Evaluation of a health promotion intervention associated with birthing centres in rural Nepal.

INTRODUCTION: Birthing centres (BC) in Nepal are mostly situated in rural areas and provide care for women without complications. However, they are often bypassed by women and their role in providing good quality maternity services is overlooked. This study evaluated an intervention to increase access and utilisation of perinatal care facilities in community settings. METHODS: This longitudinal cross-sectional study was conducted over five years in four villages in Nepal and included two BCs. An intervention was conducted in 2014-2016 that involved supporting the BCs and conducting a health promotion programme with local women. Population-based multi-stage sampling of women of reproductive age with a child below 24 months of age was undertaken. Household surveys were conducted (2012 and 2017) employing trained enumerators and using a structured validated questionnaire. The collected data were entered into SPSS and analysed comparing pre- and post-intervention surveys. RESULTS: The intervention was associated with an increase in uptake in facility birth, with an increase in utilisation of perinatal services available from BCs. The post-intervention survey provided evidence that women were more likely to give birth at primary care facilities (OR 5.60, p-value <0.001) than prior to the intervention. Similarly, the likelihood of giving birth at a health facility increased if decision for birthplace was made jointly by women and family members for primary care facilities (OR 1.76, p-value 0.023) and hospitals/tertiary care facilities (OR 1.78, p-value 0.020. If women had less than four ANC visits, then they were less likely to give birth at primary care facilities (OR 0.39, p-value <0.001) or hospitals/tertiary care facilities (OR 0.63, p-value 0.014). Finally, women were less likely to give birth at primary care facilities if they had only primary level of education (OR 0.49, p-value 0.014). CONCLUSION: BCs have the potential to increase the births at health facilities and decrease home births if their services are promoted by the local health promoters. In addition, socio-economic factors including women's education, the level of women's autonomy and having four or more ANC visits affect the utilisation of perinatal services at the health facility.

Virtual health education: Scaling practice to transform student learning: Using virtual reality learning environments in healthcare education to bridge the theory/practice gap and improve patient safety.

The advancements in and affordability of technologies offer increasing opportunities to modernise healthcare education into packages developed to meet the expectations and requirements of the digital generation. Purposefully designed and tested Virtual Reality Learning Environments (VRLE) can offer healthcare students the means to access and revisit learning materials in ways that enhance education and meet a range of needs; including those with specific learning differences and those who have traditionally been disenfranchised. Furthermore, this will make healthcare education much more readily available to those who have been previously marginalised by distance. This paper argues that Virtual Reality (VR) has the unique potential to transform healthcare education and suggests that more providers should consider collaborating with developers and investing in the technology.

Qualitative evaluation of mental health training of auxiliary nurse midwives in rural Nepal.

BACKGROUND AND OBJECTIVES: Mental illness is increasingly recognized as a global health problem. However, in many countries, including Nepal, it is difficult to talk about mental health problems due to the stigma associated with it. Hence a training programme was developed to train auxiliary nurse midwives, who otherwise are not trained in mental health as part of their pre-registration training in rural Nepal, on issues related to maternal mental health. After the training programme a selection of auxiliary nurse midwives were interviewed to establish their views on the training, its usefulness and ways to improve it. METHODS: This qualitative study reports on the analysis of interviews conducted with auxiliary nurse midwives who participated in the training programme. The interviews addressed issues associated with the training programme as well as perceptions around mental health in rural Nepal. Transcripts were thematically analysed. RESULTS: Three themes emerged from analysis: (1) issues related to training; (2) societal attitudes; and (3) support for women. The 'training' theme describes the benefits and limitations of training sessions. 'Societal attitudes' describes society's attitude towards mental health which is largely negative. 'Support' describes the positive behaviour and attitude towards pregnant women and new mothers. CONCLUSION: The study supports the need for continued training for auxiliary nurse midwives who are based in the community. This gives them the opportunity to reach the whole community group and potentially have influence over reduction of stigma; offer support and diagnosis of mental ill-health. There is still stigma around giving birth to a female child which can lead to mental health problems. It is imperative to increase awareness and educate the general public regarding mental health illnesses especially involving family members of those who are affected.

Dirty and 40 days in the wilderness: Eliciting childbirth and postnatal cultural practices and beliefs in Nepal.

BACKGROUND: Pregnancy and childbirth are socio-cultural events that carry varying meanings across different societies and cultures. These are often translated into social expectations of what a particular society expects women to do (or not to do) during pregnancy, birth and/or the postnatal period. This paper reports a study exploring beliefs around childbirth in Nepal, a low-income country with a largely Hindu population. The paper then sets these findings in the context of the wider global literature around issues such as periods where women are viewed as polluted (or dirty even) after childbirth. METHODS: A qualitative study comprising five in-depth face-to-face interviews and 14 focus group discussions with mainly women, but also men and health service providers. The qualitative findings in Nepal were compared and contrasted with the literature on practices and cultural beliefs related to the pregnancy and childbirth period across the globe and at different times in history. RESULTS: The themes that emerged from the analysis included: (a) cord cutting & placenta rituals; (b) rest & seclusion; (c) purification, naming & weaning ceremonies and (d) nutrition and breastfeeding. Physiological changes in mother and baby may underpin the various beliefs, ritual and practices in the postnatal period. These practices often mean women do not access postnatal health services. CONCLUSIONS: The cultural practices, taboos and beliefs during pregnancy and around childbirth found in Nepal largely resonate with those reported across the globe. This paper stresses that local people's beliefs and practices offer both opportunities and barriers to health service providers. Maternity care providers need to be aware of local values, beliefs and traditions to anticipate and meet the needs of women, gain their trust and work with them.

"Is it realistic?" the portrayal of pregnancy and childbirth in the media.

BACKGROUND: Considerable debate surrounds the influence media have on first-time pregnant women. Much of the academic literature discusses the influence of (reality) television, which often portrays birth as risky, dramatic and painful and there is evidence that this has a negative effect on childbirth in society, through the increasing anticipation of negative outcomes. It is suggested that women seek out such programmes to help understand what could happen during the birth because there is a cultural void. However the impact that has on normal birth has not been explored. METHODS: A scoping review relating to the representation of childbirth in the mass media, particularly on television. RESULTS: Three key themes emerged: (a) medicalisation of childbirth; (b) women using media to learn about childbirth; and (c) birth as a missing everyday life event. CONCLUSION: Media appear to influence how women engage with childbirth. The dramatic television portrayal of birth may perpetuate the medicalisation of childbirth, and last, but not least, portrayals of normal birth are often missing in the popular media. Hence midwives need to engage with television producers to improve the representation of midwifery and maternity in the media.

Alien knowledge: preparing student midwives for learning about infant feeding--education practice at a UK university.

Infant feeding education forms a key element in undergraduate midwifery education in the UK. Students must be prepared to provide women with support and information to make appropriate health choices for themselves and their infants. However, student midwives may already have developed opinions about infant feeding prior to commencing a midwifery education programme. The education literature suggests that existing attitudes may present a barrier to learning for some students. This particularly applies to learning in relation to sensitive or emotionally laden subjects. A review of the literature was undertaken to identify potential teaching approaches which might help students to overcome barriers to learning. Following this the evidence was utilised at a UK university to develop activities which prepare student midwives for effective learning around infant feeding. Students enrolled in the midwifery education programme were introduced to a number of activities aimed at encouraging them to accommodate unfamiliar ideas or 'alien knowledge'. These included placing students in situations which challenged their ideas, as well as engaging in group discussions and reflective exercises. The impact of these educational interventions was identified through formative and summative assessment, and through evaluation of the teaching strategy at the end of the programme. This demonstrated that, amongst those students with previously negative attitudes towards infant feeding, there was a move towards more positive attitudes and a greater confidence in providing evidence based information to parents.

How are babies fed? A pilot study exploring primary school children's perceptions of infant feeding.

BACKGROUND: Breastfeeding is the optimal feeding method for human infants. In the United Kingdom some women do not initiate breastfeeding, and many commence formula milk feeding after a brief period of breastfeeding. Infant feeding perceptions may develop early in life, and this research aimed to explore infant feeding awareness among primary school children as a first step toward informing appropriate health education interventions. METHOD: Fifty-six children aged 5/6, 7/8, and 10/11 years were recruited from three schools in southern England. Children were shown a series of drawings, and were read a story about a hungry newborn baby. A creative method, "draw, write and tell," was developed for this research. Children were asked to finish the story, showing how they thought the baby might be fed. They were given the opportunity to verbally interpret their work. A constant comparison method was used to analyze the data. RESULTS: Children were aware of formula milk, breastfeeding, and solid foods. Formula milk feeding was referred to more frequently than breastfeeding. Some children combined feeding methods. Children appeared to have gained their awareness in various settings. CONCLUSIONS: Children have a range of perceptions around infant feeding. They appear receptive to new ideas on the subject while of primary school age. An opportunity for education in primary schools arises to present breastfeeding to children as a normal way to feed a baby, but it is vital that education is evidence based and any interventions are evaluated.