Determinants of use of care provided by complementary and alternative health care practitioners to pregnant women in primary midwifery care: a prospective cohort study.

BACKGROUND: Pregnant women visit complementary/alternative health care practitioners in addition to regular maternal health care practitioners. A wide variation has been reported with regard to rates and determinants of use of complementary/alternative medicine (CAM), which may be due to heterogeneous populations. The aim of this study was to examine the prevalence and determinants of use of CAM practitioners by a homogeneous population of low-risk pregnant women in the Netherlands. METHODS: Data from the population-based DELIVER study was used, concerning 1500 clients from twenty midwifery practices across the Netherlands in 2009 and 2010. CAM use was measured based on patient reports. Potential determinants were derived from Andersen's behavioural model of health care utilization. RESULTS: The prevalence of CAM practitioner use by low-risk pregnant women was 9.4 %. Women were more likely to use CAM if they had supplementary health care insurance (OR 3.11; CI 1.41-6.85), rated their health as 'bad/fair' (OR 2.63; CI 1.65-4.21), reported a chronic illness or handicap (OR 1.93; CI 1.14-3.27), smoked during pregnancy (OR 1.88; CI 1.06-3.33), or used alcohol during pregnancy (OR 2.30; CI 1.46-3.63). CONCLUSIONS: CAM is relatively frequently used by low-risk pregnant women. Determinants revealed in this study diverge from other studies using heterogeneous populations. Maternal health care practitioners must be aware of CAM use by low-risk pregnant women and incorporate this knowledge into daily practice by actively discussing this subject with pregnant women.

Empowering families by engaging and relating Murri way: a grounded theory study of the implementation of the Cape York Baby Basket program.

BACKGROUND: Evaluating program outcomes without considering how the program was implemented can cause misunderstandings and inefficiencies when initiating program improvements. In conjunction with a program evaluation, reported elsewhere, this paper theorises the process of implementing an Indigenous Australian maternal and child health program. The Baby Basket program was developed in 2009 for the remote Cape York region and aimed to improve the attendance and engagement of Indigenous women at antenatal and postnatal clinics through providing three baskets of maternal and baby goods and associated health education. METHODS: Constructivist grounded theory methods were used to generate and analyse data from qualitative interviews and focus groups with Indigenous women who received the baskets, their extended family members, and healthcare workers who delivered them. Data was coded in NVivo with concepts iteratively compared until higher order constructs and their relationships could be modelled to explain the common purpose for participants, the process involved in achieving that purpose, key strategies, conditions and outcomes. Theoretical terms are italicised. RESULTS: Program implementation entailed empowering families through a process of engaging and relating Murri (Queensland Indigenous) way. Key influencing conditions of the social environment were the remoteness of communities, keeping up with demand, families' knowledge, skills and roles and organisational service approaches and capacities. Engaging and relating Murri way occurred through four strategies: connecting through practical support, creating a culturally safe practice, becoming informed and informing others, and linking at the clinic. These strategies resulted in women and families taking responsibility for health through making healthy choices, becoming empowered health consumers and advocating for community changes. CONCLUSIONS: The theoretical model was applied to improve and revise Baby Basket program implementation, including increased recognition of the importance of empowering families by extending the home visiting approach up to the child's third birthday. Engaging and relating Murri way was strengthened by formal recognition and training of Indigenous health workers as program leaders. This theoretical model of program implementation was therefore useful for guiding program improvements, and could be applicable to other Indigenous maternal and child health programs.

The traditional healer in obstetric care: A persistent wasted opportunity in maternal health.

Traditional medical systems in low income countries remain the first line service of choice, particularly for rural communities. Although the role of traditional birth attendants (TBAs) is recognised in many primary health care systems in low income countries, other types of traditional practitioners have had less traction. We explored the role played by traditional healers in northern Ghana in managing pregnancy-related complications and examined their relevance to current initiatives to reduce maternal morbidity and mortality. A grounded theory qualitative approach was employed. Twenty focus group discussions were conducted with TBAs and 19 in-depth interviews with traditional healers with expertise in managing obstetric complications. Traditional healers are extensively consulted to manage obstetric complications within their communities. Their clientele includes families who for either reasons of access or traditional beliefs, will not use modern health care providers, or those who shop across multiple health systems. The traditional practitioners claim expertise in a range of complications that are related to witchcraft and other culturally defined syndromes; conditions for which modern health care providers are believed to lack expertise. Most healers expressed a willingness to work with the formal health services because they had unique knowledge, skills and the trust of the community. However this would require a stronger acknowledgement and integration within safe motherhood programs.

The use of salutogenesis theory in empirical studies of maternity care for healthy mothers and babies.

BACKGROUND: Health care outcomes used in service evaluation and research tend to measure morbidity and mortality. This is the case even in maternity care, where most women and babies are healthy. Salutogenesis theory recognises that health is a continuum, with explicit inclusion of well-being as well as illness and pathology. This offers the potential to reframe the outcomes and therefore, the focus of, maternity care research and provision. AIM: The aim of this study was to identify how salutogenesis has been defined and used in maternity care research undertaken with healthy women. METHOD: A scoping review was undertaken, using a formal pre-defined search strategy. Inclusion criteria encompassed research papers relating to the maternity episode up to 1 year after birth, using salutogenesis or any of its associated concepts, focused on healthy women, and written in a language which any of the members of the group could understand. The search was undertaken in two phases (database inception--April 2011 and May 2011-February 2013). Included studies were subject to narrative analysis. FINDINGS: Eight papers met the inclusion criteria. They covered seven topics, spanning the antenatal, intrapartum and postnatal periods. Only two papers employed both positive health orientation and explicit use of Antonovsky's theory. The remaining studies used discrete aspects of the theory. CONCLUSION: Salutogenic framing is rarely used in maternity care research with healthy participants. An increase in research that measures salutogenically orientated outcomes could, eventually, provide a balance to the current over-emphasis on pathology in maternity care design and provision worldwide.

A retrospective, descriptive study of maternal and neonatal transfers, and clinical outcomes of a Primary Maternity Unit in rural Queensland, 2009-2011.

BACKGROUND: A widely held view in maternity services in rural Australia is they require 24-h on-site surgical and anaesthetic capability to be considered safe. This study aimed to provide a detailed description of three years of activity (2009-2011) of a rural maternity unit approximately 1h from the nearest surgical service. We describe the reasons for transfer to and from the unit, transfer times and the clinical health outcomes of all women (all risk status) and their babies. METHODS: This retrospective study utilised contemporaneously, purposefully collected audit data, routinely collected data and medical chart review. Data were analysed based on the model of care that women were allocated to at the time of booking. RESULTS: The PMU provided care to twice as many young women (13.3% MDH vs. 5.1% QLD) and almost five times as many Aboriginal and/or Torres Strait Islander women (27.5% MDH vs. 5.7% QLD). A total of 506 women booked to receive care through a midwifery group practice (MGP), and 377 (74.5%) gave birth at the local facility as planned. Clinical outcomes for women and babies birthing both at the PMU and those transferred were comparable or better than other published data. CONCLUSION: The results challenge the notion that birthing services can only be offered in rural areas with onsite surgical capability. More PMUs should be made available in rural areas, in line with national and state policy and international evidence.

Obesity in obstetrics.

Obesity is a rising global epidemic. Obesity during pregnancy is associated with increased maternal and fetal risks, which is inversely correlated with the severity level of obesity. Other comorbidities are common (diabetes mellitus, hypertensive disorders, etc.) and contribute to an even increased risk. Maternal obesity during pregnancy contributes also to offspring obesity and noncommunicable diseases later in life in a vicious cycle. Managing these problems, and potentially reducing their risk, can pose a challenge in obstetric care. It is important to provide preconception nutritional and exercise care, and guidance during pregnancy and post pregnancy for appropriate weight loss.

Developmental origins of health and disease--global public health implications.

The rapidly rising prevalence of non-communicable diseases (NCDs) represents a major challenge to public health and clinical medicine globally. NCDs are increasing rapidly in high-income countries, but even more rapidly in some low-middle-income countries with insufficient resources to meet the challenge. Whilst not identified in the Millennium Development Goals, there is much attention paid to NCDs in the discussions at many levels on the Sustainable Development Goals, as they underpin economic, social and environmental development in the post-2015 era. In this article, we discuss how a life-course approach to health, commencing of necessity in early development, can provide new opportunities for addressing this challenge. The approach can leverage human health capital throughout life and across generations. New insights into mechanisms, especially those processes by which the developmental environment affects epigenetic processes in the developing offspring, offer the prospect of identifying biomarkers of future risks. New interventions to promote health literacy, lifestyle and physical fitness in adolescents, young adults and their children hold great promise. In this respect, health-care professionals concerned with preconceptional, pregnancy and newborn care will have a vital role to play.

Lifestyle interventions to reduce risk of diabetes among women with prior gestational diabetes mellitus.

While lifestyle interventions involving exercise and a healthy diet in high-risk adults have been found to reduce progression to type 2 diabetes by >50%, little attention has been given to the potential benefits of such strategies in women with a history of gestational diabetes mellitus (GDM). We conducted a literature search of PubMed for English language studies of randomized controlled trials of lifestyle interventions among women with a history of GDM. In total, nine studies were identified which fulfilled the eligibility criteria. The majority of randomized trials of lifestyle interventions in women with GDM have been limited to pilot or feasibility studies. However, preliminary findings suggest that such interventions can improve diabetes risk factors in women with a history of GDM. Larger, well-designed controlled randomized trials are needed to assess the effects of lifestyle interventions on preventing subsequent progression to type 2 diabetes among women with GDM.

Links between maternal health and NCDs.

Non-communicable diseases (NCDs) and maternal health are closely linked. NCDs such as diabetes, obesity and hypertension have a significant adverse impact on maternal health and pregnancy outcomes, and through the mechanism of intrauterine programming maternal health impacts the burden of NCDs in future generations. The cycle of vulnerability to NCDs is repeated with increasing risk accumulation in subsequent generations. This article discusses the impact, interlinkages and advocates for integration of services for maternal and child health, NCD care and prevention and health promotion to sustainably improve maternal health as well address the rising burden of NCDs.

Current evidence supporting obstetric fistula prevention strategies in sub Saharan Africa: a systematic review of the literature.

Obstetric fistula has been eliminated in developed countries, but remains highly prevalent in sub-Saharan Africa. The End fistula campaign is the first concerted effort to eradicate the disease. The objective of this review is to retrieve and link available evidence to obstetric fistula prevention strategies in sub-Saharan Africa, since the campaign began. We searched databases for original research on obstetric fistula prevention. Fifteen articles meeting inclusion criteria were assessed for quality, and data extraction was performed. Grey literature provided context. Evidences from the articles were linked to prevention strategies retrieved from grey literature. The strategies were classified using an innovative target-focused method. Gaps in the literature show the need for fistula prevention research to aim at systematically measuring incidence and prevalence of the disease, identify the most effective and cost-effective strategies for fistula prevention and utilise innovative tools to measure impact of strategies in order to ensure eradication of fistula.

Emerging role of traditional birth attendants in mountainous terrain: a qualitative exploratory study from Chitral District, Pakistan.

OBJECTIVES: This research endeavours to identify the role of traditional birth attendants (TBAs) in supporting the maternal, newborn and child health (MNCH) care, partnership mechanism with a formal health system and also explored livelihood options for TBAs in the health system of Pakistan. SETTING: The study was conducted in district Chitral, Khyber Pakhtunkhwa province, covering the areas where the Chitral Child Survival programme was implemented. PARTICIPANTS: A qualitative exploratory study was conducted, comprising seven key informant interviews with health managers, and four focus group discussions with community midwives (CMWs), TBAs, members of Community Based Saving Groups (CBSGs) and members of village health committees (VHCs). RESULTS: The study identified that in the new scenario, after the introduction of CMWs in the health system, TBAs still have a pivotal role in health promotion activities such as breastfeeding promotion and vaccination. TBAs can assist CMWs in normal deliveries, and refer high-risk cases to the formal health system. Generally, TBAs are positive about CMWs' introduction and welcome this addition. Yet their livelihood has suffered after CMWs' deployment. Monetary incentives to them in recognition of referrals to CMWs could be one solution. The VHC is an active forum for strengthening co-ordination between the two service providers and to ensure an alternate and permanent livelihood support system for the TBAs. CONCLUSIONS: TBAs have assured their continued support in provision of continuum of care for pregnant women, lactating mothers and children under the age of 5 years. The district health authorities must figure out ways to foster a healthy interface vis-à-vis roles and responsibilities of TBAs and CMWs. In time it would be worthwhile to do further research to look into the CMWs' integration in the system, as well as TBAs' continued role for provision of MNCH care.

The effect of enhanced public-private partnerships on Maternal, Newborn and child Health Services and outcomes in Nairobi-Kenya: the PAMANECH quasi-experimental research protocol.

INTRODUCTION: Rapid urbanisation in Kenya has resulted in growth of slums in urban centres, characterised by poverty, inadequate social services and poor health outcomes. The government's initiatives to improve access to quality healthcare for mothers and children are largely limited to public health facilities, which are few and/or inaccessible in underserved areas such as the slums. The 'Partnership for Maternal, Newborn and Child Health' (PAMANECH) project is being implemented in two Nairobi slums, Viwandani and Korogocho, to assess the impact of strengthening public-private partnerships for the delivery of healthcare on the health of mothers, newborns and young children in two informal settlements in Kenya. METHODS AND ANALYSIS: This is a quasi-experimental study; our approach is to support private as well as public health providers and the community to enhance access to and demand for quality healthcare services. Key activities include: infrastructural upgrade of selected Private Not-For-Profit health facilities operating in the two slums, building capacity for healthcare providers as well as the Health Management Teams in Nairobi, facilitating provision of supportive supervision by the local health authorities and forming networks of Community Health Volunteers (CHVs) to create demand for health services. To assess the impact of the intervention, the study is utilising multiple data sources using a combination of qualitative and quantitative methods. A baseline survey was conducted in 2013 and an end-line survey will be conducted at least 1 year after full implementation of the intervention. Systematic monitoring and documentation of the intervention is on-going to strengthen the case for causal inference. ETHICS AND DISSEMINATION: Ethical approval for the study was obtained from the Kenya Medical Research Institute. Key messages from the results will be packaged and widely disseminated through workshops, conference presentations, reports, factsheets and academic publications to facilitate uptake by policymakers. PROTOCOL REGISTRATION NUMBER: KEMRI- NON-SSC-PROTOCOL No. 393.

Essential interventions: implementation strategies and proposed packages of care.

In an effort to accelerate progress towards achieving Millennium Development Goal (MDG) 4 and 5, provision of essential reproductive, maternal, newborn and child health (RMNCH) interventions is being considered. Not only should a state-of-the-art approach be taken for services delivered to the mother, neonate and to the child, but services must also be deployed across the household to hospital continuum of care approach and in the form of packages. The paper proposed several packages for improved maternal, newborn and child health that can be delivered across RMNCH continuum of care. These packages include: supportive care package for women to promote awareness related to healthy pre-pregnancy and pregnancy interventions; nutritional support package for mother to improve supplementation of essential nutrients and micronutrients; antenatal care package to detect, treat and manage infectious and noninfectious diseases and promote immunization; high risk care package to manage preeclampsia and eclampsia in pregnancy; childbirth package to promote support during labor and importance of skilled birth attendance during labor; essential newborn care package to support healthy newborn care practices; and child health care package to prevent and manage infections. This paper further discussed the implementation strategies for employing these interventions at scale.

Withdrawal from mental and psychosocial care during pregnancy.

Psychopathology, psychosocial problems and substance use (PPS) commonly occur in pregnant women, and can have a negative impact on the course of pregnancy and the healthy development of the child. As PPS often remains undetected and untreated during pregnancy, we developed and implemented a four-step screen-and-treat protocol in routine obstetric care, with: (i) screening including triage and subsequent confirmation, (ii) indication assessment, (iii) transfer towards care and (iv) utilization of care. Adherence to the protocol and risk factors associated with dropout were examined for 236 Dutch pregnant women in a deprived urban area. Seventy-nine percent of women accepted the screening, 21% dropped out during triage, 15% during confirmation, 3% during transfer and 8% thereafter. Provided reasons for dropout were lack of time and lack of perceived benefit. In particular, smokers, multiparous women, and women of non-Western ethnicity dropout on the way towards mental and psychosocial care. For a successful implementation of the protocol in the future, with improved adherence of pregnant women to the protocol, education of women on PPS risks, motivational skills and compulsory treatment are worth investigation.