Evaluation of maternal and newborn health services in Jordan

Exploring the healthcare needs and experiences of pregnant women with congenital heart disease: A qualitative study

PROBLEM

Little is known regarding the healthcare needs and experiences of pregnant women with congenital heart disease (CHD) during pregnancy.

BACKGROUND

Congenital heart diseases are the most common birth anomalies, and they embrace a wide range of defects ranging from mild to complex and life-threatening defects. Pregnancy carries many physiological and psychological changes that affect pregnant woman with CHD and need special attention and consideration.

AIM

To explore the healthcare needs and experiences of Jordanian women with CHD during pregnancy.

METHODS

A descriptive phenomenological design was used. Utilising purposive sampling, 15 participants were recruited. Data was collected using individualised semi-structured interviews. Interviews were recorded and transcribed verbatim. Data were analyzed using Colaizzi's method.

FINDINGS

Three themes were identified: a) A broad spectrum of health needs during pregnancy, b) not being cared for, c) and the healthcare journey: Challenges and recommendations. Findings revealed that pregnancy in women with CHD is associated with many challenges and needs, and the lived healthcare experiences are mostly negative.

DISCUSSION

This study addresses the healthcare needs and experiences of pregnant women with CHD during pregnancy. Our findings shed light on healthcare needs explored hidden aspects of the experiences of this vulnerable population and gave them the chance to make their voices heard.

CONCLUSION

The study concluded that pregnant women with CHD experience hardship associated with negative challenges and personal suffering. The findings highlight the importance of the basic values and the need for a holistic approach and effective teamwork to minimise suffering among pregnant women with CHD.

Receiving antenatal care via mobile clinic: Lived experiences of Jordanian mothers

Objective

To understand the perceptions of pregnant Jordanian women who received antenatal care via mobile clinic, and to contribute new insights into the experiences of these mothers and how they evaluated the services that were available.

Methods

Ten Jordanian mothers who had received antenatal care at a mobile clinic discussed their experiences in semi-structured, audiotaped interviews in a study that adopted a qualitative research design. The analysis was done using interpretative phenomenological analysis.

Results

Three main themes were identified: Being informed about the medical campaign or missing the opportunity of being informed; The experience of receiving antenatal care was wonderful, although there was only one thing lacking; and they safeguard our life and take any opportunity to educate us.

Conclusion

Data indicate that the mothers were largely satisfied with most facets of the antenatal care services they had received at the mobile clinics. However, while services are generally well received, there are clear opportunities for ameliorating the quality of services provided. For mothers living in remote, deprived areas, outreach is not just an 'optional extra' but rather an essential service.

Physical Intimate Partner Violence and Maternal Outcomes in a Hospital-Based Sample of Pregnant Women in Jordan

AIM

The purpose of this study was to examine the effect of physical intimate partner violence on maternal pregnancy/ birth outcomes.

METHODS

A cross-sectional, descriptive, comparative design was used. Consecutively, 223 birthing women were chosen. Data was collected in 2014 using the Arabic World Health Organization's Domestic Violence Questionnaire.

RESULTS

Results showed that women who had experienced physical violence during pregnancy had a significantly higher risk of pregnancyinduced hypertension, cesarean section, more pain killer use during birth, and excessive use of postnatal medication.

CONCLUSION

Jordanian health policy makers should find a strategy to eliminate intimate partner violence and reduce its negative impact on women. The inclusion of intimate partner violence screening and identification for every pregnant woman is vital. Sufferers should receive a betterfocused care in order for early detection and treatment of complications that are related to intimate partner violence.

The Jordan Stillbirth and Neonatal Mortality Surveillance (JSANDS) System: Evaluation Study

BACKGROUND

The Jordan Stillbirth and Neonatal Mortality Surveillance (JSANDS) is an electronic surveillance system that automatically transfers the data on births, stillbirths, and neonatal deaths to the concerned authorities in the Ministry of Health. JSANDS was implemented and tested in 5 maternity hospitals during the period spanning May 2019 through December 2020.

OBJECTIVE

This study aimed to evaluate the usefulness and performance of JSANDS to register births, stillbirths, and neonatal deaths, and determine their causes. Specifically, this study examined the JSANDS attributes of acceptability, simplicity, flexibility, stability, representativeness, sustainability, penetration, data quality, sensitivity, and adoption.

METHODS

An evaluation study was conducted after 18 months of the JSANDS implementation using the Updated Guidelines for Evaluating Public Health Surveillance Systems. The evaluation focused on how well the system operated to meet its purpose and objectives. The indicators assessing the system attributes were scored on a Likert scale. Each indicator and overall attribute percentage score was represented as score rank and interpreted as excellent (score ≥80%), good (score ≥60 and <80%), average (score ≥40 and <60%), and poor (score <40%).

RESULTS

A total of 270 health care professionals participated in this study and evaluated the system performance. The system users rated the usefulness of JSANDS as excellent (percentage score=85.6%). The overall acceptability (percentage score=82.3%), flexibility (percentage score=80.2%), stability (percentage score=80.0%), and representativeness (percentage score=86.6%) were also rated excellent. The overall simplicity was scored good (percentage score=75.4%). All participants were trained on JSANDS and used it in the past 12 months. Of the 270 respondents, 219 (86.2%) reported that they intend to continue using the JSANDS system to register neonatal deaths and stillbirths in the future. All variables in JSANDS had complete data with no missing values.

CONCLUSIONS

The performance of JSANDS in registering all stillbirths and neonatal deaths as well as their causes was excellent. Almost all attributes and indicators of JSANDS functionality were rated excellent. JSANDS can be scaled up to cover all maternity hospitals in Jordan. The potential for scaling up the system is very high for many reasons, including its usefulness, simplified stillbirth and neonatal death review tools, and ease of the reporting process.

Modifiable Factors and Delays Associated with Neonatal Deaths and Stillbirths in Jordan: Findings from Facility-Based Neonatal Death and Stillbirth Audits

OBJECTIVE

 This study employed the "three-delay" model to investigate the types of critical delays and modifiable factors that contribute to the neonatal deaths and stillbirths in Jordan.

STUDY DESIGN

 A triangulation research method was followed in this study to present the findings of death review committees (DRCs), which were formally established in five major hospitals across Jordan. The DRCs used a specific death summary form to facilitate identifying the type of delay, if any, and to plan specific actions to prevent future similar deaths. A death case review form with key details was also filled immediately after each death. Moreover, data were collected from patient notes and medical records, and further information about a specific cause of death or the contributing factors, if needed, were collected.

RESULTS

 During the study period (August 1, 2019-February 1, 2020), 10,726 births, 156 neonatal deaths, and 108 stillbirths were registered. A delay in recognizing the need for care and in the decision to seek care (delay 1) was believed to be responsible for 118 (44.6%) deaths. Most common factors included were poor awareness of when to seek care, not recognizing the problem or the danger signs, no or late antenatal care, and financial constraints and concern about the cost of care. Delay 2 (delay in seeking care or reaching care) was responsible for nine (3.4%) cases. Delay 3 (delay in receiving care) was responsible for 81 (30.7%) deaths. The most common modifiable factors were the poor or lack of training that followed by heavy workload, insufficient staff members, and no antenatal documentation. Effective actions were initiated across all the five hospitals in response to the delays to reduce preventable deaths.

CONCLUSION

 The formation of the facility-based DRCs was vital in identifying critical delays and modifiable factors, as well as developing initiatives and actions to address modifiable factors.

KEY POINTS

· Death review committees play key roles in identifying critical delays and modifiable factors.. · The "three-delay" model was successful in identifying preventable neonatal deaths and stillbirths.. · Death review committees are central in developing actions to reduce preventable deaths..

Health insurance coverage and maternal healthcare services utilization in Jordan: evidence from the 2017-18 Jordan demographic and health survey

BACKGROUND

Despite the relationship between health insurance coverage and maternal healthcare services utilization, previous studies in Jordan on the use of maternal healthcare services have mainly focused on patterns and determinants of maternal healthcare services utilization in Jordan. Therefore, this study investigated the relationship between health insurance coverage and maternal healthcare services utilization in Jordan.

METHODS

This study used secondary data published in 2017-18 Jordan Demographic and Health Survey on 4656 women of reproductive age (15-49 years). The independent variable was health insurance coverage and the outcome variable was maternal healthcare services utilization, measured through timing of first antenatal visit, four or more antenatal care visits, and skilled birth attendance. The data were analyzed using descriptive statistics and binary logistic regression.

RESULTS

Out of the total number of women who participated in the study, 38.2% were not covered by health insurance. With maternal healthcare utilization, 12.5%, 23.2%, and 10.1% respectively, failed to make early first antenatal care visit, complete four or more antenatal care visits and have their delivery attended by a skilled worker. After controlling for the socio-demographic factors, health insurance coverage was associated with increased odds of early timing of first antenatal care visits and completion of four or more antenatal care visits (aOR = 1.33, p < 0.05, aOR = 1.25, p < 0.01, respectively). However, women who were covered by health insurance were less likely to use skilled birth attendance during delivery (aOR = 0.72 p < 0.001).

CONCLUSIONS

Jordanian women with health insurance coverage were more likely to have early first antenatal care visits and complete four or more antenatal care visits. However, they were less likely to have their delivery attended by a skilled professional. This study provides evidence that health insurance coverage has contributed to increased maternal healthcare services utilization, only in terms of number and timing of antenatal care visits in Jordan. It is recommended that policy makers in Jordan should strengthen the coverage of health insurance in the country, especially among women of reproductive age in order to enhance the use of maternal healthcare services in the country.

Walk the Talk: The Transforming Journey of Facility-Based Death Review Committee from Stillbirths to Neonates

Background

Facility-based death review committee (DRC) of neonatal deaths and stillbirths can encourage stakeholders to enhance the quality of care during the antenatal period and labour to improve birth outcomes. To understand the benefits and impact of the DRCs, this study was aimed at exploring the DRC members' perception about the role and benefits of the newly developed facility-based DRCs in five pilot hospitals in Jordan, to assess women empowerment, decision-making process, power dynamics, culture and genderism as contributing factors for deaths, and impact of COVID-19 lockdown on births.

Methods

A descriptive study of a qualitative design—using focus group discussions—was conducted after one year of establishing DRCs in 5 pilot large hospitals. The number of participants in each focus group ranged from 8 to10, and the total number of participants was 45 HCPs (nurses and doctors). Questions were consecutively asked in each focus group. The moderator asked the main questions from the guide and then used probing as needed. A second researcher observed the conversation and took field notes.

Results

Overall, there was an agreement among the majority of DRC members across all hospitals that the DRC was successful in identifying the exact cause of neonatal deaths and stillbirths as well as associated modifiable factors. There was also a consensus that the DRC contributed to an improvement in health services provided for pregnant women and newborns as well as protecting human rights and enabling women to be more interdependent in taking decisions related to family planning. Moreover, the DRC agreed that a proportion of the neonatal deaths and stillbirths occurring in the hospitals could have been prevented if adequate antenatal care was provided and some traditional harmful practices were avoided.

Conclusions

Facility-based neonatal death review audit is practical and can be used to identify exact causes of maternal and neonatal deaths and is a valuable tool for hospital quality indicators. It can also change the perception and practice of health care providers, which may be reflected in improving the quality of provided healthcare services.

Assessment and comparison of mortality and short-term outcomes among premature infants before and after 32-week gestation: A cross-sectional analysis

BACKGROUND

Prematurity is a major cause of neonatal morbidity and mortality. The aim of this study is to assess the rate of prematurity and determine the mortality rate and short-term outcomes among premature infants admitted at King Abdullah University Hospital (KAUH) in Jordan.

MATERIALS AND METHODS

A retrospective cross-sectional review of all premature infants admitted at KAUH between August 2016 and August 2018 was conducted. Collected data include characteristics, medical interventions, morbidities, mortality, and discharge outcomes. Included infants were divided into two groups: less than 32-week gestation (group 1) and ≥32-week gestation (group 2). The outcomes were compared between both groups and reported accordingly.

RESULTS

Out of 7020 newborns, 1102 were delivered before 37-week gestation, representing a prematurity rate of 15.7%. The mean gestational age and birth weight were 33.8 weeks and 2116 grams respectively. Group 1 comprised 13%. Late preterm infants (gestational age 34 to 36 6/7 weeks) accounted for 74%. The mortality rate was 4.6%. More infants died from group 1 (29% vs. 1.5%, p < 0.05). Group 1 infants had higher rates of respiratory distress syndrome (92% vs. 30%), bronchopulmonary dysplasia (28.4% vs. 1.1%), severe intraventricular hemorrhage (5.9% vs. 0.1%), high-stage retinopathy of prematurity (6.6% vs. 0.2%), necrotizing enterocolitis (9.2% vs. 0%), and sepsis (18.4% vs. 2.1%). At discharge, there was a significant difference in the length of stay, corrected gestational age, and weight in favor of group 2 (p < 0.05).

CONCLUSIONS

Although high rate of prematurity was observed, the majority were late preterm with reassuring outcomes. Compared with >32-week infants, the mortality and short-term complications were more frequent among those born before 32 weeks. Still, the overall mortality rate and risk of morbidities were reasonable. Population-based analysis of the risk factors among the more vulnerable very preterm and extremely premature infants is recommended to better understand the outcomes.

Indications and Clinical Profile of Neonatal Admissions: A Cross-Sectional Descriptive Analysis from a Single Academic Center in Jordan

PURPOSE

To review the indications and clinical profile of neonatal admissions at King Abdullah University Hospital in Jordan.

MATERIALS AND METHODS

We conducted a cross-sectional review of all neonates admitted to the neonatal intensive care unit between September 2016 and September 2018. Collected data include demographic characteristics, indications for admission, morbidities and mortality, and discharge outcomes. Findings were reported among term and preterm infants.

RESULTS

A total of 1444 infants were admitted during the study period of whom 1332 (92.2%) were inborn and 612 (42.4%) were term neonates. Of the 832 preterm infants, 545 were late preterm (34-36 6/7 gestation) and 125 had very low birth weight (˂ 1500 grams); 925 (64%) were born by cesarean section. Respiratory failure of the newborn (41.2%) and prematurity (33.3%) were the main indications for admission among the whole cohort. Maternal prolonged premature rupture of membranes (PROM) was observed in nearly half the admissions of term infants. Hypoxic ischemic encephalopathy (3.2% vs 0.7%, p 0.01) and congenital anomalies (5% vs 1.2%, p 0.03) were more common in term infants. The rate of bronchopulmonary dysplasia was 39% among <28-week and 28% among <32-week premature infants. Sepsis was encountered in 59 infants. The overall mortality rate was 3.8%. Prematurity was the main predisposing factor for mortality (Adjusted OR: 9.9, 95% CI: 3.5, 27.6).

CONCLUSION

The majority of neonatal admissions at our institution are term and late preterm infants delivered by cesarean section. Prematurity, respiratory failure of the newborn, and suspected sepsis due to maternal PROM are the leading causes of admission. The mortality rate is within WHO target to achieve Sustainable Development Goal 3. Population-based studies are needed to make better conclusions that represent the whole Jordanian population. A revisit for the indications of cesarean deliveries may help to improve the neonatal outcomes.

Sociocultural, political, and health system-related determinants of perinatal deaths in Jordan from the perspectives of health care providers: a qualitative study

BACKGROUND

Perinatal mortality is a fundamental indicator of the quality of the healthcare provided to women during pregnancy and childbirth, as well as the healthcare provided to neonates in the first week of life. At the national level, determining the direct and indirect causes of these deaths is vital, as it will assist in tracking the quality of antenatal, natal and postnatal care and help to detect the areas for avoidance. This study aimed to identify the main determinants of perinatal deaths in Jordan from the perspectives of health care providers (HCPs).

METHODS

A descriptive qualitative approach using focus group discussion was used. Four focus groups were conducted in each of the four hospitals where the approached HCPs are employed. An average of 5 HCPs were interviewed in each focus group with a total of 80 HCPs participating in the 16 focus groups. Thematic analysis was carried out to analyze the data.

RESULTS

The HCPs provided a detailed description of the determinants of perinatal and neonatal death from their points of view. Four main themes with multiple subthemes emerged, namely maternal factors (ignorance, concealment of medical condition, and husbands' negligence), sociocultural factors (socioeconomic status, tribal and consanguineous marriage, and harmful cultural practices), political factors (early marriage driven by displacement and war consequences on maternal health), and health system-related factors (services management including capabilities and logistics, overcrowding of emergency rooms, discharge against medical advice, and unskilled general practitioners in private maternity clinics).

CONCLUSIONS

As perceived by HCPs, maternal factors, sociocultural factors, political factors, and health system-related factors are the main determinants of perinatal deaths in Jordan. Improvement in the quality of maternal and neonatal health care services, maternal health education, and maternity staff training are strongly recommended.

Personal, professional and workplace factors associated with burnout in Jordanian midwives: A national study

OBJECTIVE

To investigate the prevalence of burnout and explore associated socio-demographic and work-related factors among Jordanian midwives.

DESIGN

A cross-sectional survey design. The survey tool included the Copenhagen Burnout Inventory (CBI) and socio-demographic and work-related data forms.

SETTING

All government-funded hospitals in Jordan (18 hospitals) that provide antenatal, labour and birth, or postnatal care for women.

PARTICIPANTS

A sample of 321 midwives participated.

DATA ANALYSIS

Frequencies, means, and standard deviations were calculated as appropriate on the demographic variables and scale scores. The CBI was assessed for internal consistency using Cronbach's alpha. Multiple regression analyses using backward elimination were undertaken to determine associations between variables and CBI subscales. An alpha level of 0.05 was used for all statistical tests.

FINDINGS

Over three-quarters of midwives reported personal (78.1%), work-related (82.2%), and client-related (71.3%) burnout (scored >50 on CBI). Compared to midwives aged between 21 - 30 years, those between 31 - 40 years of age scored on average a 11.75 (95% CI = 7.05 - 16.45) points lower personal burnout score. Married midwives had on average a 6.44 (95% CI = 1.57 - 11.31) points higher personal burnout score compared to single midwives. Midwives with ≥ 10 years' experience had on average a 4.29 (95% CI = 1.93 - 6.64), 5.27 (95% CI = 3.17 - 7.36), and 7.31 (95% CI = 4.84 - 9.78) points lower personal, work-related, and client-related burnout scores respectively compared to midwives with < 10 years' experience.Compared to midwives providing care for 1 - 5 women per shift, those providing care for > 10 women per shift reported 9.98 (95% CI = 6.06 - 13.90) and 5.35 (95% CI = 0.71 - 9.99) points higher work-related and client-related burnout scores respectively. Midwives who rotated between shifts had on average a 5.87 (95% CI = 1.27 - 10.48) and 11.2 (95% CI = 5.78 - 16.66) points higher work-related and client-related burnout scores respectively than those who did not rotate.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The high prevalence of burnout identifies the urgent need for a national plan to address midwives' psychological health in Jordan. Midwives should be appropriately trained to recognize the signs and symptoms of burnout in a timely way, and for support services to be offered. The government could consider implementing continuity of midwifery care models, reducing the administrative burden on midwives, and empowering them to work to their full scope of practice.

The quality of maternal-fetal and newborn care services in Jordan: a qualitative focus group study

Background

The antenatal, intrapartum, and postnatal periods are considered high-risk periods for the health of mothers and their newborns. Although the current utilization rate of some maternal and child care services in Jordan is encouraging, detailed information about the quality of these services is limited. Therefore, this study aimed to explore the quality of maternal-fetal and newborn antenatal care (ANC), delivery, and postnatal care (PNC) services in Jordan.

Methods

We conducted 12 focus group discussions (FGDs) with pregnant and postpartum women who attended maternal-child care services in three major hospitals in Jordan. All FGDs were recorded and transcribed verbatim. An inductive thematic analysis approach was used to identify themes and subthemes.

Results

The content analysis of the FGDs revealed a consensus among the discussants regarding the importance of ANC and PNC services for the health of mothers and their newborns. However, the participating women viewed ANC to be much more important than PNC. With regards to the choice between public and private antenatal care services, some of the discussants were disposed towards the private sector. Reasons for this included longer consultation time, a higher quality of services, better interpersonal and communication skills of healthcare providers, better treatment, more advanced equipment and devices, availability of female obstetricians, and more flexible appointment times. These women only perceived public hospital services to be necessary in cases of pregnancy-related complications and labor, as the costs of private sector services in such cases are too high. The findings also revealed that mothers usually only seek PNC services to check up on their newborn’s health and not their own.

Conclusion

Visiting private ANC clinics throughout pregnancy while giving birth in public facilities leads to the discontinuity and fragmentation in maternal-fetal and child healthcare services. To address this fragmentation, healthcare systems are proposed to establish interprofessional teamwork that requires different healthcare providers with complementary skills and practices in both public and private settings to work co-operatively and collectively. Investment in new technologies and interventions which enhance coordination and collaboration between public and private healthcare settings is necessary for the provision of non-traditional maternal healthcare.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4232-9) contains supplementary material, which is available to authorized users.

Traditional methods for managing illness in newborns and infants in an Arab society

AIM

This study explored self-management practices in relation to traditional methods for managing illness in newborns and infants and the implications of these practices on infant health.

BACKGROUND

Self-medication with folk remedies is believed to have short- and long-term impacts on well-being. Little is known about how mothers in Arab societies used their traditional beliefs and practices in self-managing their newborns' and infants' health.

METHODS

Data were collected from five focus groups using open-ended questions with 37 mothers. Participants were selected using snowball sampling and were recruited from four different cities in Jordan between June 2016 and August 2016.

ETHICAL APPROVAL

All identifying information regarding the study participants has been omitted, and this study was approved by the Academic Research Committee at the University of Jordan.

FINDINGS

Mothers were more willing to try herbal remedies, traditional massage and certain foods to self-manage their infants' health. Folk remedies were not restricted to traditions handed down through generations, but included a representation of newly emerged trends towards 'safety' or 'nature'.

CONCLUSIONS

While the use of folk remedies have been handed down generations as customs, today, virtual support groups and social media provide modern resources for folk remedies' promotion in care and self-management.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Nursing and health policymakers can use our findings for planning and developing strategies and health policies that increase public awareness about adverse health effects associated with herbal remedies. Such strategies are likely to be facilitated through partnerships between nursing and midwifery education institutions, antenatal clinics and social media in the region.