The Safety and Feasibility of a Family First Aid Approach for the Management of Postpartum Hemorrhage in Home Births: A Pre-post Intervention Study in Rural Pakistan.

OBJECTIVE: To evaluate the safety and feasibility of a Family First Aid approach whereby women and their families are provided misoprostol in advance to manage postpartum hemorrhage (PPH) in home births. METHODS: A 12-month prospective, pre-post intervention study was conducted from February 2017 to February 2018. Women in their second and third trimesters were enrolled at home visits. Participants and their families received educational materials and were counseled on how to diagnose excessive bleeding and the importance of seeking care at a facility if PPH occurs. In the intervention phase, participants were also given misoprostol and counselled on how to administer the four 200 mcg tablets for first aid in case of PPH. Participants were followed-up postpartum to collect data on use of misoprostol for Family First Aid at home deliveries (primary outcome) and record maternal and perinatal outcomes. RESULTS: Of the 4008 participants enrolled, 97% were successfully followed-up postpartum. Half of the participants in each phase delivered at home. Among home deliveries, the odds of reporting PPH almost doubled among in the intervention phase (OR 1.98; CI 1.43, 2.76). Among those reporting PPH, women in the intervention phase were significantly more likely to have received PPH treatment (OR 10.49; CI 3.37, 32.71) and 90% administered the dose correctly. No maternal deaths, invasive procedures or surgery were reported in either phase after home deliveries. CONCLUSIONS: The Family First Aid approach is a safe and feasible model of care that provides timely PPH treatment to women delivering at home in rural communities.

Helping rural women in Pakistan to prevent postpartum hemorrhage: a quasi experimental study.

BACKGROUND: According to the Pakistan Demographic and Health Survey from 2006-2007, the maternal mortality ratio in rural areas is 319 per 100,000 live births. Postpartum hemorrhage is the leading cause of maternal deaths in Pakistan. The objectives of the study were to document the feasibility of distribution of misoprostol tablets by community-based providers mainly traditional birth attendants and acceptability and use of misoprostol by women who gave birth at home. METHODS: A quasi-experimental design, comprising intervention and comparison areas, was used to document the acceptability of providing misoprostol tablets to pregnant women to prevent postpartum hemorrhage in the rural community setting in Pakistan. Data were collected using structured questionnaires administered to women before and after delivery at home and their birth attendants. RESULTS: Out of 770 women who delivered at home, 678 (88%) ingested misoprostol tablets and 647 (84%) ingested the tablets after the birth of the neonate but prior to the delivery of the placenta. The remaining women took misoprostol tablets after delivery of the placenta. Side effects were experienced by 40% of women and were transitory in nature. Among women who delivered at home, 80% said that they would use misoprostol tablets in the future and 74% were willing to purchase them in the future. CONCLUSIONS: Self-administration of misoprostol in the home setting is feasible. Community-based providers, such as traditional birth attendants and community midwives with proper training and counseling, play an important role in reducing postpartum hemorrhage. Proper counseling and information exchange are helpful for introducing new practices in resource-constrained rural communities. Until such a time that skilled birth attendance is made more universally available in the rural setting, alternative strategies, such as training and using the services of traditional birth attendants to provide safe pregnancy care, must be considered.

Impact of a training package for community birth attendants in Madagascar.

This brief report assesses the impact of community birth attendant training and explores barriers to safe delivery in rural Madagascar. We assessed the knowledge of 25 community birth attendants using interviewer-administered questionnaires and explored attitudes to delivery in 4 focus groups of 10 women of reproductive age and 1 focus group of 10 birth attendants. We found a mismatch between hygiene knowledge and reported practice. Clinical experience appears to reinforce training to achieve longer lasting change in practitioner knowledge (e.g. of labour complications). Focus groups helped to identify practical barriers to clean (delivery kits) and safe delivery (cost) despite this knowledge. We proposed that a facilitated women's group programme may complement such training.

Communities, birth attendants and health facilities: a continuum of emergency maternal and newborn care (the Global Network's EmONC trial).

BACKGROUND: Maternal and newborn mortality rates remain unacceptably high, especially where the majority of births occur in home settings or in facilities with inadequate resources. The introduction of emergency obstetric and newborn care services has been proposed by several organizations in order to improve pregnancy outcomes. However, the effectiveness of emergency obstetric and neonatal care services has never been proven. Also unproven is the effectiveness of community mobilization and community birth attendant training to improve pregnancy outcomes. METHODS/DESIGN: We have developed a cluster-randomized controlled trial to evaluate the impact of a comprehensive intervention of community mobilization, birth attendant training and improvement of quality of care in health facilities on perinatal mortality in low and middle-income countries where the majority of births take place in homes or first level care facilities. This trial will take place in 106 clusters (300-500 deliveries per year each) across 7 sites of the Global Network for Women's and Children's Health Research in Argentina, Guatemala, India, Kenya, Pakistan and Zambia. The trial intervention has three key elements, community mobilization, home-based life saving skills for communities and birth attendants, and training of providers at obstetric facilities to improve quality of care. The primary outcome of the trial is perinatal mortality. Secondary outcomes include rates of stillbirth, 7-day neonatal mortality, maternal death or severe morbidity (including obstetric fistula, eclampsia and obstetrical sepsis) and 28-day neonatal mortality. DISCUSSION: In this trial, we are evaluating a combination of interventions including community mobilization and facility training in an attempt to improve pregnancy outcomes. If successful, the results of this trial will provide important information for policy makers and clinicians as they attempt to improve delivery services for pregnant women and newborns in low-income countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT01073488.

High ANC coverage and low skilled attendance in a rural Tanzanian district: a case for implementing a birth plan intervention.

BACKGROUND: In Tanzania, more than 90% of all pregnant women attend antenatal care at least once and approximately 62% four times or more, yet less than five in ten receive skilled delivery care at available health units. We conducted a qualitative study in Ngorongoro district, Northern Tanzania, in order to gain an understanding of the health systems and socio-cultural factors underlying this divergent pattern of high use of antenatal services and low use of skilled delivery care. Specifically, the study examined beliefs and behaviors related to antenatal, labor, delivery and postnatal care among the Maasai and Watemi ethnic groups. The perspectives of health care providers and traditional birth attendants on childbirth and the factors determining where women deliver were also investigated. METHODS: Twelve key informant interviews and fifteen focus group discussions were held with Maasai and Watemi women, traditional birth attendants, health care providers, and community members. Principles of the grounded theory approach were used to elicit and assess the various perspectives of each group of participants interviewed. RESULTS: The Maasai and Watemi women's preferences for a home birth and lack of planning for delivery are reinforced by the failure of health care providers to consistently communicate the importance of skilled delivery and immediate post-partum care for all women during routine antenatal visits. Husbands typically serve as gatekeepers of women's reproductive health in the two groups - including decisions about where they will deliver- yet they are rarely encouraged to attend antenatal sessions. While husbands are encouraged to participate in programs to prevent maternal-to-child transmission of HIV, messages about the importance of skilled delivery care for all women are not given emphasis. CONCLUSIONS: Increasing coverage of skilled delivery care and achieving the full implementation of Tanzania's Focused Antenatal Care Package in Ngorongoro depends upon improved training and monitoring of health care providers, and greater family participation in antenatal care visits.

Pregnancy and Village Outreach Tibet: a descriptive report of a community- and home-based maternal-newborn outreach program in rural Tibet.

OBJECTIVE: The Pregnancy and Village Outreach Tibet (PAVOT) program, a model for community- and home-based maternal-newborn outreach in rural Tibet, is presented. METHODS: This article describes PAVOT, including the history, structure, content, and activities of the program, as well as selected program outcome measures and demographic characteristics, health behaviors, and pregnancy outcomes of women who recently participated in the program. RESULTS: The PAVOT program was developed to provide health-related services to pregnant rural Tibetan women at risk of having an unattended home birth. The program involves training local healthcare workers and laypersons to outreach pregnant women and family members. Outreach includes basic maternal-newborn health education and simple obstetric and neonatal life-saving skills training. In addition, the program distributes safe and clean birth kits, newborn hats, blankets, and maternal micronutrient supplements (eg, prenatal vitamins and minerals). More than 980 pregnant women received outreach during the study period. More than 92% of outreach recipients reported receiving safe pregnancy and birth education, clean birthing and uterine massage skills instruction, and clean umbilical cord care training. Nearly 80% reported basic newborn resuscitation skills training. Finally, nearly 100% of outreach recipients received maternal micronutrient supplements and safe and clean birth kits. CONCLUSION: The PAVOT program is a model program that has been proven to successfully provide outreach to rural-living Tibetans by delivering maternal-newborn health education, skills training, and resources to the home.

Effect of an in-situ simulation workshop on home birth practice in Australia.

PROBLEM: Interprofessional training programs for obstetric emergencies have been introduced for up-skilling birth unit staff in hospitals but not frequently used in training midwives and paramedicine staff for home birth emergency. BACKGROUND: Practical Obstetric Multiprofessional Training (PROMPT) has previously been described in the home birth setting using in-situ simulation training of home births for midwifery and paramedicine staff. AIM: The aim of this study was to evaluate the benefit of the home birth simulation in clinical practice and to explore how the simulation program prepared the midwives for a birth-related emergency in a publicly funded home birth program. METHODS: Midwives conducting home births, the midwifery educator and the simulated woman in labour (n=9) attended an interview that explored how the midwives' learning through simulation affected their home birth clinical practice. The simulated woman and the facilitator who conducted the simulation for more than six years were also interviewed to comment on the observed change in performance in simulation. The interview transcripts were thematically analysed. FINDINGS: The themes that were identified and agreed upon, were applying learning to clinical practice, learning in teams, valuing realism, facilitating simulation based education and managing variation. DISCUSSION: In-situ nature of simulation with home birth midwives and paramedical staff facilitated learning transfer and team-based approach to practice. The careful simulation design provided a breadth of experience in emergencies. CONCLUSION: Applying learning to prepare for clinical emergency situations changed the midwives' approach in managing home births. This provided evidence for a change in behaviour (Level 3 Kirkpatrick's framework) and transfer of learning, leading to changed protocols (Level 4a Kirkpatrick's framework).

Simulation based training in a publicly funded home birth programme in Australia: A qualitative study.

BACKGROUND: Birth at home is a safe and appropriate choice for healthy women with a low risk pregnancy. However there is a small risk of emergencies requiring immediate, skilled management to optimise maternal and neonatal outcomes. We developed and implemented a simulation workshop designed to run in a home based setting to assist with emergency training for midwives and paramedical staff. The workshop was evaluated by assessing participants' satisfaction and response to key learning issues. METHODS: Midwifery and emergency paramedical staff attending home births participated in a simulation workshop where they were required to manage birth emergencies in real time with limited availability of resources to suit the setting. They completed a pre-test and post-test evaluation form exploring the content and utility of the workshops. Content analysis was performed on qualitative data regarding the most important learning from the simulation activity. RESULTS: A total of 73 participants attended the workshop (midwifery=46, and paramedical=27). There were 110 comments, made by 49 participants. The most frequently identified key learning elements were related to communication (among midwives, paramedical and hospital staff and with the woman's partner), followed by recognising the role of other health care professionals, developing an understanding of the process and the importance of planning ahead. CONCLUSION: Home birth simulation workshop was found to be a useful tool by staff that provide care to women who are having a planned home birth. Developing clear communication and teamwork were found to be the key learning principles guiding their practice.

The American College of Nurse-Midwives' home-based lifesaving skills program: a review of the Ethiopia field test.

The Home-Based Lifesaving Skills program (HBLSS) is a family- and community-focused, competency-based program that aims to reduce maternal and newborn mortality by increasing access to basic lifesaving measures within the home and community and by decreasing delays in reaching referral facilities where obstetric complications, such as postpartum hemorrhage and newborn asphyxia, can be managed. HBLSS was field tested in rural southern Ethiopia where over 90% of births take place at home with unskilled attendants. The program review assessed 1) the performance of HBLSS-trained guides; 2) management of postpartum hemorrhage and newborn infection by women, family, and birth attendants; 3) exposure of women and families to HBLSS training; and 4) community support. There was improved performance in management of postpartum hemorrhage, a leading cause of maternal death. Findings for management of newborn infection were less compelling. None of the communities had established reliable emergency transportation. Exposure to HBLSS training in the community was estimated at 38%, and there was strong community support. Organizations incorporating HBLSS into proposals focusing on maternal and newborn health during birth and the immediate postpartum period are encouraged to conduct research necessary to establish the evidence base for this promising new approach.

Effect of shifting policies on traditional birth attendant training.

Traditional birth attendant (TBA) training commenced in many places in the non-Western world in the 1970s, supported by the World Health Organization and other funding bodies. By 1997, senior policy makers decided to refocus priorities on the provision of "skilled attendants" to assist birthing women. The definition of skilled attendants excluded TBAs and resulted in the subsequent withdrawal of funding for TBA training globally. A review of the health and sociological literature and international policy documents that address TBA training revealed how international policy and professional orientation are reflected in education programs designed for the TBA. Policy makers risk ignoring the important cultural and social roles TBAs fulfill in their local communities and fail to recognize the barriers to the provision of skilled care. The provision of skilled attendants for all birthing women cannot occur in isolation from TBAs who in themselves are also highly skilled. This article argues a legitimacy of alternative worldviews and acknowledges the contribution TBAs make to childbearing women across the world.

Does traditional birth attendant training increase use of antenatal care? A review of the evidence.

A combined narrative review and metanalytic review was conducted to summarize published and unpublished studies completed between 1970 and 2002 on the relationship between traditional birth attendant (TBA) training and increased use of professional antenatal care (ANC). Fifteen studies (n = 15) from 8 countries and 2 world regions were analyzed. There are, to varying degrees, positive associations between TBA training and TBA knowledge of the value and timing of ANC services, TBA behavior in offering advice or assistance to obtain ANC, and compliance and use of ANC services by women cared for by TBAs or living in areas served by TBAs. There is a serious lack of information about TBA training program characteristics. Although the findings cannot be causally attributed to TBA training, the results suggest that training may increase ANC attendance rates by about 38%. This magnitude of improvement could contribute to a reduction in maternal and perinatal mortality in areas where women have access to quality antenatal and emergency obstetric care. There is an urgent need to improve capacity for evaluation and research of the effect of TBA training programs and other factors that influence women's use of ANC services.

Behavior change following implementation of home-based life-saving skills in Liberia, West Africa.

INTRODUCTION: Home-Based Life-Saving Skills (HBLSS) has been fully integrated into Liberia's long-term plan to decrease maternal and newborn mortality and morbidity, coordinated through the Ministry of Health and Social Welfare. The objective of this article is to disseminate evaluation data from project monitoring and documentation on translation of knowledge and skills obtained through HBLSS into behavior change at the community level. METHODS: One year after completion of HBLSS training, complication audits were conducted with 434 postpartum women in 1 rural county in Liberia. RESULTS: Sixty-two percent (n = 269) of the women were attended during birth by an HBLSS-trained traditional midwife or family member, while 38% (n = 165) were attended by a traditional midwife or family member who did not receive HBLSS training. Home-Based Life-Saving Skills-trained birth attendants performed significantly more first actions (life-saving actions taught to be performed after every birth) than the attendants not HBLSS trained. Fourteen percent of our sample (n = 62) reported too much bleeding following the birth. Of these women, approximately half (n = 29) were attended by an HBLSS-trained traditional midwife or family member. There was a significant difference in secondary actions (those actions taught to be performed when a woman experiences too much bleeding following childbirth) that were reported to have been performed by HBLSS-trained attendants (mean 5.26, standard deviation [SD] 1.88) and untrained attendants (mean 2.73, SD 1.97; P < .0001). DISCUSSION: Our findings suggest that HBLSS knowledge is being transferred into behavior change and used at the community level by traditional midwives and family members.

Re-examining authoritative knowledge in the design and content of a TBA training in India.

UNLABELLED: Since the 1990s, the TBA training strategy in developing countries has been increasingly seen as ineffective and hence its funding was subsequently reallocated to providing skilled attendants during delivery. The ineffectiveness of training programmes is blamed on TBAs lower literacy, their inability to adapt knowledge from training and certain practices that may cause maternal and infant health problems. However most training impact assessments evaluate post-training TBA practices and do not assess the training strategy. There are serious deficiencies noted in information on TBA training strategy in developing countries. The design and content of the training is vital to the effectiveness of TBA training programmes. We draw on Jordan's concept of 'authoritative knowledge' to assess the extent to which there is a synthesis of both biomedical and locally practiced knowledge in the content and community involvement in the design of TBA a training programme in India. FINDINGS: The implementation of the TBA training programme at the local level overlooks the significance of and need for a baseline study and needs assessment at the local community level from which to build a training programme that is apposite to the local mother's needs and that fits within their 'comfort zone' during an act that, for most, requires a forum in which issues of modesty can be addressed. There was also little scope for the training to be a two way process of learning between the health professionals and the TBAs with hands-on experience and knowledge. The evidence from this study shows that there is an overall 'authority' of biomedical over traditional knowledge in the planning and implementation process of the TBA training programme. Certain vital information was not covered in the training content including advice to delay bathing babies for at least six hours after birth, to refrain from applying oil on the infant, and to wash hands again before directly handling mother or infant. Information on complication management and hypothermia was not adequately covered in the local TBA training programme. KEY CONCLUSIONS: The suggested improvements include the need to include a baseline study, appropriate selection criteria, improve information in the training manual to increase clarity of meaning, and to encourage beneficial traditional practices through training.

Evaluation of a traditional birth attendant training programme in Bangladesh.

BACKGROUND AND CONTEXT: the 1997 Safe Motherhood Initiative effectively eliminated support for training traditional birth attendants (TBAs) in safe childbirth. Despite this, TBAs are still active in many countries such as Bangladesh, where 88% of deliveries occur at home. Renewed interest in community-based approaches and the urgent need to improve birth care has necessitated a re-examination of how provider training should be conducted and evaluated. OBJECTIVE: to demonstrate how a simple evaluation tool can provide a quantitative measure of knowledge acquisition and intended behaviour following a TBA training program. DESIGN: background data were collected from 45 TBAs attending two separate training sessions conducted by Bangladeshi non-governmental organization (NGO) Gonoshasthaya Kendra (GK). A semi-structured survey was conducted before and after each training session to assess the TBAs' knowledge and reported practices related to home-based management of childbirth. SETTING: two training sessions conducted in Vatshala and Sreepur in rural Bangladesh. PARTICIPANTS: 45 active TBAs were recruited for this training evaluation. FINDINGS: there were significant improvements following the training sessions regarding how TBAs reported they would: (a) measure blood loss, (b) handle an apneic newborn, (c) refer women with convulsions and (d) refer women who are bleeding heavily. A greater degree of improvement, and higher scores overall, were observed among TBAs with no prior training and with less birth experience. KEY CONCLUSIONS AND RECOMMENDATIONS FOR PRACTICE: as the Safe Motherhood community strives to improve safe childbirth care, the quality of care in pregnancy and childbirth for women who rely on less-skilled providers should not be ignored. These communities need assistance from governments and NGOs to help improve the knowledge and skill levels of the providers upon which they depend. Gonoshasthaya Kendra's extensive efforts to train and involve TBAs, with the aim of improving the quality of care provided to Bangladeshi women, is a good example of how to effectively integrate TBAs into safe motherhood efforts in resource-poor settings. The evaluation methodology described in this paper demonstrates how trainees' prior experiences and beliefs may affect knowledge acquisition, and highlights the need for more attention to course content and pedagogic style.