Prevalence and risk factors for postpartum depression among women seen at Primary Health Care Centres in Damascus.

BACKGROUND: In Syria, there are no previous studies on postpartum depression. The aim of this study is was identify the prevalence of postpartum depression and investigate its risk factors among Syrian women seen at the Primary Health Care Centres in Damascus. METHODS: This descriptive cross-sectional study was carried out between January and December 2017 in Damascus, Syria. Postpartum women seen at a convenience sample of the largest and well-utilized primary health care centres in Damascus were invited to participate in the study. The Arabic version of the validated Edinburgh Postnatal Depression Scale questionnaire was used to measure postpartum depression. A cut-off score of 13 was considered to indicate probable depression. RESULTS: Out of a total of 1105 women participated in this study, 28.2% had a score of 13 (probable Depression). The multivariate analysis showed that postpartum depression was significantly associated with a reported a health problem during last pregnancy (OR = 2.2; 95% confidence interval [CI]: 1.4-3.5); displacement (OR = 1.4; 95% confidence interval [CI]: 1.04-1.97); perceived exposure to a lot of life stressors (OR = 5.04; 95% confidence interval [CI]: 2.4-10.5); while antenatal care had a protective effect (OR = 0.52; 95% confidence interval [CI]: 0.36-0.75). CONCLUSIONS: The prevalence of postpartum depression among Syrian women in this study was relatively high, as compared to other Arab and Non-Arab countries. Displacement due to the Syrian crisis among other factors was associated with postpartum depression. Obstetricians and other professionals should be sensitized about the importance of screening for the problem for better management.

Implementation of a labour companionship model in three public hospitals in Arab middle-income countries.

AIM: To assess the feasibility, acceptability, effectiveness and cost of the integration of a tailored labour companionship model in three public hospitals in Egypt, Lebanon and Syria. METHODS: Phased implementation research using mixed methods. Implementation strategies consisted of steering committees in hospitals, seminars for healthcare providers, information, education and communication materials, and adjustments in labour rooms. The labour companionship model consisted of (i) identification of a female relative as labour companion by women; (ii) provision of information, education and communication materials to women and companions; and (iii) allowing companions to accompany women throughout the first stage of labour. Semi-structured interviews with women, labour companions and healthcare providers were used to assess feasibility and acceptability of the model. Effectiveness was assessed through structured interviews with women, information abstracted from medical records and cost data. The comparison was made between the pre-implementation and the implementation phases. RESULTS: This model was found to be feasible, acceptable, effective and cost-beneficial. Women's satisfaction and perception of control improved and caesarean section rates were reduced significantly. CONCLUSION: This model can be adopted for these countries and elsewhere with comparable health systems. It enhances the quality of care and the provision of equitable and respectful maternity services.

Women's satisfaction and perception of control in childbirth in three Arab countries.

Women's satisfaction and perceived control in childbirth are important attributes of the childbirth experience and quality of care indicators. This article presents findings from the pre-intervention phase of a multi-centre implementation study in Egypt, Lebanon and Syria, to introduce a labour companionship model in these countries. A sample of 2620 women giving birth in three public teaching hospitals from November 2014 to July 2015 in Beirut and Mansoura, and from November 2014 to April 2015 in Damascus were interviewed by trained field workers. Additional information was abstracted from medical charts. An adapted version of the Mackey Childbirth Satisfaction Rating Scale was used to measure women's satisfaction and the shortened version of the Labor Agentry Scale was used to assess perception of control. The total satisfaction score was high in all sites with the lowest being in Egypt. Perceived control was directly related to satisfaction. Women with low education levels had higher levels of childbirth satisfaction. Women who had fewer children from Egypt and Lebanon, and those who received care by a team including both male and female physicians in the Syrian hospital were more likely to be dissatisfied than their counterparts. Variations in the management and provision of care between the three countries may explain the differences in satisfaction levels observed. Further qualitative research is needed to deepen our understanding of the concepts of control and satisfaction in the Arab culture as well as to establish the factors associated with women's positive childbirth experiences to inform the provision of quality maternity care.

A cross sectional study of maternal 'near-miss' cases in major public hospitals in Egypt, Lebanon, Palestine and Syria.

BACKGROUND: The maternal near-miss approach has been increasingly used as a tool to evaluate and improve the quality of care in maternal health. We report findings from the formative stage of a World Health Organization (WHO) funded implementation research study that was undertaken to collect primary data at the facility level on the prevalence, characteristics, and management of maternal near-miss cases in four major public referral hospitals - one each in Egypt, Lebanon, Palestine and Syria. METHODS: We conducted a cross sectional study of maternal near-miss cases in the four contexts beginning in 2011, where we collected data on severe maternal morbidity in the four study hospitals, using the WHO form (Individual Form HRP A65661). In each hospital, a research team including trained hospital healthcare providers carried out the data collection. RESULTS: A total of 9,063 live birth deliveries were reported during the data collection period across the four settings, with a total of 77 cases of severe maternal outcomes (71 maternal near-miss cases and 6 maternal deaths). Higher indices for the maternal mortality index were found in both Al Galaa hospital, in Egypt (8.6%) and Dar Al Tawleed hospital in Syria (14.3%), being large referral hospitals, compared to Ramallah hospital in Palestine and Rafik Hariri University hospital in Lebanon. Compared to the WHO's Multicountry Survey using the same data collection tool, our study's mortality indices are higher than the index of 5.6% among countries with a moderate maternal mortality ratio in the WHO Survey. Overall, haemorrhage-related complications were the most frequent conditions among maternal near-miss cases across the four study hospitals. In all hospitals, coagulation dysfunctions (76.1%) were the most prevalent dysfunction among maternal near-miss cases, followed by cardiovascular dysfunctions. The coverage of key evidence-based interventions among women experiencing a near-miss was either universal or very high in the study hospitals. CONCLUSIONS: Findings from this formative stage confirmed the need for quality improvement interventions. The high reported coverage of the main clinical interventions in the study hospitals would appear to be in contradiction with the above findings as the level of coverage of key evidence-based interventions was high.

Childbirth Experiences and Delivery Care During Times of War: Testimonies of Syrian Women and Doctors.

Background: Until the eruption of violence in 2011, Syria made good progress in improving maternal health indicators including reducing the maternal mortality ratio and increasing the level of skilled birth attendance. The war in Syria has been described as one of the worst humanitarian crises in recent times. Damascus Maternity Teaching Hospital is the largest maternity public hospital in the country that survived the war and continued to provide its services even during periods of pronounced instability. The main aim of this paper is to highlight the experience of childbirth and delivery care as described by women and doctors at times of severe violence affecting Damascus. Methods: This paper is based on secondary analysis of qualitative data collected between 2012 and 2014 for a WHO-funded implementation research project introducing clinical audits for maternal near-misses. This analysis specifically looked at the effects of violence on the childbirth experience and delivery care from the perspective of both women and physicians. A total of 13 in-depth interviews with women who had recently delivered and survived a complication and 13 in-depth interviews with consultant obstetricians were reviewed and analyzed, in addition to three focus group discussions with 31 junior care providers. Results: Three themes emerged concerning the experiences of women and doctors in these times of war. First, both women and doctors experienced difficulty reaching the hospital and accessing and providing the services, respectively; second, quality of care was challenged at that time as perceived by both women and doctors; and third, women and doctors expressed their psychological suffering in times of hardship and uncertainty and how this affected them. Conclusions: Efforts to safeguard the safety of delivery and prevent maternal mortality in Syria continued despite very violent and stressful conditions. Both women and providers developed strategies to navigate the challenges posed by conflict to the provision of delivery care. Lessons learned from the experiences of both women and doctors should be considered in any plans to improve maternal healthcare in a country like Syria that remains committed to achieving the Sustainable Development Goals in 2030 in the aftermath of nearly 10 years of war.

The effect of training doctors in communication skills on women's satisfaction with doctor-woman relationship during labour and delivery: a stepped wedge cluster randomised trial in Damascus.

OBJECTIVES: To determine the effect of training residents in interpersonal and communication skills on women's satisfaction with doctor-woman relationship in labour and delivery rooms. DESIGN: A stepped wedge cluster randomised trial. SETTING: 4 tertiary care teaching maternity hospitals in Damascus, Syria. PARTICIPANTS: 2000 women who gave birth to a living baby in the four study hospitals and consented to participate in the intervention took part in the study. Women with difficult labour and high-risk pregnancies were excluded. All were interviewed at home after discharge. INTERVENTIONS: A specially designed training package in communication skills was delivered to all resident doctors at the four hospitals. PRIMARY OUTCOME MEASURES: The main outcome measure was women's satisfaction with interpersonal relationships in labour and delivery rooms measured via a series of questions on a Likert scale modified from the Medical Interview Satisfaction Scale. RESULTS: At the individual level, the mean for the average satisfaction score was 3.23 (SD 0.72) of a possible score of 5 in the control group and 3.42 (SD 0.73) in the intervention group. Using generalised linear mixed models, we were unable to detect a difference between the mean for the average satisfaction score of women in the intervention arm and that of women in the control arm; the 95% CI associated with the effect of the intervention ranged from -0.08 to 0.15. CONCLUSIONS: Despite slight changes in the observed residents' communication skills, the training package in communication skills does not seem to be associated with higher satisfaction scores of women. This raises the question of whether training individuals without further structural changes in the delivery of care and without further reinforcement of the training can have an impact on improving the quality of doctor-patient communication. TRIAL REGISTRATION NUMBER: ISRCTN80243969.

Effect of postnatal home visits on maternal/infant outcomes in Syria: a randomized controlled trial.

OBJECTIVE: Early postpartum home visiting is universal in many Western countries. Studies from developing countries on the effects of home visits are rare. In Syria, where the postpartum period is rather ignored, this study aimed to assess whether a community-based intervention of postnatal home visits has an effect on maternal postpartum morbidities; infant morbidity; uptake of postpartum care; use of contraceptive methods; and on selected neonatal health practices. DESIGN: A randomized controlled trial was carried out in Damascus. Three groups of new mothers were randomly allocated to receive either 4 postnatal home visits (A), one visit (B), or no visit (C). SAMPLE: A total of 876 women were allocated and followed up. INTERVENTION: Registered midwives with special training made a one or a series of home visits providing information, educating, and supporting women. RESULTS: A significantly higher proportion of mothers in Groups A and B reported exclusively breastfeeding their infants (28.5% and 30%, respectively) as compared with Group C (20%), who received no visits. There were no reported differences between groups in other outcomes. CONCLUSIONS: While postpartum home visits significantly increased exclusive breastfeeding, other outcomes did not change. Further studies framed in a nonbiomedical context are needed. Other innovative approaches to improve postnatal care in Syria are needed.