and family involvement in escalation of care probably have few adverse effects on patient's anxiety levels (moderate-certainty evidence). None of the studies measured or reported patient and family perceptions of involvement in escalation of care or patient and family experience of patient care. Reported outcomes related to healthcare professionals were also not reported in any studies.

AUTHORS' CONCLUSIONS

Our review identified that interactional patient-facing interventions and multi-component programmes (including staff) to increase patient and family involvement in escalation of care for acute life-threatening illness may improve patient and family knowledge about danger signs and care-seeking responses, and probably have few adverse effects on patient's anxiety levels when compared to usual care. Multi-component interventions probably have little impact on mortality rates. Further high-quality trials are required using multi-component interventions and a focus on relational elements of care. Cognitive and behavioural outcomes should be included at patient and staff level.

What happens during antenatal visits? An ethnographic study of pregnant women's experiences with midwives in Benin

Pregnancy and childbirth place women at risk of morbidity and mortality, particularly in Benin where the health system is fragile. This study aimed to understand women's experiences concerning their interactions with midwives during antenatal visits and to explore contextual factors influencing these interactions and the quality of care received. A qualitative study was conducted from June to August 2015 in two primary health facilities in So-Ava, Benin. One hundred seven individual in-depth interviews with 100 pregnant women, five midwives, and two physicians and one focus group discussion with seven government decision-makers were conducted. Despite midwives' good intentions, most pregnant women reported absenteeism, delays, cold attitudes, fear-based communication, and arbitrary and non-consensual interventions during antenatal visits and believed midwives would interfere with their family relationships. The suboptimal quality of care provided by midwives was interpreted as due to several factors, including lack of accountability of midwives in health facilities. The communication of midwives with pregnant women needs improvement. Results of this study highlight the importance of understanding the problem from the perspective of the political economy of the Benin health system to address its structural and systemic failures with open dialogue, including implementation of accountability measures.

Factors influencing the capacity of women to voice their concerns about maternal health services in the Muanda and Bolenge Health Zones, Democratic Republic of the Congo: a multi-method study

Background

This paper aims to identify factors that influence the capacity of women to voice their concerns regarding maternal health services at the local level.

Methods

A secondary analysis was conducted of the data from three studies carried out between 2013 and 2015 in the Democratic Republic of the Congo (DRC) in the context of a WOTRO initiative to improve maternal health services through social accountability mechanisms in the DRC. The data processing and analysis focused on data related to factors that influence the capacity of women to voice their concerns and on the characteristics of women that influence their ability to identify, and address specific problems. Data from 21 interviews and 12 focus group discussions (n = 92) were analysed using an inductive content analysis, and those from one household survey (n = 517) were summarized.

Results

The women living in the rural setting were mostly farmers/fisher-women (39.7%) or worked at odd jobs (20.3%). They had not completed secondary school (94.6%). Around one-fifth was younger than 20 years old (21.9%). The majority of women could describe the health service they received but were not able to describe what they should receive as care. They had insufficient knowledge of the health services before their first visit. They were not able to explain the mandate of the health providers. The information they received concerned the types of healthcare they could receive but not the real content of those services, nor their rights and entitlements. They were unaware of their entitlements and rights. They believed that they were laypersons and therefore unable to judge health providers, but when provided with some tools such as a checklist, they reported some abusive and disrespectful treatments. However, community members asserted that the reported actions were not reprehensible acts but actions to encourage a woman and to make her understand the risk of delivery.

Conclusions

Factors influencing the capacity of women to voice their concerns in DRC rural settings are mainly associated with insufficient knowledge and socio-cultural context. These findings suggest that initiatives to implement social accountability have to address community capacity-building, health providers’ responsiveness and the socio-cultural norms issues.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2842-2) contains supplementary material, which is available to authorized users.

Patients’ perspectives of emergency care quality and priorities for care improvement

Purpose

Studies have examined strategies implemented to strengthen quality of emergency care in healthcare provider institutions in Ghana. But few studies have focused on what determines quality of emergency care from the patient’s perspective. The purpose of this paper is to fill that gap by examining factors salient to gauging quality of emergency care and priority areas for care improvement.

Design/methodology/approach

Cross-sectional data were collected from patients admitted in emergency units of public hospitals in two regions: Greater Accra and Central Regions. A structured questionnaire designed with inputs from emergency medicine physicians and patients was used to collect data from 381 patients. Principal component analysis (PCA) and logistic regression models were computed to respectively determine salient measures of emergency care quality and their association with patient overall perceived quality of emergency care.

Findings

Using the PCA, four factors (social and relational care, attentive prehospitalised care, ward quality and privacy and medical supplies) were derived as salient measures of emergency care quality. All the factors derived had statistically significant association with patient overall perception of quality.

Originality/value

Emergency care quality improvement strategies that incorporate the dimensions identified can produce effective therapeutic outcomes.

A Qualitative Study on Women's Experiences of Intrapartum Nursing Care at Tamale Teaching Hospital (TTH), Ghana

Introduction: Labor and delivery process is an exciting, anxiety-provoking, but rewarding time for a woman and her family after successful delivery of a newborn. The intrapartum period is the time where mothers expect more care. Taking care of a mother through delivery with no side effects is the task of a professional midwife who is trained with the skill to take the responsibility of caring for mothers and babies. Therefore, the aim of this study was to explore mother's experiences regarding quality of intrapartum nursing/midwifery care. Methods: Focused ethnographic study was employed. Data were collected from May to June 2016 TTH, Ghana using semi structured interview guide. Purposive sampling was employed to recruit 20 participants. Eight individual interviews were conducted in the post natal ward after 48 hours of delivery, followed by three focus group discussions two weeks after delivery when mothers visited post natal clinic. Interviews lasted for about 30-45 minutes during each session. Data were analyzed using thematic analysis. Results: The average age of women were 29 years with ranging from 19-43 years. Participants' experiences of nursing/midwifery care during birth were influenced by reception and respect, provision of information, technical skill, providers' behavior, pain management and availability of nurses/midwives. Conclusion: The study findings have revealed that women's experience of care is affected by a wide range of determinants. Therefore, maternal health programs and policies in Ghana must take into account women's perspective on the care they need and their feedback on services they receive. Nursing education should re-enforce communication/relational skills.

Access barriers to obstetric care at health facilities in sub-Saharan Africa-a systematic review

BACKGROUND

Since 2000, the United Nations' Millennium Development Goals, which included a goal to improve maternal health by the end of 2015, has facilitated significant reductions in maternal morbidity and mortality worldwide. However, despite more focused efforts made especially by low- and middle-income countries, targets were largely unmet in sub-Saharan Africa, where women are plagued by many challenges in seeking obstetric care. The aim of this review was to synthesise literature on barriers to obstetric care at health institutions in sub-Saharan Africa.

METHODS

This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases were electronically searched to identify studies on barriers to health facility-based obstetric care in sub-Saharan Africa, in English, and dated between 2000 and 2015. Combinations of search terms 'obstetric care', 'access', 'barriers', 'developing countries' and 'sub-Saharan Africa' were used to locate articles. Quantitative, qualitative and mixed-methods studies were considered. A narrative synthesis approach was employed to synthesise the evidence and explore relationships between included studies.

RESULTS

One hundred and sixty articles met the inclusion criteria. Currently, obstetric care access is hindered by several demand- and supply-side barriers. The principal demand-side barriers identified were limited household resources/income, non-availability of means of transportation, indirect transport costs, a lack of information on health care services/providers, issues related to stigma and women's self-esteem/assertiveness, a lack of birth preparation, cultural beliefs/practices and ignorance about required obstetric health services. On the supply-side, the most significant barriers were cost of services, physical distance between health facilities and service users' residence, long waiting times at health facilities, poor staff knowledge and skills, poor referral practices and poor staff interpersonal relationships.

CONCLUSION

Despite similarities in obstetric care barriers across sub-Saharan Africa, country-specific strategies are required to tackle the challenges mentioned. Governments need to develop strategies to improve healthcare systems and overall socioeconomic status of women, in order to tackle supply- and demand-side access barriers to obstetric care. It is also important that strategies adopted are supported by research evidence appropriate for local conditions. Finally, more research is needed, particularly, with regard to supply-side interventions that may improve the obstetric care experience of pregnant women.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2014 CRD42014015549.

Violência obstétrica: revisão integrativa de pesquisas qualitativas

Objetivo: Describir cómo los factores que afectan las prácticas de atención del parto interfieren en la experiencia del parto y en el nacimiento.Síntesis de contenido: Se trata de una revisión integradora de investigaciones cualitativas. A partir de las búsquedas en las bases de datos seleccionadas, se encontraron 17 051 artículos,de los cuales, según los criterios preestablecidos, se eligieron 54. De acuerdo con el análisis de los estudios elegidos, emergieron cuatro categorías, a saber: Preconcepciones contemporáneas sobre el parto normal y la cesárea, Elementos desfavorables para la vivencia satisfactoria del parto, Banalización de la violencia obstétrica y Presupuestos sobre la asistencia humanizada del parto. Los resultados revelaron que las prácticas de asistencia al parto estaban desactualizadas, eran inapropiadas, se consideraban“normales” y estaban marcadas por el autoritarismo y por la falta de respeto hacia las mujeres, lo cual caracteriza la violencia obstétrica. Por su parte, el modelo humanizado, al valorar elprotagonismo femenino, hace que la experiencia del parto sea más gratificante. Conclusión: Las prácticas de asistencia al parto en Brasil no respetan los derechos sexuales y reproductivos, lo que se refleja en los altos índices de cesáreas innecesarias y en los maltratos que las mujeres sufren en los hospitales materno-infantilesbrasileños.

Understanding the local context and its possible influences on shaping, implementing and running social accountability initiatives for maternal health services in rural Democratic Republic of the Congo: a contextual factor analysis

Background

Social accountability has to be configured according to the context in which it operates. This paper aimed to identify local contextual factors in two health zones in the Democratic Republic of the Congo and discuss their possible influences on shaping, implementing and running social accountability initiatives.

Methods

Data on local socio-cultural characteristics, the governance context, and socio-economic conditions related to social accountability enabling factors were collected in the two health zones using semi-structured interviews and document reviews, and were analyzed using thematic analysis.

Results

The contexts of the two health zones were similar and characterized by the existence of several community groups, similarly structured and using similar decision-making processes. They were not involved in the health sector’s activities and had no link with the health committee, even though they acknowledged its existence. They were not networked as they focused on their own activities and did not have enough capacity in terms of social mobilization or exerting pressure on public authorities or providers.

Women were not perceived as marginalized as they often occupied other positions in the community besides carrying out domestic tasks and participated in community groups. However, they were still subject to the local male dominance culture, which restrains their involvement in decision-making, as they tend to be less educated, unemployed and suffer from a lack of resources or specific skills.

The socio-economic context is characterized by subsistence activities and a low employment rate, which limits the community members’ incomes and increases their dependence on external support.

The governance context was characterized by imperfect implementation of political decentralization. Community groups advocating community rights are identified as “political” and are not welcomed. The community groups seemed not to be interested in the health center’s information and had no access to media as it is non-existent.

Conclusions

The local contexts in the two health zones seemed not to be supportive of the operation of social accountability initiatives. However, they offer starting points for social accountability initiatives if better use is made of existing contextual factors, for instance by making community groups work together and improving their capacities in terms of knowledge and information.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1895-3) contains supplementary material, which is available to authorized users.

Barriers to Male Involvement in Antenatal Care in Rural Mozambique

Low rates of antenatal care (ANC) service uptake limit the potential impact of mother-to-child HIV-prevention strategies. Zambézia province, Mozambique, has one of the lowest proportions of ANC uptake among pregnant women in the country, despite the availability of free services. We sought to identify factors influencing ANC service uptake (including HIV counseling and testing) through qualitative methods. In addition, we encouraged discussion about strategies to improve uptake of services. We conducted 14 focus groups to explore community views on these topics. Based on thematic coding of discourse, two main themes emerged: (a) gender inequality in decision making and responsibility for pregnancy and (b) community beliefs that uptake of ANC services, particularly, if supported by a male partner, reflects a woman's HIV-positive status. Interventions to promote ANC uptake must work to shift cultural norms through male partner participation. Potential strategies to promote male engagement in ANC services are discussed.

The costs of 'free': Experiences of facility-based childbirth after Benin's caesarean section exemption policy

As one of many similar policies in the region, in 2009 Benin launched a free c-section policy in publicly funded hospitals intended to decrease the barriers to facility delivery and the heavy financial burdens on women and their families. We conducted a qualitative study for eight months between 2012 and 2014 to understand women's experiences of care in maternity wards. We carried out semi-structured interviews with 30 women who had delivered via c-section at five hospitals. Two of these hospitals became case study sites where in-depth research was undertaken that consisted of participant observation in each maternity ward and 32 further interviews with women who had complicated, vaginal and c-section deliveries. Overall, women continue to pay for care, both in the form of under-the-table payments to health workers and prescribed payments for services not covered by the policy, though they consider the costs reasonable compared to what the charges were before. Lifting the fees has facilitated conditions for midwives to alert doctors that the procedure might be needed. Partly because c-sections are still feared by most women, in one hospital this led to some women perceiving them as a threat if their labour was progressing more slowly. Implementation of the policy differed greatly between the two case study hospitals. We conclude that some burdens on women's access to care have been addressed but deterrents remain to the improved perception of quality of care on the part of women. Findings detail how important context is to the implementation of the policy, and suggest that similar user-fee removal policies should be accompanied by other measures addressing staff management and quality of care.

Effect of pay for performance to improve quality of maternal and child care in low- and middle-income countries: a systematic review

Background

Pay for Performance (P4P) mechanisms to health facilities and providers are currently being tested in several low- and middle-income countries (LMIC) to improve maternal and child health (MCH). This paper reviews the existing evidence on the effect of P4P program on quality of MCH care in LMICs.

Methods

A systematic review of literature was conducted according to a registered protocol. MEDLINE, Web of Science, and Embase were searched using the key words maternal care, quality of care, ante natal care, emergency obstetric and neonatal care (EmONC) and child care. Of 4535 records retrieved, only eight papers met the inclusion criteria. Primary outcome of interest was quality of MCH disaggregated into structural quality, process quality and outcomes. Risk of bias across studies was assessed through a customized quality checklist.

Results and discussion

There were four controlled before after intervention studies, three cluster randomized controlled trials and one case control with post-intervention comparison of P4P programs for MCH care in Burundi, Democratic Republic of Congo, Egypt, the Philippines, and Rwanda. There is some evidence of positive effect of P4P only on process quality of MCH. The effect of P4P on delivery, EmONC, post natal care and under-five child care were not evaluated in these studies. There is weak evidence for P4P’s positive effect on maternal and neonatal health outcomes and out-of-pocket expenses. P4P program had a few negative effects on structural quality.

Conclusion

P4P is effective to improve process quality of ante natal care. However, further research is needed to understand P4P’s impact on MCH and their causal pathways in LMICs.

Trial registration

PROSPERO registration number CRD42014013077.

After surgery: the effects of life-saving caesarean sections in Burkina Faso

Background

In African countries, caesarean sections are usually performed to save mothers and babies’ lives, sometimes in extremis and at considerable costs. Little is known about the health and lives of women once discharged after such surgery. We investigated the long-term effects of life-saving caesarean section on health, economic and social outcomes in Burkina Faso.

Methods

We conducted a 4 year prospective cohort study of women and their babies using mixed methods. The quantitative sample was selected in seven hospitals and included 950 women: 100 women with a caesarean section associated with near-miss complication (life-saving caesareans); 173 women with a vaginal birth associated with near-miss complication; and 677 women with uncomplicated vaginal childbirth. Structured interviews were conducted at 3 months, 6 months, 12 months and 3 and 4 years postpartum. These were supplemented by medical record data on delivery and physical examinations at 6 and 12 months postpartum. The lives and experiences of 21 women were documented ethnographically. Data were analysed with multivariable logistic regressions, using survival analysis and thematic analysis.

Results

The physical effects of life-saving caesareans appeared to be similar to women who had an uncomplicated childbirth, although 55 % of women with life-saving caesareans had another caesarean in their next pregnancy. The negative effects were generally economic, social and reproductive when compared to vaginal births, including increased debts (AOR = 3.91 (1.46–10.48) and sexual violence (AOR = 4.71 (1.04–21.3)) and lower fertility (AOR = 0.44 (0.24–0.80)) 4 years after life-saving caesareans. In the short and medium term, women with life-saving caesareans appeared to suffer increased psychological distress compared to uncomplicated births. They were more likely to use contraceptives (AOR = 5.95 (1.53–23.06); 3 months). Mortality of the index child was increased in both near-miss groups, independent of delivery mode. Ethnographic data suggest that these consequences are significant for Burkinabe women, whose well-being and social standing are mostly determined by their fertility, marriage strength and family links.

Conclusions

Life-saving caesareans have broad consequences beyond clinical sequelae. The recent policy to subsidise emergency obstetric care costs implemented in Burkina Faso should help avoid the majority of catastrophic costs, shown to be problematic for women undergoing emergency caesarean section.

Social accountability for maternal health services in Muanda and Bolenge Health Zones, Democratic Republic of Congo: a situation analysis

BACKGROUND

The Democratic Republic of the Congo is one of the countries in Sub-Saharan Africa with the highest maternal mortality ratio estimated at 846 deaths per 100,000 live births. Innovative strategies such as social accountability are needed to improve both health service delivery and utilization. Indeed, social accountability is a form of citizen engagement defined as the 'extent and capability of citizens to hold politicians, policy makers and providers accountable and make them responsive to their needs.' This study explores existing social accountability mechanisms through which women's concerns are expressed and responded to by health providers in local settings.

METHODS

An exploratory study was conducted in two health zones with purposively sampled respondents including twenty-five women, five men, five health providers, two health zone officers and eleven community stakeholders. Data on women's voice and oversight and health providers' responsiveness were collected using semi-structured interviews and analysed using thematic analysis.

RESULTS

In the two health zones, women rarely voiced their concerns and expectations about health services. This reluctance was due to: the absence of procedures to express them, to the lack of knowledge thereof, fear of reprisals, of being misunderstood as well as factors such as age-related power, ethnicity backgrounds, and women's status. The means most often mentioned by women for expressing their concerns were as individuals rather than as a collective. They did not use them instead; instead they looked to intermediaries, mostly, trusted health providers, community health workers and local leaders. Their perceptions of health providers' responsiveness varied. For women, there were no mechanisms for oversight in place. Individual discontent with malpractice was not shown to health providers. In contrast, health providers mentioned community health workers, health committee, and community based organizations as formal oversight mechanisms. All respondents recognized the lack of coalition around maternal health despite the many local associations and groups.

CONCLUSIONS

Social accountability is relatively inexistent in the maternal health services in the two health zones. For social accountability to be promoted, efforts need to be made to create its mechanisms and to open the local context settings to dialogue, which appears structurally absent.

Challenges and opportunities for implementing evidence-based antenatal care in Mozambique: a qualitative study

Background

Maternal mortality remains a daunting problem in Mozambique and many other low-resource countries. High quality antenatal care (ANC) services can improve maternal and newborn health outcomes and increase the likelihood that women will seek skilled delivery care. This study explores the factors influencing provider uptake of the recommended package of ANC interventions in Mozambique.

Methods

This study used qualitative research methods including key informant interviews with stakeholders from the health sector and a total of five focus group discussions with women with experience with ANC or women from the community. Study participants were selected from three health centers located in Maputo city, Tete, and Cabo Delgado provinces in Mozambique. Staff responsible for the medicines/supply chain at national, provincial and district level were interviewed. A check list was implemented to confirm the availability of the supplies required for ANC. Deductive content analysis was conducted.

Results

Three main groups of factors were identified that hinder the implementation of the ANC package in the study setting: a) system or organizational: include chronic supply chain deficiencies, failures in the continuing education system, lack of regular audits and supervision, absence of an efficient patient record system and poor environmental conditions at the health center; b) health care provider factors: such as limited awareness of current clinical guidelines and a resistant attitude to adopting new recommendations; and c) Users: challenges with accessing ANC, poor recognition amongst women about the purpose and importance of the specific interventions provided through ANC, and widespread perception of an unfriendly environment at the health center.

Conclusions

The ANC package in Mozambique is not being fully implemented in the three study facilities, and a major barrier is poor functioning of the supply chain system. Recommendations for improving the implementation of antenatal interventions include ensuring clinical protocols based on the ANC model. Increasing the community understanding of the importance of ANC would improve demand for high quality ANC services. The supply chain functioning could be strengthened through the introduction of a kit system with all the necessary supplies for ANC and a simple monitoring system to track the stock levels is recommended.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0625-x) contains supplementary material, which is available to authorized users.

Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review

Background

High maternal mortality and morbidity persist, in large part due to inadequate access to timely and quality health care. Attitudes and behaviours of maternal health care providers (MHCPs) influence health care seeking and quality of care.

Methods

Five electronic databases were searched for studies from January 1990 to December 2014. Included studies report on types or impacts of MHCP attitudes and behaviours towards their clients, or the factors influencing these attitudes and behaviours. Attitudes and behaviours mentioned in relation to HIV infection, and studies of health providers outside the formal health system, such as traditional birth attendants, were excluded.

Findings

Of 967 titles and 412 abstracts screened, 125 full-text papers were reviewed and 81 included. Around two-thirds used qualitative methods and over half studied public-sector facilities. Most studies were in Africa (n = 55), followed by Asia and the Pacific (n = 17). Fifty-eight studies covered only negative attitudes or behaviours, with a minority describing positive provider behaviours, such as being caring, respectful, sympathetic and helpful. Negative attitudes and behaviours commonly entailed verbal abuse (n = 45), rudeness such as ignoring or ridiculing patients (n = 35), or neglect (n = 32). Studies also documented physical abuse towards women, absenteeism or unavailability of providers, corruption, lack of regard for privacy, poor communication, unwillingness to accommodate traditional practices, and authoritarian or frightening attitudes. These behaviours were influenced by provider workload, patients’ attitudes and behaviours, provider beliefs and prejudices, and feelings of superiority among MHCPs. Overall, negative attitudes and behaviours undermined health care seeking and affected patient well-being.

Conclusions

The review documented a broad range of negative MHCP attitudes and behaviours affecting patient well-being, satisfaction with care and care seeking. Reported negative patient interactions far outweigh positive ones. The nature of the factors which influence health worker attitudes and behaviours suggests that strengthening health systems, and workforce development, including in communication and counselling skills, are important. Greater attention is required to the attitudes and behaviours of MHCPs within efforts to improve maternal health, for the sake of both women and health care providers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12992-015-0117-9) contains supplementary material, which is available to authorized users.

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.

The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review

BACKGROUND

Despite growing recognition of neglectful, abusive, and disrespectful treatment of women during childbirth in health facilities, there is no consensus at a global level on how these occurrences are defined and measured. This mixed-methods systematic review aims to synthesize qualitative and quantitative evidence on the mistreatment of women during childbirth in health facilities to inform the development of an evidence-based typology of the phenomenon.

METHODS AND FINDINGS

We searched PubMed, CINAHL, and Embase databases and grey literature using a predetermined search strategy to identify qualitative, quantitative, and mixed-methods studies on the mistreatment of women during childbirth across all geographical and income-level settings. We used a thematic synthesis approach to synthesize the qualitative evidence and assessed the confidence in the qualitative review findings using the CERQual approach. In total, 65 studies were included from 34 countries. Qualitative findings were organized under seven domains: (1) physical abuse, (2) sexual abuse, (3) verbal abuse, (4) stigma and discrimination, (5) failure to meet professional standards of care, (6) poor rapport between women and providers, and (7) health system conditions and constraints. Due to high heterogeneity of the quantitative data, we were unable to conduct a meta-analysis; instead, we present descriptions of study characteristics, outcome measures, and results. Additional themes identified in the quantitative studies are integrated into the typology.

CONCLUSIONS

This systematic review presents a comprehensive, evidence-based typology of the mistreatment of women during childbirth in health facilities, and demonstrates that mistreatment can occur at the level of interaction between the woman and provider, as well as through systemic failures at the health facility and health system levels. We propose this typology be adopted to describe the phenomenon and be used to develop measurement tools and inform future research, programs, and interventions.

Factors affecting attendance at and timing of formal antenatal care: results from a qualitative study in Madang, Papua New Guinea

BACKGROUND

Appropriate antenatal care (ANC) is key for the health of mother and child. However, in Papua New Guinea (PNG), only a third of women receive any ANC during pregnancy. Drawing on qualitative research, this paper explores the influences on ANC attendance and timing of first visit in the Madang region of Papua New Guinea.

METHODS

Data were collected in three sites utilizing several qualitative methods: free-listing and sorting of terms and definitions, focus group discussions, in-depth interviews, observation in health care facilities and case studies of pregnant women. Respondents included pregnant women, their relatives, biomedical and traditional health providers, opinion leaders and community members.

RESULTS

Although generally reported to be important, respondents' understanding of the procedures involved in ANC was limited. Factors influencing attendance fell into three main categories: accessibility, attitudes to ANC, and interpersonal issues. Although women saw accessibility (distance and cost) as a barrier, those who lived close to health facilities and could easily afford ANC also demonstrated poor attendance. Attitudes were shaped by previous experiences of ANC, such as waiting times, quality of care, and perceptions of preventative care and medical interventions during pregnancy. Interpersonal factors included relationships with healthcare providers, pregnancy disclosure, and family conflict. A desire to avoid repeat clinic visits, ideas about the strength of the fetus and parity were particularly relevant to the timing of first ANC visit.

CONCLUSIONS

This long-term in-depth study (the first of its kind in Madang, PNG) shows how socio-cultural and economic factors influence ANC attendance. These factors must be addressed to encourage timely ANC visits: interventions could focus on ANC delivery in health facilities, for example, by addressing healthcare staff's attitudes towards pregnant women.

Stakeholder views on the incorporation of traditional birth attendants into the formal health systems of low-and middle-income countries: a qualitative analysis of the HIFA2015 and CHILD2015 email discussion forums

Background

Health workforce shortages are key obstacles to the achievement of the health-related Millennium Development Goals. Task shifting is seen as a way to improve access to pregnancy and childbirth care. However, the role of traditional birth attendants (TBAs) within task shifting initiatives remains contested. The objective of this study was to explore stakeholder views and justifications regarding the incorporation of TBAs into formal health systems.

Methods

Data were drawn from messages submitted to the HIFA2015 and CHILD2015 email discussion forums. The forums focus on the healthcare information needs of frontline health workers and citizens in low - and middle-income countries, and how these needs can be met, and also include discussion of diverse aspects of health systems. Messages about TBAs submitted between 2007-2011 were analysed thematically.

Results

We identified 658 messages about TBAs from a total of 193 participants. Most participants supported the incorporation of trained TBAs into primary care systems to some degree, although their justifications for doing so varied. Participant viewpoints were influenced by the degree to which TBA involvement was seen as a long-term or short-term solution and by the tasks undertaken by TBAs.

Conclusions

Many forum members indicated that they were supportive of trained TBAs being involved in the provision of pregnancy care. Members noted that TBAs were already frequently used by women and that alternative options were lacking. However, a substantial minority regarded doing so as a threat to the quality and equity of healthcare. The extent of TBA involvement needs to be context-specific and should be based on evidence on effectiveness as well as evidence on need, acceptability and feasibility.

Delivery should happen soon and my pain will be reduced: understanding women's perception of good delivery care in India

Background

Understanding a woman's perspective and her needs during childbirth and addressing them as part of quality-improvement programmes can make delivery care safe, affordable, and respectful. It has been pointed out that the patient's judgement on the quality and goodness of care is indispensible to improving the management of healthcare systems.

Objective

The objective of the study is to understand the aspects of care that women consider important during childbirth.

Design

Individual in-depth interviews (IDIs) and focus-group discussions (FGDs) with women who recently delivered were the techniques used. Seventeen IDIs and four FGDs were conducted in Jharkhand state in east India between January and March 2012. Women who had normal deliveries with live births at home and in primary health centres were included. To minimise recall bias, interviews were conducted within 42 days of childbirth. Using the transcripts of interviews, the data were analysed thematically.

Results

Aspects of care most commonly cited by women to be important were: availability of health providers and appropriate medical care (primarily drugs) in case of complications; emotional support; privacy; clean place after delivery; availability of transport to reach the institution; monetary incentives that exceed expenses; and prompt care. Other factors included kind interpersonal behaviour, cognitive support, faith in the provider's competence, and overall cleanliness of the facility and delivery room.

Conclusions

Respondents belonging to low socio-economic strata with basic literacy levels might not understand appropriate clinical aspects of care, but they want care that is affordable and accessible, along with privacy and emotional support during delivery. The study highlighted that healthcare quality-improvement programmes in India need to include non-clinical aspects of care as women want to be treated humanely during delivery – they desire respectful treatment, privacy, and emotional support. Further research into maternal satisfaction could be made more policy relevant by assessing the relative strength of various factors in influencing maternal satisfaction; this could help in prioritising appropriate interventions for improved quality of care (QoC).

Why do women not use antenatal services in low- and middle-income countries? A meta-synthesis of qualitative studies

BACKGROUND

Almost 50% of women in low- and middle-income countries (LMICs) don't receive adequate antenatal care. Women's views can offer important insights into this problem. Qualitative studies exploring inadequate use of antenatal services have been undertaken in a range of countries, but the findings are not easily transferable. We aimed to inform the development of future antenatal care programmes through a synthesis of findings in all relevant qualitative studies.

METHODS AND FINDINGS

Using a predetermined search strategy, we identified robust qualitative studies reporting on the views and experiences of women in LMICs who received inadequate antenatal care. We used meta-ethnographic techniques to generate themes and a line-of-argument synthesis. We derived policy-relevant hypotheses from the findings. We included 21 papers representing the views of more than 1,230 women from 15 countries. Three key themes were identified: "pregnancy as socially risky and physiologically healthy", "resource use and survival in conditions of extreme poverty", and "not getting it right the first time". The line-of-argument synthesis describes a dissonance between programme design and cultural contexts that may restrict access and discourage return visits. We hypothesize that centralised, risk-focused antenatal care programmes may be at odds with the resources, beliefs, and experiences of pregnant women who underuse antenatal services.

CONCLUSIONS

Our findings suggest that there may be a misalignment between current antenatal care provision and the social and cultural context of some women in LMICs. Antenatal care provision that is theoretically and contextually at odds with local contextual beliefs and experiences is likely to be underused, especially when attendance generates increased personal risks of lost family resources or physical danger during travel, when the promised care is not delivered because of resource constraints, and when women experience covert or overt abuse in care settings.

Perceptions of prenatal and obstetric care in Sub-Saharan Africa

BACKGROUND

The maternal mortality ratio in Sub-Saharan Africa remains high, despite progress in reducing maternal mortality in other parts of the world.

OBJECTIVE

To explore the perceptions of women and communities to identify barriers to the uptake of obstetric services.

SEARCH STRATEGY

A systematic review of qualitative studies exploring perceptions of pregnancy and obstetric services, with thematic synthesis of the included studies.

SELECTION CRITERIA

Qualitative studies reporting findings from focus group discussions and in-depth interviews between 1996 and 2009 were included.

DATA COLLECTION AND ANALYSIS

Thematic synthesis involved collating and reviewing quotations taken directly from included studies. Themes were generated and clustered for analysis.

MAIN RESULTS

Twenty-seven studies were included and 6 major themes identified: perceptions of healthcare workers; perceptions of the hospital environment; cultural perceptions of women; cultural perceptions of pregnancy; perceptions of traditional birth attendants and traditional healers; and role of the community in pregnancy and birth.

CONCLUSION

Community attitudes regarding cultural beliefs and interactions with healthcare providers were identified as barriers to the utilization of healthcare services during pregnancy in Sub-Saharan Africa. These prevent engagement with prenatal care and timely use of medical services. Addressing the barriers will be seminal to the success of any healthcare intervention.

Do Malawian women critically assess the quality of care? A qualitative study on women's perceptions of perinatal care at a district hospital in Malawi

Background

Malawi has a high perinatal mortality rate of 40 deaths per 1,000 births. To promote neonatal health, the Government of Malawi has identified essential health care packages for improving maternal and neonatal health in health care facilities. However, regardless of the availability of health services, women’s perceptions of the care is important as it influences whether the women will or will not use the services. In Malawi 95% of pregnant women receive antenatal care from skilled attendants, but the number is reduced to 71% deliveries being conducted by skilled attendants. The objective of this study was to describe women’s perceptions on perinatal care among the women delivered at a district hospital.

Methods

A descriptive study design with qualitative data collection and analysis methods. Data were collected through face-to-face in-depth interviews using semi-structured interview guides collecting information on women’s perceptions on perinatal care. A total of 14 in depth interviews were conducted with women delivering at Chiradzulu District Hospital from February to March 2011. The women were asked how they perceived the care they received from health workers during antepartum, intrapartum and postpartum. They were also asked about the information they received during provision of care. Data were manually analyzed using thematic analysis.

Results

Two themes from the study were good care and unsatisfactory care. Subthemes under good care were: respect, confidentiality, privacy and normal delivery. Providers’ attitude, delay in providing care, inadequate care, and unavailability of delivery attendants were subthemes under unsatisfactory care.

Conclusions

Although the results show that women wanted to be well received at health facilities, respected, treated with kindness, dignity and not shouted at, they were not critical of the care they received. The women did not know the quality of care to expect because they were not well informed. The women were not critical of the care they received because they were not aware of the standard of care. Instead they had low expectations. Health workers have a responsibility to inform women and their families about the care that women should expect. There is also a need for standardization of the antenatal information that is provided.

Parity and institutional delivery in rural Tanzania: a multilevel analysis and policy implications

OBJECTIVES

We assess the extent to which the use of healthcare facilities for childbirth varies by parity, conditional on socio-economic, psychological and health characteristics. We also assess differences in the determinants of institutionalized delivery for first-time mothers and multiparous, and explore village-level variations in observed relationships.

METHODS

Survey data from a three-stage cross-sectional cluster sample of 1205 women from a rural district of Tanzania were analysed using random-intercept multilevel models.

RESULTS

Use of health facilities for delivery was low (39%), with odds of institutionalized delivery three times higher among nulliparous women (0 children prior to current delivery) compared with women with one to four children; and 30% lower among women with five or more children compared with those with one to four children. In parity group analyses, women with at least some education and women with more than three antenatal care visits had higher odds of institutionalized delivery among nulliparous. Belief in the importance of institutionalized delivery increased the odds of delivering in a facility among multiparous women; so did health insurance for women with five or more children. We found a significant variation in institutionalized delivery among multiparous women based on their village of residence (one to four and five or more children), but these variations were not observed among nulliparous women.

CONCLUSION

Parity is a pivotal determinant of the use of health facilities for delivery, and its significance varies by village of residence; hence, interventions targeting women according to parity may increase the use of facilities for delivery in rural Tanzania. Future research should focus on the village-level characteristics that influence institutionalized delivery in multiparous.

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.

Stillbirths: why they matter

In this first paper of The Lancet's Stillbirths Series we explore the present status of stillbirths in the world-from global health policy to a survey of community perceptions in 135 countries. Our findings highlight the need for a strong call for action. In times of global focus on motherhood, the mother's own aspiration of a liveborn baby is not recognised on the world's health agenda. Millions of deaths are not counted; stillbirths are not in the Global Burden of Disease, nor in disability-adjusted life-years lost, and they are not part of the UN Millennium Development Goals. The grief of mothers might be aggravated by social stigma, blame, and marginalisation in regions where most deaths occur. Most stillborn babies are disposed of without any recognition or ritual, such as naming, funeral rites, or the mother holding or dressing the baby. Beliefs in the mother's sins and evil spirits as causes of stillbirth are rife, and stillbirth is widely believed to be a natural selection of babies never meant to live. Stillbirth prevention is closely linked with prevention of maternal and neonatal deaths. Knowledge of causes and feasible solutions for prevention is key to health professionals' priorities, to which this Stillbirths Series paper aims to contribute.

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.

High ANC coverage and low skilled attendance in a rural Tanzanian district: a case for implementing a birth plan intervention

Background

In Tanzania, more than 90% of all pregnant women attend antenatal care at least once and approximately 62% four times or more, yet less than five in ten receive skilled delivery care at available health units. We conducted a qualitative study in Ngorongoro district, Northern Tanzania, in order to gain an understanding of the health systems and socio-cultural factors underlying this divergent pattern of high use of antenatal services and low use of skilled delivery care. Specifically, the study examined beliefs and behaviors related to antenatal, labor, delivery and postnatal care among the Maasai and Watemi ethnic groups. The perspectives of health care providers and traditional birth attendants on childbirth and the factors determining where women deliver were also investigated.

Methods

Twelve key informant interviews and fifteen focus group discussions were held with Maasai and Watemi women, traditional birth attendants, health care providers, and community members. Principles of the grounded theory approach were used to elicit and assess the various perspectives of each group of participants interviewed.

Results

The Maasai and Watemi women's preferences for a home birth and lack of planning for delivery are reinforced by the failure of health care providers to consistently communicate the importance of skilled delivery and immediate post-partum care for all women during routine antenatal visits. Husbands typically serve as gatekeepers of women's reproductive health in the two groups - including decisions about where they will deliver- yet they are rarely encouraged to attend antenatal sessions. While husbands are encouraged to participate in programs to prevent maternal-to-child transmission of HIV, messages about the importance of skilled delivery care for all women are not given emphasis.

Conclusions

Increasing coverage of skilled delivery care and achieving the full implementation of Tanzania's Focused Antenatal Care Package in Ngorongoro depends upon improved training and monitoring of health care providers, and greater family participation in antenatal care visits.

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.

Non-uptake of facility-based maternity services in an inner-city community in Lagos, Nigeria: an observational study

Scaling-up of skilled attendants and facility-based services is necessary for improving maternal and child care in developing countries but their effectiveness is crucially influenced by the uptake of such services. This study set out to establish the pattern and uptake of maternity services and associated factors against the backdrop of rapid urbanization in Nigeria. A cross-sectional study of socio-demographic and obstetric characteristics of mothers attending the Bacille Calmette-Guérin (BCG) immunization clinics in inner-city Lagos was conducted from July 2005 to December 2007, and their association with non-hospital delivery and use of unskilled attendants was determined by multiple logistic regression analyses. Of the 6465 participants, over half (51.4%) delivered outside hospital facilities and 81.8% of this group had no skilled attendants at delivery. Non-hospital delivery or the presence of unskilled attendants at delivery was associated with teenage mothers, Muslim religion, low or middle social class and use of herbal drugs in pregnancy. Additionally, non-hospital delivery was associated with ethnicity (Yoruba tribe), lack of tertiary education or full-time employment, accommodation with shared sanitation facilities and multiparity. The results suggest that availability of and access/proximity to hospital facilities or skilled attendants is no guarantee of uptake of maternity services. Efforts aimed at improving maternal and child health in developing countries should take cognisance of the socio-demographic and cultural underpinnings of maternal health-seeking behaviour of urban mothers beyond the provision of facility-based services or strengthening of the existing health care systems.

Maternal and neonatal factors associated with mode of delivery under a universal newborn hearing screening programme in Lagos, Nigeria

Background

Emerging evidence from a recent pilot universal newborn hearing screening (UNHS) programme suggests that the burden of obstetric complications associated with mode of delivery is not limited to maternal and perinatal mortality but may also include outcomes that undermine optimal early childhood development of the surviving newborns. However, the potential pathways for this association have not been reported particularly in the context of a resource-poor setting. This study therefore set out to establish the pattern of delivery and the associated neonatal outcomes under a UNHS programme.

Methods

A cross-sectional study in which all consenting mothers who delivered in an inner-city tertiary maternity hospital in Lagos, Nigeria from May 2005 to December 2007 were enrolled during the UNHS programme. Socio-demographic, obstetric and neonatal factors independently associated with vaginal, elective and emergency caesarean deliveries were determined using multinomial logistic regression analyses.

Results

Of the 4615 mothers enrolled, 2584 (56.0%) deliveries were vaginal, 1590 (34.4%) emergency caesarean and 441 (9.6%) elective caesarean section. Maternal age, parity, social class and all obstetric factors including lack of antenatal care, maternal HIV and multiple gestations were associated with increased risk of emergency caesarean delivery compared with vaginal delivery. Only parity, lack of antenatal care and prolonged/obstructed labour were associated with increased risk of emergency compared with elective caesarean delivery. Infants delivered by vaginal method or by emergency caesarean section were more likely to be associated with the risk of sensorineural hearing loss but less likely to be associated with hyperbilirubinaemia compared with infants delivered by elective caesarean section. Emergency caesarean delivery was also associated with male gender, low five-minute Apgar scores and admission into special care baby unit compared with vaginal or elective caesarean delivery.

Conclusions

The vast majority of caesarean delivery in this population occur as emergencies and are associated with socio-demographic factors as well as several obstetric complications. Mode of delivery is also associated with the risk of sensorineural hearing loss and other adverse birth outcomes that lie on the causal pathways for potential developmental deficits.

Social differentiation and embodied dispositions: a qualitative study of maternal care-seeking behaviour for near-miss morbidity in Bolivia

Background

Use of maternal health care in low-income countries has been associated with several socioeconomic and demographic factors, although contextual analyses of the latter have been few. A previous study showed that 75% of women with severe obstetric morbidity (near-miss) identified at hospitals in La Paz, Bolivia were in critical conditions upon arrival, underscoring the significance of pre-hospital barriers also in this setting with free and accessible maternal health care. The present study explores how health care-seeking behaviour for near-miss morbidity is conditioned in La Paz, Bolivia.

Methods

Thematic interviews with 30 women with a near-miss event upon arrival at hospital. Near-miss was defined based on clinical and management criteria. Modified analytic induction was applied in the analysis that was further influenced by theoretical views that care-seeking behaviour is formed by predisposing characteristics, enabling factors, and perceived need, as well as by socially shaped habitual behaviours.

Results

The self-perception of being fundamentally separated from "others", meaning those who utilise health care, was typical for women who customarily delivered at home and who delayed seeking medical assistance for obstetric emergencies. Other explanations given by these women were distrust of authority, mistreatment by staff, such as not being kept informed about their condition or the course of their treatment, all of which reinforced their dissociation from the health-care system.

Conclusion

The findings illustrate health care-seeking behaviour as a practise that is substantially conditioned by social differentiation. Social marginalization and the role health institutions play in shaping care-seeking behaviour have been de-emphasised by focusing solely on endogenous cultural factors in Bolivia.

Human resources and the quality of emergency obstetric care in developing countries: a systematic review of the literature

BACKGROUND

This paper reports on a systematic literature review exploring the importance of human resources in the quality of emergency obstetric care and thus in the reduction of maternal deaths.

METHODS

A systematic search of two electronic databases (ISI Web of Science and MEDLINE) was conducted, based on the following key words "quality obstetric* care" OR "pregnancy complications OR emergency obstetric* care OR maternal mortality" AND "quality health care OR quality care" AND "developing countries. Relevant papers were analysed according to three customary components of emergency obstetric care: structure, process and results.

RESULTS

This review leads to three main conclusions: (1) staff shortages are a major obstacle to providing good quality EmOC; (2) women are often dissatisfied with the care they receive during childbirth; and (3) the technical quality of EmOC has not been adequately studied. The first two conclusions provide lessons to consider when formulating EmOC policies, while the third point is an area where more knowledge is needed.

Pierre Bourdieu and transformative agency: a study of how patients in Benin negotiate blame and accountability in the context of severe obstetric events

This paper explores the social and institutional processes that constrain and enable obstetric patients in Benin to critically evaluate quality of healthcare and to stimulate positive changes in the health system. Based on qualitative data collected as part of a hospital auditing system, the paper analyses semi-structured patient feedback interviews and their function as a primary mechanism through which critical patient evaluation can develop constructively. Using a Bourdieuan framework, we explore the dynamic social conditions that give rise to transformative agency and institutional change. Our results show that hospitals are often permeated with the habitus of employment, kinship and reproductive social fields, through which a number of social, economic and healthcare conflicts, power struggles and blame-inducing interactions emerge. These conflicts generally serve to keep patients quiescent and passive when it comes to developing critical statements of quality of care. In a subset of cases, however, these conflicts are transformed by patients and their family members into opportunities for modifying the values and practices of each habitus in new and creative ways. The active negotiation of social conflict and blame enabled a minority of patients actively to divert blame from themselves and to develop and maintain critical healthcare evaluations.

Social costs of skilled attendance at birth in rural Ghana

OBJECTIVE

To examine the social costs to women of skilled attendance at birth in rural Ghana.

METHOD

Ethnographic data were obtained through participant observation, interviews, case histories, and focus groups and were analyzed alongside data from a birth cohort of 2878 singletons born in the Kintampo study district between July 2003 and June 2004.

RESULTS

Most women delivered at home. Home delivery raises a woman's status in her community, while seeking skilled attendance lowers it. Women feel that seeking assistance in childbirth wastes other people's time and they value secrecy in labor. Negative treatment by health providers and expensive supplies needed for delivery also act as barriers.

CONCLUSION

The social costs of obtaining skilled attendance at birth must be offset by community level strategies such as mobilization of older women and husbands, and ensuring health providers extend professional, humane care to laboring women.

Men's perception of maternal mortality in Nigeria

Innovative and effective options toward reducing maternal mortality rates in African nations must include the active participation of all stakeholders. This study was carried out to assess men's level of knowledge and attitude to preventing maternal deaths. In a cross-sectional, community-based survey complemented with exploratory in-depth interviews, data were collected from men from different socio-economic areas using a two-stage cluster sampling technique. Mean age of the 316 respondents was 39.9 years (range 19-66). Nearly half (47.8%) knew someone who had died at childbirth. They blamed maternal deaths on healthcare workers not being skilled enough, financial barriers, failure to use family planning, emergency, antenatal, and delivery care services. Factors associated with knowledge and attitude to preventing maternal mortality are discussed. Healthcare reforms must be coupled with socio-economic improvements and efforts made to improve men's attitudes and knowledge in such a way as to make them active stakeholders, more supportive of preventing maternal mortality.

Health Seeking Behavior Among Pregnant Women in Rural Haiti

The purpose of this study was to further knowledge of health care seeking behavior among pregnant women in rural Haiti. Eighty-two pregnant women were interviewed to assess care seeking behaviors during pregnancy, satisfaction with services, reliance on social networks, and management of pregnancy-related illness. Twenty-five percent reported not seeking care in the formal health sector for a pregnancy-related illness; 32% delayed seeking care. Women relied primarily on their husbands and mothers for health care advice during pregnancy and times of illness, and coped with illness by lying down. Strategies for improving awareness and health care access are discussed.

Maternal health in poor countries: the broader context and a call for action

In this paper, we take a broad perspective on maternal health and place it in its wider context. We draw attention to the economic and social vulnerability of pregnant women, and stress the importance of concomitant broader strategies, including poverty reduction and women's empowerment. We also consider outcomes beyond mortality, in particular, near-misses and long-term sequelae, and the implications of the close association between the mother, the fetus, and the child. We make links to a range of global survival initiatives, particularly neonatal health, HIV, and malaria, and to reproductive health. Finally, after examining the political and financial context, we call for action. The need for strategic vision, financial resources, human resources, and information are discussed.

[Emergency obstetrical care in Benin referral hospitals: 'near miss' patients' views]

OBJECTIVE

To evaluate emergency obstetric care and the perceptions and expectations of women who experienced 'near miss' events to improve maternal health in Benin.

METHODS

Qualitative survey in seven hospitals at the three referral levels of the health pyramid from July to October 2003. We used two methods: 557 women with near miss events were interviewed in hospital and a standard questionnaire completed; then semi-structured individual interviews were conducted at home with 42 of these 557 women.

RESULTS

Provided care, accommodation, facilities, costs and modalities of recovery, hygiene of the premises, dynamism, expertise, social support, behaviours and attitude of staff were the criteria used to express patients' satisfaction. Most women interviewed in hospital were happy with physical access, organization, functioning and environment. However, excessive costs and coercive recovery of the expenses, failure of the referral system, lack of empathy and discrimination of the nursing staff, lack of resources for emergencies, lack of hygiene and comfort of the premises were criticized by the women interviewed at home.

CONCLUSION

The current maternal care system fails to effectively deal with obstetric complications. It needs to be better resourced, more easily available, cheaper and take into account the women's needs.

Occupational working conditions as risk factors for preterm birth in Benin, West Africa

BACKGROUND

Although many studies from developed countries have established a relationship between various occupational working conditions during pregnancy and preterm birth, there is little data available in developing countries where both maternal physical labor during pregnancy and preterm birth are common. The aim of this study was to examine the association between difficult occupational working conditions of pregnant women and premature births in the Republic of Benin in West Africa.

METHOD

The case-control study included 99 women with preterm babies and 104 women with full-term babies. The participants were residents of the Republic of Benin who delivered between May 1, 2000 and April 30, 2002. Preterm delivery was defined as delivery prior to 37 completed weeks of gestation. The study sample was selected randomly from birth records. Data were collected both reviewing birth records and conducting semi-structured personal interviews with mothers. Logistic regression models were adjusted for mother's age, mother's education, health problems during pregnancy, and twin birth.

RESULTS

Although working state of mother during pregnancy did not increase the risk for preterm delivery, carrying heavy loads more than 5 days per week was significantly associated with having a preterm baby (adjusted OR: 5.0; 95% CI: 1.38-18.8; P=0.018). Carrying heavy loads and having worked a lot more than 5 days per week was also significantly associated with preterm birth (adjusted OR: 6.88; 95% CI: 1.45-32.2; P=0.015).

CONCLUSION

Reducing heavy loads carrying during pregnancy may also prevent preterm delivery in developing countries. Though replication of these data using a prospective design is needed, our results suggest that educating women about the risks associated with heavy labor during pregnancy is indicated.

Please understand when I cry out in pain: women's accounts of maternity services during labour and delivery in Ghana

BACKGROUND

This study was undertaken to investigate women's accounts of interactions with health care providers during labour and delivery and to assess the implications for acceptability and utilisation of maternity services in Ghana.

METHODS

Twenty-one individual in-depth interviews and two focus group discussions were conducted with women of reproductive age who had delivered in the past five years in the Greater Accra Region. The study investigated women's perceptions and experiences of care in terms of factors that influenced place of delivery, satisfaction with services, expectations of care and whether they would recommend services.

RESULTS

One component of care which appeared to be of great importance to women was staff attitudes. This factor had considerable influence on acceptability and utilisation of services. Otherwise, a successful labour outcome and non-medical factors such as cost, perceived quality of care and proximity of services were important. Our findings indicate that women expect humane, professional and courteous treatment from health professionals and a reasonable standard of physical environment. Women will consciously change their place of delivery and recommendations to others if they experience degrading and unacceptable behaviour.

CONCLUSION

The findings suggest that inter-personal aspects of care are key to women's expectations, which in turn govern satisfaction. Service improvements which address this aspect of care are likely to have an impact on health seeking behaviour and utilisation. Our findings suggest that user-views are important and warrant further investigation. The views of providers should also be investigated to identify channels by which service improvements, taking into account women's views, could be operationalised. We also recommend that interventions to improve delivery care should not only be directed to the health professional, but also to general health system improvements.

Utilization of delivery services at the primary health care level in rural Vietnam

The objective of this study is to investigate factors that influence the utilization of delivery services at the primary health care level in rural Vietnam. A quantitative survey was conducted amongst 200 women who had given birth within the past 3 months. Focus group discussions and in-depth-interviews were then undertaken using the attitudes--social influence--self-efficacy model to obtain complementary information on the delivery decision. The results show that client-perceived quality of services and socio-cultural and economic factors, rather than geographical access, can affect the utilization of delivery services. It is therefore important to improve the cost-efficiency of the health care network, and delivery services should be provided in a client-oriented manner taking into account economic, social and cultural factors.

A qualitative study of women's perspectives of antenatal care in a rural area of Zimbabwe

OBJECTIVE

To describe the perspectives and experiences of women in their use of antenatal care and in their reasoning on specific antenatal care routines.

DESIGN

Two qualitative methods including focus group discussions and individual interviews were combined.

SETTING

: a rural district in Zimbabwe where a randomised control trial had been undertaken to introduce a new antenatal care package.

PARTICIPANTS

Forty-four women and twenty-four men participated in the study.

FINDINGS

Women were observed to take actions contrary to those assumed professionally acceptable in antenatal care generally and in some specific changed routines. Visits were to be reduced and weighing was to be omitted, but women, especially younger women, said they preferred more than the stipulated five goal oriented visits. One reason for this was the importance of being assured that the fetus was growing well. They considered that visits spaced too widely would make it difficult for service providers to help, should complications develop. On the other hand, older women (above 35 years old), a group professionally considered to be at high risk, were not so concerned with the visits. All the women said they wanted to be weighed at all the visits. The antenatal care visits are simply known as 'going for scale'. The health care providers complied by weighing the women without recording. Cultural beliefs had great influence, especially on the time a pregnancy is acknowledged and reported. It is believed that pregnant women and the pregnancy are vulnerable to witchcraft during the early period of pregnancy.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

We concluded that, whether in its traditional or new form, antenatal care ignores the experiences and views of women and the way they make sense of pregnancy and the care of pregnancy. The importance of understanding the perspectives of different stakeholders as the key to effective change is underlined.

Low use of rural maternity services in Uganda: impact of women's status, traditional beliefs and limited resources

In Uganda, lack of resources and skilled staff to improve quality and delivery of maternity services, despite good policies and concerted efforts, have not yielded an increase in utilisation of these services by women or a reduction in the high ratio of maternal deaths. This paper reports a study conducted from November 2000 to October 2001 in Hoima, a rural district in western Uganda, whose aim was to enhance understanding of why, when faced with complications of pregnancy or delivery, women continue to choose high risk options leading to severe morbidity and even their own deaths. The findings demonstrate that adherence to traditional birthing practices and beliefs that pregnancy is a test of endurance and maternal death a sad but normal event, are important factors. The use of primary health units and the referral hospital, including when complications occur, was considered only as a last resort. Lack of skilled staff at primary health care level, complaints of abuse, neglect and poor treatment in hospital and poorly understood reasons for procedures, plus health workers' views that women were ignorant, also explain the unwillingness of women to deliver in health facilities and seek care for complications. Appropriate interventions are needed to address the barriers between rural mothers and the formal health care system, including community education on all aspects of essential obstetric care and sensitisation of service providers to the situation of rural mothers.