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Barabara ML, Cohen SR, Masenga G, Minja LM, Mlay PS, Stephens MJ, Olomi GA, Mlay J, Marchand V, Weglarz A, Hanson O, Mmbaga BT, Watt MH. Factors associated with respectful maternity care and influence of HIV status among women giving birth in Kilimanjaro, Tanzania. Birth 2024; 51:307-318. [PMID: 37902177 PMCID: PMC11058110 DOI: 10.1111/birt.12787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/25/2023] [Accepted: 09/26/2023] [Indexed: 10/31/2023]
Abstract
BACKGROUND Respectful maternity care (RMC) is a rights-based approach to childbirth that centers the dignity, autonomy, and well-being of birthing women. This study aimed to examine factors associated with RMC among women giving birth in Tanzania and to examine whether HIV status was associated with self-reported RMC. METHODS We enrolled 229 postpartum women in six clinics in the Kilimanjaro Region; of them, 103 were living with HIV. Participants completed a survey within 48 h after birth before being discharged. RMC was measured using a 30-item scale with three subscales (dignity and respect; supportive care; communication and autonomy), each standardized from 0 to 100. Univariable and multivariable regression models examined factors associated with RMC. RESULTS The median score of the full RMC score was 74, differing slightly by subscale: 83 for dignity and respect, 76 for supportive care, and 67 for communication and autonomy. RMC did not differ by HIV status (median 67.0 vs. 67.0, p = 0.89). In multivariable linear regression, women who would not recommend the birth facility to their friends and who did not receive breastfeeding education had significantly lower RMC scores on the full RMC scale. In the dignity and respect subscale, variables associated with significantly lower RMC scores were not being able to read and write, delivering in a public facility, and delivering vaginally. CONCLUSIONS Although self-reported RMC was generally high, we identified areas for improvement. Practitioners need ongoing training on RMC principles and the delivery of equitable care.
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Affiliation(s)
- Mariam L. Barabara
- Kilimanjaro Christian Medical University College, Tanzania - PhD candidate
| | - Susanna R. Cohen
- University of Utah, Department of Obstetrics and Gynecology, Utah – Research Associate Professor
| | - Gileard Masenga
- Kilimanjaro Christian Medical Center Consultant Hospital, Tanzania – Executive Director
| | - Linda M. Minja
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania – Statistician
| | - Pendo S. Mlay
- Kilimanjaro Christian Medical Center, Department of Obstetrics and Gynecology, Tanzania – Chair and Consultant Obstetric and Gynaecologist
| | - Maya J. Stephens
- University of Utah, Department of Population Health Sciences, Utah – Research Coordinator
| | - Gaudensia A. Olomi
- Kilimanjaro Regional Secretary’s Office – Health Management Department, Tanzania – Regional Nursing Officer and Regional Research Director
| | - Janeth Mlay
- Kilimanjaro Clinical Research Institute, Tanzania – Research Assistant
| | | | - Anya Weglarz
- University of Utah, Department of Population Health Sciences, Utah – Research Assistant
| | - Olivia Hanson
- University of Utah, Department of Population Health Sciences, Utah – Research Assistant
| | | | - Melissa H. Watt
- University of Utah, Department of Population Health Sciences, Utah - Research Associate Professor
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Utilization of Maternal Healthcare Services among Adolescent Mothers in Indonesia. Healthcare (Basel) 2023; 11:healthcare11050678. [PMID: 36900683 PMCID: PMC10000571 DOI: 10.3390/healthcare11050678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/19/2023] [Accepted: 02/23/2023] [Indexed: 03/03/2023] Open
Abstract
Providing maternal healthcare services is one of the strategies to decrease maternal mortality. Despite the availability of healthcare services, research investigating the utilization of healthcare services for adolescent mothers in Indonesia is still limited. This study aimed to examine the utilization of maternal healthcare services and its determinants among adolescent mothers in Indonesia. Secondary data analysis was performed using the Indonesia Demographic and Health Survey 2017. Four hundred and sixteen adolescent mothers aged 15-19 years were included in the data analysis of frequency of antenatal care (ANC) visits and place of delivery (home/traditional birth vs. hospital/birth center) represented the utilization of maternal healthcare services. Approximately 7% of the participants were 16 years of age or younger, and over half lived in rural areas. The majority (93%) were having their first baby, one-fourth of the adolescent mothers had fewer than four ANC visits and 33.5% chose a traditional place for childbirth. Pregnancy fatigue was a significant determinant of both antenatal care and the place of delivery. Older age (OR 2.43; 95% CI 1.12-5.29), low income (OR 2.01; 95% CI 1.00-3.74), pregnancy complications of fever (OR 2.10; 95% CI 1.31-3.36), fetal malposition (OR 2.01; 95% CI1.19-3.38), and fatigue (OR 3.63; 95% CI 1.27-10.38) were significantly related to four or more ANC visits. Maternal education (OR 2.14; 95% CI 1.35-3.38), paternal education (OR 1.62; 95% CI 1.02-2.57), income level (OR 2.06; 95% CI 1.12-3.79), insurance coverage (OR 1.68; 95% CI 1.11-2.53), and presence of pregnancy complications such as fever (OR 2.03; 95% CI 1.33-3.10), convulsion (OR 7.74; 95% CI 1.81-32.98), swollen limbs (OR 11.37; 95% CI 1.51-85.45), and fatigue (OR 3.65; 95% CI 1.50-8.85) were significantly related to the place of delivery. Utilization of maternal healthcare services among adolescent mothers was determined by not only socioeconomic factors but also pregnancy complications. These factors should be considered to improve the accessibility, availability, and affordability of healthcare utilization among pregnant adolescents.
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Girma D, Waleligne A, Dejene H. Birth preparedness and complication readiness practice and associated factors among pregnant women in Central Ethiopia, 2021: A cross-sectional study. PLoS One 2022; 17:e0276496. [PMID: 36301854 PMCID: PMC9612452 DOI: 10.1371/journal.pone.0276496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/09/2022] [Indexed: 11/05/2022] Open
Abstract
Background Birth preparedness and complication readiness (BP/CR) is an intervention designated by the World Health Organization (WHO) as an essential element of the antenatal (ANC) package with a concept of a global strategy to reduce maternal mortality. In Ethiopia, the proportion of pregnant women preparing for birth and related complications has remained low. Whereas, the need for additional study is indicated to add more evidence to the country’s efforts to end preventable maternal death. Methods A facility-based cross-sectional study was conducted from March 01 to May 01, 2021. A systematic random sampling technique was applied to recruit 422 pregnant women. Bivariable and multivariable binary logistic regression was fitted to identify factors associated with BP/CR practice. Variables with a p-value ≤ 0.25 on the bivariable analysis were included in multivariable analysis. Adjusted odds ratios (AOR) with the respective 95% confidence interval (CI) and a p-value <0.05 was used to set statistically significant variables in the multivariable analysis. Results A total of 414 pregnant women have participated in the study. The overall BP/CR practice level was 44.9% (95% CI: 40.1, 49.7). Preconception care utilization (PCC) (AOR = 2.31; 95% CI:1.38–3.86), urban residents (AOR = 2.00; 95% CI:1.21–3.31), knowledge of BP/CR (AOR = 2.29; 95% CI:1.27–3.47), knowledge of danger signs during pregnancy (AOR = 2.05; 95% CI:1.21–3.47), knowledge of danger signs in newborns (AOR = 2.06; 95% CI:1.21–3.47), starting ANC visits in the 1st and 2nd trimester (AOR = 2.52; 95% CI:1.40–4.52), number of ANC visit ≥ three (AOR = 1.66; 95% CI;1.01–2.74), knowing Expected Date of Delivery (EDD) (AOR = 3.71; 95% CI:2.01–6.82), and joint decision-making on obstetric services (AOR = 3.51; 95% CI;1.99–6.20) were factors significantly associated with BP/CR practice. Conclusion Based on the WHO standard, this study revealed a low level of BP/CR practice among pregnant women, with only less than half of women adequately prepared for childbirth and its complications. Moreover, it has been shown that BP/CR practice is influenced by socio-economic, maternal knowledge, and health service-related factors. Therefore, improving the status of BP/CR practice by expanding awareness creation opportunities, strengthening PCC and early ANC initiation by improving pregnant women’s understanding, and promoting joint decision-making on obstetric services are recommended.
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Affiliation(s)
- Derara Girma
- Public Health Department, College of Health Sciences, Salale University, Fitche, Oromia Regional State, Central Ethiopia
- * E-mail:
| | - Addisu Waleligne
- Public Health Department, College of Health Sciences, Salale University, Fitche, Oromia Regional State, Central Ethiopia
| | - Hiwot Dejene
- Public Health Department, College of Health Sciences, Salale University, Fitche, Oromia Regional State, Central Ethiopia
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Straneo M, Beňová L, van den Akker T, Pembe AB, Smekens T, Hanson C. No increase in use of hospitals for childbirth in Tanzania over 25 years: Accumulation of inequity among poor, rural, high parity women. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000345. [PMID: 36962703 PMCID: PMC10021586 DOI: 10.1371/journal.pgph.0000345] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 07/14/2022] [Indexed: 11/19/2022]
Abstract
Improving childbirth care in rural settings in sub-Saharan Africa is essential to attain the commitment expressed in the Sustainable Development Goals to leave no one behind. In Tanzania, the period between 1991 and 2016 was characterized by health system expansion prioritizing primary health care and a rise in rural facility births from 45% to 54%. Facilities however are not all the same, with advanced management of childbirth complications generally only available in hospitals and routine childbirth care in primary facilities. We hypothesized that inequity in the use of hospital-based childbirth may have increased over this period, and that it may have particularly affected high parity (≥5) women. We analysed records of 16,080 women from five Tanzanian Demographic and Health Surveys (1996, 1999, 2004, 2010, 2015/6), using location of the most recent birth as outcome (home, primary health care facility or hospital), wealth and parity as exposure variables and demographic and obstetric characteristics as potential confounders. A multinomial logistic regression model with wealth/parity interaction was run and post-estimation margins analysis produced percentages of births for various combinations of wealth and parity for each survey. We found no reduction in inequity in this 25-year period. Among poorest women, lowest use of hospital-based childbirth (around 10%) was at high parity, with no change over time. In women having their first baby, hospital use increased over time but with a widening pro-rich gap (poorest women predicted use increased from 36 to 52% and richest from 40 to 59%). We found that poor rural women of high parity were a vulnerable group requiring specifically targeted interventions to ensure they receive effective childbirth care. To leave no one behind, it is essential to look beyond the average coverage of facility births, as such a limited focus masks different patterns and time trends among marginalised groups.
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Affiliation(s)
- Manuela Straneo
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- Athena Institute, VU University, Amsterdam, The Netherlands
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Lenka Beňová
- Institute of Tropical Medicine, Antwerp, Belgium
- London School of Hygiene &Tropical Medicine, London, United Kingdom
| | - Thomas van den Akker
- Athena Institute, VU University, Amsterdam, The Netherlands
- Department of Obstetrics and Gynecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Andrea B Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Tom Smekens
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- London School of Hygiene &Tropical Medicine, London, United Kingdom
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Lee H, Maffioli EM, Veliz PT, Sakala I, Chiboola NM, Lori JR. Direct and opportunity costs related to utilizing maternity waiting homes in rural Zambia. Midwifery 2021; 105:103211. [PMID: 34894428 PMCID: PMC8811481 DOI: 10.1016/j.midw.2021.103211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 11/13/2021] [Accepted: 11/24/2021] [Indexed: 11/18/2022]
Abstract
Lack of financial resources is a critical barrier to utilising Maternity Waiting Homes (MWHs) in low-income countries (LICs). Food and user fees are most frequent expenditures for women utilising MWHs in rural Zambia. Being away from various household chores, the loss of income generating activities (IGAs), may also be a financial constraint in utilising MWHs.
Aim To assess the direct and opportunity costs involved in utilising maternity waiting homes. Method A cross-sectional admission survey administered to women who used ten maternity waiting homes across two rural districts in Zambia. A total of 3,796 women participated in the survey. Descriptive analysis was conducted on three domains of the data: demographic characteristics of women, direct costs, and opportunity costs. Findings Waiting to deliver (86.3%), safe birth (70.8%), and distance (56.0%) were the most frequent reasons women reported for using a maternity waiting home. In terms of direct costs, roughly 65% of the women brought seven days or fewer days' worth of food to the maternity waiting homes, with salt, mealie meals, and vegetables being the most frequently brought items. Only 5.8% of the women spent money on transport. More than half of the women reported paying user fees that ranged from 1 to 5 or more kwacha (US$0.10- 0.52). In terms of opportunity costs, 52% of the women participated in some form of income generating activities (IGAs) when at home. Approximately 35% of the women reported they lost earned income (1 to 50 or more kwacha) by staying at a maternity waiting home. Conclusion A large proportion of women paid for food and user fees to access a maternity waiting home, while a low number of women paid for transport. Even though it is difficult to assign monetary value to women's household chores, being away from these responsibilities and the potential loss of earned income appear to remain a cost to accessing maternity waiting homes. More research is needed to understand how to overcome these financial constraints and assist women in utilising a maternity waiting home.
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Affiliation(s)
- HaEun Lee
- School of Nursing, University of Michigan, 400 N Ingalls St. Ann Arbor, MI 48104, United States.
| | - Elisa M Maffioli
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, United States
| | - Philip T Veliz
- School of Nursing, University of Michigan, 400 N Ingalls St. Ann Arbor, MI 48104, United States
| | - Isaac Sakala
- Africare Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road, Ibex Hill, Box 33921 Lusaka, Zambia
| | - Nchimunya M Chiboola
- Africare Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road, Ibex Hill, Box 33921 Lusaka, Zambia
| | - Jody R Lori
- School of Nursing, University of Michigan, 400 N Ingalls St. Ann Arbor, MI 48104, United States
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Gardiner E, Lai JF, Khanna D, Meza G, de Wildt G, Taylor B. Exploring women's decisions of where to give birth in the Peruvian Amazon; why do women continue to give birth at home? A qualitative study. PLoS One 2021; 16:e0257135. [PMID: 34506573 PMCID: PMC8432815 DOI: 10.1371/journal.pone.0257135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 08/24/2021] [Indexed: 11/18/2022] Open
Abstract
Background Despite improvements in maternal mortality globally, hundreds of women continue to die daily. The World Health Organisation therefore advises all women in low-and-middle income countries to give birth in healthcare facilities. Barriers to seeking intrapartum care have been described in Thaddeus and Maine’s Three Delays Model, however these decisions are complex and often unique to different settings. Loreto, a rural province in Peru has one of the highest homebirth rates in the country at 31.8%. The aim of this study was to explore facilitators and barriers to facility births and explore women’s experiences of intrapartum care in Amazonian Peru. Methods Through purposive sampling, postnatal women were recruited for semi-structured interviews (n = 25). Interviews were transcribed verbatim and thematically analysed. A combination of deductive and inductive coding was used. Analytical triangulation was undertaken, and data saturation was used to determine when no further interviews were necessary. Results Five themes were generated from the data: 1) Financial barriers; 2) Accessing care; 3) Fear of healthcare facilities; 4) Importance of seeking care and 5) Comfort and traditions of home. Generally, participants realised the importance of seeking skilled care however barriers persisted, across all areas of the Three Delays Model. Barriers identified included fear of healthcare facilities and interventions, direct and indirect costs, continuation of daily activities, distance and availability of transport. Women who delivered in healthcare facilities had mixed experiences, many reporting good attention, however a selection experienced poor treatment including abusive behaviour. Conclusion Despite free care, women continue to face barriers seeking obstetric care in Amazonian Peru, including fear of hospitals, cost and availability of transport. However, women accessing care do not always receive positive care experiences highlighting implications for changes in accessibility and provision of care. Minimising these barriers is critical to improve maternal and neonatal outcomes in rural Peru.
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Affiliation(s)
- Esme Gardiner
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- * E-mail:
| | - Jo Freda Lai
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Divya Khanna
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Graciella Meza
- Facultad de Medicina Human, Universidad Nacional de la Amazonía Peruana, Iquitos, Peru
| | - Gilles de Wildt
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Beck Taylor
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
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Camara BS, Benova L, Delvaux T, Sidibé S, El Ayadi AM, Grietens KP, Delamou A. Women's progression through the maternal continuum of care in Guinea: Evidence from the 2018 Guinean Demographic and Health Survey. Trop Med Int Health 2021; 26:1446-1461. [PMID: 34310807 PMCID: PMC9292596 DOI: 10.1111/tmi.13661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objective To examine women's progression through the antenatal, birth, and post‐partum maternal care in Guinea in 2018. Methods Using the Guinea Demographic and Health Survey of 2018, we analysed data on most recent live births in the 24 months preceding the survey among women aged 15–49 and the determinants (health system, quality of care, reproductive and sociodemographic factors) of women's progression through three steps of the continuum of care, using multivariable logistic regression. Results In the sample of 3,018 women, 87% reported at least one ANC visit (ANC1) with a health professional and 36% reported ANC4+, at least one of which was with a health professional. In the study, 26% of women reported ANC4+ plus birth in a health facility, and 20% reported ANC4+, birth in a health facility, plus post‐partum check‐up. Predictors of woman's progression from ANC1 to ANC4+ visits included living in the administrative regions of Kindia (AOR: 1.96, 95% CI: 1.23–3.14) and Nzérékoré (AOR: 0.50, 95% CI: 0.32–0.79) vs. Kankan, being aged 15 to 17 (AOR: 0.55, 95% CI: 0.35–0.86) vs. aged 25 to 34, having primary or more education (AOR: 1.37, 95% CI: 1.09–1.72), and being from a middle (AOR: 1.52, 95% CI: 1.18–1.96) or wealthier (AOR: 2.38, 95% CI: 1.67–3.39) household vs. a poor household. Living in the administrative regions of Nzérékoré (AOR: 6.27, 95% CI: 1.57–25.05) vs. Kankan, in a middle (AOR: 1.64, 95% CI: 1.05–2.57) or wealthier (AOR: 3.23, 95% CI: 1.98–5.29) household vs. a poor household, nulliparity (AOR: 1.75, 95% CI: 1.03–2.97) vs. 2–4 previous births, the distance to health facility perceived as not being a problem (AOR: 1.75, 95% CI: 1.23–2.50), and higher ANC content score (AOR: 1.29, 95% CI: 1.10–1.52) remained independently associated with progression from ANC4+ to birth in a health facility. Predictors of progression from birth in the health facility to post‐partum check‐up included residing in the administrative regions of Labé (AOR: 0.22, 95% CI: 0.09–0.51) or Faranah (AOR: 0.43, 95% CI: 0.19–0.96) vs. Kankan, higher ANC content score (AOR: 1.76, 95% CI: 1.36–2.28), skin‐to‐skin contact after birth (AOR: 3.00, 95% CI: 1.70–5.31), and being attended at birth by a health professional (AOR: 17.52, 95% CI: 4.68–65.54). Conclusions Removing financial barriers and improving quality of care appear to be important to increase the percentage of women receiving the full maternal continuum of care.
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Affiliation(s)
- Bienvenu Salim Camara
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands.,Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Thérèse Delvaux
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Sidikiba Sidibé
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea.,Centre d'Excellence Africain pour la Prévention et le Contrôle des Maladies Transmissibles (CEA-PCMT), Université Gamal Abdel Nasser, Conakry, Guinea
| | - Alison Marie El Ayadi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, California, USA
| | | | - Alexandre Delamou
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea.,Centre d'Excellence Africain pour la Prévention et le Contrôle des Maladies Transmissibles (CEA-PCMT), Université Gamal Abdel Nasser, Conakry, Guinea
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Lee H, Maffioli EM, Veliz PT, Munro-Kramer ML, Phiri TK, Sakala I, Kaunda J, Chiboola NM, Lori JR. Role of Savings and Internal Lending Communities (SILCs) in improving household wealth and financial preparedness for birth in rural Zambia. Health Policy Plan 2021; 36:1269-1278. [PMID: 33909075 PMCID: PMC8428586 DOI: 10.1093/heapol/czab049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/23/2021] [Accepted: 04/14/2021] [Indexed: 12/15/2022] Open
Abstract
Savings and Internal Lending Communities (SILCs) are a type of informal microfinance mechanism adapted in many low- and middle-income countries (LMICs) to improve financial resources for poor and rural communities. Although SILCs are often paired with other health and non-health-related interventions, few studies have examined SILCs in the context of maternal health. This study examined the association between SILC participation, household wealth and financial preparedness for birth. The study also examined the association between sex and financial preparedness for birth. A secondary analysis was conducted on individual survey data collected from SILC participants in two rural districts of Zambia between October 2017 and February 2018. A convenience sample of 600 participants (Lundazi: n = 297; Mansa: n = 303) was analysed. Descriptive analyses were run to examine SILC participation and household wealth. Multiple binary logistic regression models were fit to assess the unadjusted and adjusted relationship between (1) SILC participation and household wealth, (2) SILC participation and financial preparedness for birth and (3) sex and financial preparedness for birth. The results show that SILC participation led to an average increase of 7.32 items of the 13 household wealth items. SILC participants who had their most recent childbirth after joining SILCs were more likely to be financially prepared for birth [adjusted odds ratio (AOR): 2.99; 95% confidence interval (95% CI): 1.70-5.26; P < 0.001] than participants who had their most recent childbirth before joining SILCs. Females were more likely to be financially prepared for birth than males if they had their most recent birth before joining an SILC (AOR: 1.79; 95% CI: 1.16-2.66; P < 0.01). SILC participation is shown to increase household wealth and financial preparedness for birth for both men and women. SILCs are a promising intervention that can help poor and rural populations by increasing financial resources and financially preparing parents for birth.
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Affiliation(s)
- HaEun Lee
- Health Behavior and Biological Sciences, University of Michigan, School of Nursing, 400 North Ingalls Street, Ann Arbor, MI 48109-5482, USA
| | - Elisa M Maffioli
- Health Management and Policy, University of Michigan, School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, USA
| | - Philip T Veliz
- Applied Biostatistics Laboratory, University of Michigan, School of Nursing, 400 North Ingalls Street, Ann Arbor, MI 48109-5482, USA
| | - Michelle L Munro-Kramer
- Health Behavior and Biological Sciences, University of Michigan, School of Nursing, 400 North Ingalls Street, Ann Arbor, MI 48109-5482, USA
| | - Tenford K Phiri
- Africare Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road, Ibex Hill, Lusaka 33921, Zambia
| | - Isaac Sakala
- Africare Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road, Ibex Hill, Lusaka 33921, Zambia
| | - Jameson Kaunda
- Africare Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road, Ibex Hill, Lusaka 33921, Zambia
| | - Nchimunya M Chiboola
- Africare Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road, Ibex Hill, Lusaka 33921, Zambia
| | - Jody R Lori
- Associate Dean of Global Affairs, Health Behavior and Biological Sciences, University of Michigan, School of Nursing, 400 North Ingalls Street, Ann Arbor, MI 48109-5482, USA
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Eze II, Mbachu CO, Ossai EN, Nweze CA, Uneke CJ. Unlocking community capabilities for addressing social norms/practices: behavioural change intervention study to improve birth preparedness and complication readiness among pregnant women in rural Nigeria. BMC Pregnancy Childbirth 2020; 20:369. [PMID: 32571247 PMCID: PMC7310128 DOI: 10.1186/s12884-020-03061-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/16/2020] [Indexed: 11/16/2022] Open
Abstract
Background Maternal mortality is attributed to combination of contextual factors that cause delay in seeking care, leading to poor utilization of skilled health services. Community participation is one of the acknowledged strategies to improve health services utilization amongst the poor and rural communities. The study aimed at assessing the potentials of improving birth preparedness and complication readiness (BP/CR) using community-driven behavioural change intervention among pregnant women in rural Nigeria. Methods A pre-post intervention study was conducted from June 2018 to October 2019 on 158 pregnant women selected through multi-stage sampling technique from 10 villages. Data on knowledge and practices of birth preparedness and utilization of facility health services were collected through interviewer-administered pre-tested structured questionnaire. Behavioural change intervention comprising of stakeholders’ engagement, health education, facilitation of emergency transport and fund saving system, and distribution of educational leaflets/posters were delivered by twenty trained volunteer community health workers. The intervention activities focused on sensitization on danger signs of pregnancy, birth preparedness and complication readiness practices and emergency response. Means, standard deviations, and percentages were calculated for descriptive statistics; and T-test and Chi square statistical tests were carried out to determine associations between variables. Statistical significance was set at p-value < 0.05. Results The result showed that after the intervention, mean knowledge score of danger signs of pregnancy increased by 0.37 from baseline value of 3.94 (p < 0.001), and BP/CR elements increased by 0.27 from baseline value of 4.00 (p < 0.001). Mean score for BP/CR practices increased significantly by 0.22 for saving money. The proportion that had antenatal care (76.6%) and had facility delivery (60.0%) increased significantly by 8.2 and 8.3% respectively. Participation in Community-related BP/CR activities increased by 11.6% (p = 0.012). Conclusion With the improvements recorded in the community-participatory intervention, birth preparedness and complication readiness should be promoted through community, household and male-partner inclusive strategies. Further evaluation will be required to ascertain the sustainability and impact of the programme.
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Affiliation(s)
- Irene Ifeyinwa Eze
- Department of Community Medicine, College of Medicine, Ebonyi State University, Abakaliki, Nigeria. .,African Institute for Health Policy and Health Systems, Ebonyi State University, Abakaliki, Nigeria.
| | - Chinyere Ojiugo Mbachu
- Department of Community Medicine, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria
| | - Edmund Ndudi Ossai
- Department of Community Medicine, College of Medicine, Ebonyi State University, Abakaliki, Nigeria
| | - Celestina Adaeze Nweze
- African Institute for Health Policy and Health Systems, Ebonyi State University, Abakaliki, Nigeria
| | - Chigozie Jesse Uneke
- African Institute for Health Policy and Health Systems, Ebonyi State University, Abakaliki, Nigeria
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10
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Naanyu V, Mujumdar V, Ahearn C, McConnell M, Cohen J. Why do women deliver where they had not planned to go? A qualitative study from peri-urban Nairobi Kenya. BMC Pregnancy Childbirth 2020; 20:30. [PMID: 31931745 PMCID: PMC6958584 DOI: 10.1186/s12884-019-2695-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 12/23/2019] [Indexed: 11/22/2022] Open
Abstract
Background In urban Kenya, couples face a wide variety of choices for delivery options; however, many women end up delivering in different facilities from those they had intended while pregnant. One potential consequence of this is delivering in facilities that do not meet minimum quality standards and lack the capacity to provide treatment for obstetric and neonatal complications. Methods This study investigated why women in peri-urban Nairobi, Kenya deliver in facilities they had not intended to use. We used 60 in-depth audio-recorded interviews in which mothers shared their experiences 2–6 months after delivery. Descriptive statistics were used to summarize socio-demographic characteristics of participants. Qualitative data were analyzed in three steps i) exploration and generation of initial codes; ii) searching for themes by gathering coded data that addressed specific themes; and iii) defining and naming identified themes. Verbatim excerpts from participants were provided to illustrate study findings. The Health Belief Model was used to shed light on individual-level drivers of delivery location choice. Results Findings show a confluence of factors that predispose mothers to delivering in unintended facilities. At the individual level, precipitate labor, financial limitations, onset of pain, complications, changes in birth plans, undisclosed birth plans, travel during pregnancy, fear of health facility providers, misconception of onset of labor, wrong estimate of delivery date, and onset of labor at night, contributed to delivery at unplanned locations. On the supply side, the sudden referral to other facilities, poor services, wrong projection of delivery date, and long distance to chosen delivery facility, were factors in changes in delivery location. Lack of transport discouraged delivery at a chosen health facility. Social influences included others’ perspectives on delivery location and lack of aides/escorts. Conclusions Results from this study suggest that manifold factors contribute to the occurrence of women delivering in facilities that they had not intended during pregnancy. Future studies should consider whether these changes in delivery location late in pregnancy contribute to late facility arrival and the use of lower quality facilities. Deliberate counseling during antenatal care regarding birth plans is likely to encourage timely arrival at facilities consistent with women’s preferences.
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Affiliation(s)
- V Naanyu
- Department of Health Policy and Management, School of Public Health, College of Health Science, Moi University, Eldoret, Kenya.
| | - V Mujumdar
- Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - C Ahearn
- Department of HIV, ID and Global Medicine, UCSF, San Francisco, California, USA
| | - M McConnell
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - J Cohen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
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11
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Shimpuku Y, Madeni FE, Horiuchi S, Kubota K, Leshabari SC. A family-oriented antenatal education program to improve birth preparedness and maternal-infant birth outcomes: A cross sectional evaluation study. Reprod Health 2019; 16:107. [PMID: 31311563 PMCID: PMC6636146 DOI: 10.1186/s12978-019-0776-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 07/10/2019] [Indexed: 11/12/2022] Open
Abstract
Background In Tanzania, the information on Birth Preparedness and Complication Readiness is insufficiently provided to pregnant women and their families. The aim of this study was to evaluate the maternal and infant outcomes of a family-oriented antenatal group education program that promotes Birth Preparedness and Complication Readiness in rural Tanzania. Methods Pregnant women and families were enrolled in a program about nutrition and exercise, danger signs, and birth preparedness. The cross sectional survey was conducted one year later to evaluate if the participants of the program (intervention group) were different from those who did not participate (control group) with respect to birth-preparedness and maternal and infant outcomes. Results A total of 194 participants (intervention group, 50; control group, 144) were analyzed. For Birth Preparedness and Complication Readiness, the intervention group participants knew a health facility in case of emergency (OR: 3.11, 95% CI: 1.39–6.97); arranged accompaniment to go to a health facility for birth (OR: 2.56, 95% CI: 1.17–5.60); decided the birthplace with or by the pregnant women (OR: 3.11, 95% CI: 1.44–6.70); and attended antenatal clinic more than four times (OR: 2.39, 95% CI: 1.20–4.78). For birth outcomes, the intervention group had less bleeding or seizure during labour and birth (OR: 0.28, 95%CI: 0.13–0.58); fewer Caesarean sections (OR: 0.16, 95% CI: 0.07–0.36); and less neonatal complications (OR: 0.28, 95% CI: 0.13–0.60). Conclusions The four variables were significantly better in the intervention group, i.e., identifying a health facility for emergencies, family accompaniment for facility birth, antenatal visits, and involvement of women in decision-making, which may be key factors for improving birth outcome variables. Having identified these key factors, male involvement and healthy pregnant lives should be emphasized in antenatal education to reduce pregnancy and childbirth complications. Trial registration No.2013–273-NA-2013-101. Registered 12 August 2013.
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Affiliation(s)
- Yoko Shimpuku
- Graduate School of Medicine, Kyoto University, 53 Shogoin-kawaharacho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Frida E Madeni
- Magunga District Hospital, P. O. Box 430, Old-Korogwe, Tanga, Tanzania
| | - Shigeko Horiuchi
- Graduate School of Nursing Science, St. Luke's International University, 10-1 Akashi-cho, Chuo-ku, Tokyo, 104-0044, Japan
| | - Kazumi Kubota
- Department of Biostatistics, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Sebalda C Leshabari
- School of Nursing, Muhimbili University of Health and Allied Sciences, P. O. Box 65169, Dar es Salaam, Tanzania
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12
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Shelley KD, Mpembeni R, Frumence G, Stuart EA, Killewo J, Baqui AH, Peters DH. Integrating Community Health Worker Roles to Improve Facility Delivery Utilization in Tanzania: Evidence from an Interrupted Time Series Analysis. Matern Child Health J 2019; 23:1327-1338. [PMID: 31228143 DOI: 10.1007/s10995-019-02783-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Despite renewed interest in expansion of multi-tasked community health workers (CHWs) there is limited research on HIV and maternal health integration at the community-level. This study assessed the impact of integrating CHW roles for HIV and maternal health promotion on facility delivery utilization in rural Tanzania. METHODS A 36-month time series data set (2014-2016) of reported facility deliveries from 68 health facilities in two districts of Tanzania was constructed. Interrupted time series analyses evaluated population-averaged longitudinal trends in facility delivery at intervention and comparison facilities. Analyses were stratified by district, controlling for secular trends, seasonality, and type of facility. RESULTS There was no significant change from baseline in the average number of facility deliveries observed at intervention health centers/dispensaries relative to comparison sites. However, there was a significant 16% increase (p < 0.001) in average monthly deliveries in hospitals, from an average of 202-234 in Iringa Rural and from 167 to 194 in Kilolo. While total facility deliveries were relatively stable over time at the district-level, during intervention the relative change in the proportion of hospital deliveries out of total facility deliveries increased by 17.2% in Iringa Rural (p < 0.001) and 14.7% in Kilolo (p < 0.001). CONCLUSIONS FOR PRACTICE Results suggest community-delivered outreach by dual role CHWs was successful at mobilizing pregnant women to deliver at facilities and may be effective at reaching previously under-served pregnant women. More research is necessary to understand the effect of dual role CHWs on patterns of service utilization, including decisions to use referral level facilities for obstetric care.
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Affiliation(s)
- Katharine D Shelley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Rose Mpembeni
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Gasto Frumence
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Elizabeth A Stuart
- Department of Mental Health, Department of Biostatistics, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Japhet Killewo
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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13
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Shamba D, Tancred T, Hanson C, Wachira J, Manzi F. Delayed illness recognition and multiple referrals: a qualitative study exploring care-seeking trajectories contributing to maternal and newborn illnesses and death in southern Tanzania. BMC Health Serv Res 2019; 19:225. [PMID: 30975142 PMCID: PMC6460539 DOI: 10.1186/s12913-019-4019-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 03/18/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Maternal and neonatal mortality remain high in southern Tanzania despite an increasing number of births occurring in health facilities. In search for reasons for the persistently high mortality rates, we explored illness recognition, decision-making and care-seeking for cases of maternal and neonatal illness and death. METHODS We conducted 48 in-depth interviews (16 participants who experienced maternal illnesses, 16 mothers whose newborns experienced illness, eight mothers whose newborns died, and eight family members of a household with a maternal death), and five focus group discussions with community leaders in two districts of Mtwara region. Thematic analysis was used for interpretation of findings. RESULTS Our data indicated relatively timely illness recognition and decision-making for maternal complications. In contrast, families reported difficulties interpreting newborn illnesses. Decisions on care-seeking involved both the mother and her partner or other family members. Delays in care-seeking were therefore also reported in absence of the husband, or at night. Primary-level facilities were first consulted. Most respondents had to consult more than one facility and described difficulties accessing and receiving appropriate care. Definitive treatment for maternal and newborn complications was largely only available in hospitals. CONCLUSIONS Delays in reaching a facility that can provide appropriate care is influenced by multiple referrals from one facility to another. Referral and care-seeking advice should include direct care-seeking at hospitals in case of severe complications and primary facilities should facilitate prompt referral.
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Affiliation(s)
- Donat Shamba
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania.
| | - Tara Tancred
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Claudia Hanson
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.,Department of Public Health Sciences-Global Health, Karolinska Institute, Stockholm, Sweden
| | - Juddy Wachira
- School of Medicine/AMPATH, Moi University, Nairobi, Kenya
| | - Fatuma Manzi
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
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Scott NA, Henry EG, Kaiser JL, Mataka K, Rockers PC, Fong RM, Ngoma T, Hamer DH, Munro-Kramer ML, Lori JR. Factors affecting home delivery among women living in remote areas of rural Zambia: a cross-sectional, mixed-methods analysis. Int J Womens Health 2018; 10:589-601. [PMID: 30349403 PMCID: PMC6181475 DOI: 10.2147/ijwh.s169067] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Access to skilled care and facilities with capacity to provide emergency obstetric and newborn care is critical to reducing maternal mortality. In rural areas of Zambia, 42% of women deliver at home, suggesting persistent challenges for women in seeking, reaching, and receiving quality maternity care. This study assessed the determinants of home delivery among remote women in rural Zambia. METHODS A household survey was administered to a random selection of recently delivered women living 10 km or more from their catchment area health facility in 40 sites. A subset of respondents completed an in-depth interview. Multiple regression and content analysis were used to analyze the data. RESULTS The final sample included 2,381 women, of which 240 also completed an interview. Households were a median of 12.8 km (interquartile range 10.9, 16.2) from their catchment area health facility. Although 1% of respondents intended to deliver at home, 15.3% of respondents actually delivered at home and 3.2% delivered en route to a facility. Respondents cited shorter than expected labor, limited availability and high costs of transport, distance, and costs of required supplies as reasons for not delivering at a health facility. After adjusting for confounders, women with a first pregnancy (adjusted OR [aOR]: 0.1, 95% CI: 0.1, 0.2) and who stayed at a maternity waiting home (MWH) while awaiting delivery were associated with reduced odds of home delivery (aOR 0.1, 95% CI: 0.1, 0.2). Being over 35 (aOR 1.3, 95% CI: 0.9, 1.9), never married (aOR 2.1, 95% CI: 1.2, 3.7), not completing the recommended four or more antenatal visits (aOR 2.0, 95% CI: 1.5, 2.5), and not living in districts exposed to a large-scale maternal health program (aOR 3.2, 95% CI: 2.3, 4.5) were significant predictors of home delivery. After adjusting for confounders, living nearer to the facility (9.5-10 km) was not associated with reduced odds of home delivery, though the CIs suggest a trend toward significance (aOR 0.7, 95% CI: 0.4, 1.1). CONCLUSION Findings highlight persistent challenges facing women living in remote areas when it comes to realizing their intentions regarding delivery location. Interventions to reduce home deliveries should potentially target not only those residing farthest away, but multigravida women, those who attend fewer antenatal visits, and those who do not utilize MWHs.
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Affiliation(s)
- Nancy A Scott
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | - Elizabeth G Henry
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | | | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | - Rachel M Fong
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | | | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Michelle L Munro-Kramer
- Department of Health Behavior & Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Jody R Lori
- Department of Health Behavior & Biological Sciences, University of Michigan, School of Nursing, Ann Arbor, MI USA
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15
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Tokhi M, Comrie-Thomson L, Davis J, Portela A, Chersich M, Luchters S. Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions. PLoS One 2018; 13:e0191620. [PMID: 29370258 PMCID: PMC5784936 DOI: 10.1371/journal.pone.0191620] [Citation(s) in RCA: 178] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/08/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Emerging evidence and program experience indicate that engaging men in maternal and newborn health can have considerable health benefits for women and children in low- and middle-income countries. Previous reviews have identified male involvement as a promising intervention, but with a complex evidence base and limited direct evidence of effectiveness for mortality and morbidity outcomes. OBJECTIVE To determine the effect of interventions to engage men during pregnancy, childbirth and infancy on mortality and morbidity, as well as effects on mechanisms by which male involvement is hypothesised to influence mortality and morbidity outcomes: home care practices, care-seeking, and couple relationships. METHODS Using a comprehensive, highly sensitive mapping of maternal health intervention studies conducted in low- and middle-income countries between 2000 and 2012, we identified interventions that have engaged men to improve maternal and newborn health. Primary outcomes were care-seeking for essential services, mortality and morbidity, and home care practices. Secondary outcomes relating to couple relationships were extracted from included studies. RESULTS Thirteen studies from nine countries were included. Interventions to engage men were associated with improved antenatal care attendance, skilled birth attendance, facility birth, postpartum care, birth and complications preparedness and maternal nutrition. The impact of interventions on mortality, morbidity and breastfeeding was less clear. Included interventions improved male partner support for women and increased couple communication and joint decision-making, with ambiguous effects on women's autonomy. CONCLUSION Interventions to engage men in maternal and newborn health can increase care-seeking, improve home care practices, and support more equitable couple communication and decision-making for maternal and newborn health. These findings support engaging men as a health promotion strategy, although evidence gaps remain around effects on mortality and morbidity. Findings also indicate that interventions to increase male involvement should be carefully designed and implemented to mitigate potential harmful effects on couple relationship dynamics.
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Affiliation(s)
- Mariam Tokhi
- Burnet Institute, Melbourne, Victoria, Australia
| | - Liz Comrie-Thomson
- Burnet Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Uro-gynaecology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- * E-mail:
| | | | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Matthew Chersich
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Stanley Luchters
- Burnet Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium
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