Social and economic development and pregnancy mental health: secondary analyses of data from rural Vietnam.

BACKGROUND: This study aimed to establish whether changes in the socioeconomic context were associated with changes in population-level antenatal mental health indicators in Vietnam. METHODS: Social, economic and public policies introduced in Vietnam (1986-2010) were mapped. Secondary analyses of data from two cross-sectional community-based studies conducted in 2006 (n = 134) and 2010 (n = 419), involving women who were ≥ 28 weeks pregnant were completed. Data for these two studies had been collected in structured individual face-to-face interviews, and included indicators of antenatal mental health (mean Edinburgh Postnatal Depression Scale Vietnam-validation (EPDS-V) score), intimate partner relationships (Intimate Bonds Measure Vietnam-validation) and sociodemographic characteristics. Socioeconomic characteristics and mean EPDS-V scores in the two study years were compared and mediation analyses were used to establish whether indicators of social and economic development mediated differences in EPDS-V scores. RESULTS: Major policy initiatives for poverty reduction, hunger eradication and making domestic violence a crime were implemented between 2006 and 2010. Characteristics and circumstances of pregnant women in Ha Nam improved significantly. Mean EPDS-V score was lower in 2010, indicating better population-level antenatal mental health. Household wealth and intimate partner controlling behaviours mediated the difference in EPDS-V scores between 2006 and 2010. CONCLUSIONS: Changes in the socioeconomic and political context, particularly through policies to improve household wealth and reduce domestic violence, appear to influence women's lives and population-level antenatal mental health. Cross-sectoral policies that reduce social risk factors may be a powerful mechanism to improve antenatal mental health at a population level.

Distance to care, care seeking and child mortality in rural Burkina Faso: findings from a population-based cross-sectional survey.

OBJECTIVE: Although distance has been identified as an important barrier to care, evidence for an effect of distance to care on child mortality is inconsistent. We investigated the association of distance to care with self-reported care seeking behaviours, neonatal and post-neonatal under-five child mortality in rural areas of Burkina Faso. METHODS: We performed a cross-sectional survey in 14 rural areas from November 2014 to March 2015. About 100 000 women were interviewed on their pregnancy history and about 5000 mothers were interviewed on their care seeking behaviours. Euclidean distances to the closest facility were calculated. Mixed-effects logistic and Poisson regressions were used respectively to compute odds ratios for care seeking behaviours and rate ratios for child mortality during the 5 years prior to the survey. RESULTS: Thirty per cent of the children lived more than 7 km from a facility. After controlling for confounding factors, there was a strong evidence of a decreasing trend in care seeking with increasing distance to care (P ≤ 0.005). There was evidence for an increasing trend in early neonatal mortality with increasing distance to care (P = 0.028), but not for late neonatal mortality (P = 0.479) and post-neonatal under-five child mortality (P = 0.488). In their first week of life, neonates living 7 km or more from a facility had an 18% higher mortality rate than neonates living within 2 km of a facility (RR = 1.18; 95%CI 1.00, 1.39; P = 0.056). In the late neonatal period, despite the lack of evidence for an association of mortality with distance, it is noteworthy that rate ratios were consistent with a trend and similar to or larger than estimates in early neonatal mortality. In this period, neonates living 7 km or more from a facility had an 18% higher mortality rate than neonates living within 2 km of a facility (RR = 1.18; 95%CI 0.92, 1.52; P = 0.202). Thus, the lack of evidence may reflect lower power due to fewer deaths rather than a weaker association. CONCLUSION: While better geographic access to care is strongly associated with increased care seeking in rural Burkina Faso, the impact on child mortality appears to be marginal. This suggests that, in addition to improving access to services, attention needs to be paid to quality of those services.

Use of Electronic Patient Portals in Pregnancy: An Overview.

Electronic patient portals are increasingly utilized in contemporary health care systems. Patient portal use has been found to be beneficial in multiple specialties, particularly in management of chronic diseases. However, there are disparities within portal use. For example, individuals who are racial and ethnic minorities and persons from lower socioeconomic status are less likely to enroll and use patient portals than non-Hispanic white persons and persons with higher socioeconomic status. Because portal use and, specifically, patient-provider secure messaging has been associated with favorable health outcomes, disparities in use of these portals could affect health outcomes. Electronic patient portal use by childbearing women has not been well studied, and data on portal use during pregnancy are limited. This article reviews the current literature regarding electronic patient portal use and highlights the need for further maternity care-focused research regarding this new avenue of care delivery during pregnancy.

Inequities and their determinants in coverage of maternal health services in Burkina Faso.

BACKGROUND: Poor and marginalized segments of society often display the worst health status due to limited access to health enhancing interventions. It follows that in order to enhance the health status of entire populations, inequities in access to health care services need to be addressed as an inherent element of any effort targeting Universal Health Coverage. In line with this observation and the need to generate evidence on the equity status quo in sub-Saharan Africa, we assessed the magnitude of the inequities and their determinants in coverage of maternal health services in Burkina Faso. METHODS: We assessed coverage for three basic maternal care services (at least four antenatal care visits, facility-based delivery, and at least one postnatal care visit) using data from a cross-sectional household survey including a total of 6655 mostly rural, poor women who had completed a pregnancy in the 24 months prior to the survey date. We assessed equity along the dimensions of household wealth, distance to the health facility, and literacy using both simple comparative measures and concentration indices. We also ran hierarchical random effects regression to confirm the presence or absence of inequities due to household wealth, distance, and literacy, while controlling for potential confounders. RESULTS: Coverage of facility based delivery was high (89%), but suboptimal for at least four antenatal care visits (44%) and one postnatal care visit (53%). We detected inequities along the dimensions of household wealth, literacy and distance. Service coverage was higher among the least poor, those who were literate, and those living closer to a health facility. We detected a significant positive association between household wealth and all outcome variables, and a positive association between literacy and facility-based delivery. We detected a negative association between living farther away from the catchment facility and all outcome variables. CONCLUSION: Existing inequities in maternal health services in Burkina Faso are likely going to jeopardize the achievement of Universal Health Coverage. It is important that policy makers continue to strengthen and monitor the implementation of strategies that promote proportionate universalism and forge multi-sectoral approach in dealing with social determinants of inequities in maternal health services coverage.

The Health and Economic Well-Being of US Mothers with Intellectual Impairments.

BACKGROUND: While the United States has seen increased attention by policymakers on the rights of parents with disabilities, there is limited understanding of the health and economic well-being of parents with intellectual impairments. This study compares the health and economic well-being of mothers with and without intellectual impairments. METHODS: This descriptive, exploratory study is a secondary analysis of the Fragile Families and Child Wellbeing Study. This study includes a subsample of mothers of three-year-old children (n = 1561), including mothers with intellectual impairments (n = 263) and without intellectual impairments (n = 1298). RESULTS: US Mothers with intellectual impairments are more likely to report serious health conditions, have less instrumental support, live in poverty, receive public benefits and experience certain material hardships. CONCLUSION: Findings from this study indicate the need for policies and programmes to support parents with intellectual impairments by addressing their health and economic needs.

Health promotion and empowerment in Henganofi District, Papua New Guinea.

Evidence shows that the government of Papua New Guinea is failing to provide basic services in health to the majority of its people. Local non-government organisations (NGOs), partnered with international NGOs, are attempting to fill this gap. With limited resources, these small Indigenous organisations must focus much of their effort on training that supports self-reliance as the main strategy for communities to improve their quality of life. This project explored the training content and methodology of Touching The Untouchables (TTU), a small Indigenous NGO based in Goroka, Eastern Highlands Province, that has trained a network of village volunteers in health promotion and safe motherhood.
Village life imposes multiple demands, from self-sufficiency in food to maintaining law and order. There are established attitudes about power and dependence, referred to as 'cargo thinking'. Cargo thinking stands as a barrier to the necessity of self-reliance, and requires training strategies that seek to empower participants to create change from their own initiative. Empowerment is understood as oriented towards individual people taking collective action to improve their circumstances by rectifying disparities in social power and control. To achieve self-reliance, empowerment is necessarily operational on the levels of person, community and society.
In addition to being operational on all three levels of empowerment, the training content and methodology adopted and developed by TTU demonstrate that empowering practice in training employs approaches to knowledge that are evidence-based, reflexive, contextual and skill-based. Creating knowledge that is reflexive and exploring knowledge about the broader context uses special kinds of communicative tools that facilitate discussion on history, society and political economy. Furthermore, training methodologies that are oriented to empowerment create settings that require the use of all three types of communication required for cooperative action: dramaturgical, normative and teleological communication.
The success of TTU's training content and methodology demonstrates that creating the conditions for achieving collective self-reliance through empowerment is a necessary part of primary health promotion in Papua New Guinea, and that underlying the success of empowerment oriented training are definable types of knowledge and communication.

Emergency obstetric and neonatal care needs assessment: Results of the 2010 and 2014 surveys in Burkina Faso.

OBJECTIVE: To analyze and compare the availability, utilization, and quality of services for maternal and neonatal health in 2010 and 2014 in Burkina Faso. METHODS: A cross-sectional study of emergency obstetric and neonatal care services (EmONC) in all public and private health facilities in Burkina Faso in 2010 and a sample of 812 health facilities in 2014. The generic tools developed by the Averting Maternal Death and Disability (AMDD) program were used as the basic tools for evaluation. RESULTS: In 2010, 25 health facilities were considered as EmONC health facilities and there were 23 in 2014. In 2010 and 2014, the proportion of births in EmONC health facilities was low (4.5%). The cesarean delivery rate also remained very low, at 0.9% in 2010 and 1.13% in 2014. The proportion of obstetric complications supported in health facilities was 12.3% in 2010 and 17.1% in 2014. The direct complication case fatality rate in EmONC health facilities was 1.6% in 2010 and 1.3% in 2014. CONCLUSION: The two surveys did not show a significant improvement in the availability, utilization, and quality of maternal and neonatal healthcare services between 2010 and 2014.

Availability and utilization of obstetric and newborn care in Guinea: A national needs assessment.

OBJECTIVE: To assess the availability and utilization of emergency obstetric and neonatal care (EmONC) in Guinea given the high maternal and neonatal mortality rates. METHODS: We used the Guinea 2012 needs assessment data collected via a national cross-sectional census of health facilities conducted from September to October 2012. All public, private, and faith-based health facilities that performed at least one delivery during the period of the study were included. RESULTS: A total of 502 health facilities were visited, of which 81 were hospitals. Only 15 facilities were classified as fully functioning EmONC facilities, all of which were reference hospitals. None of the first level health facilities were fully functioning EmONC facilities. The ratio of availability of EmONC was one fully functioning EmONC facility for 745 415 inhabitants. The institutional delivery rate was 32.3% and the proportion of all births in EmONC facilities was 7.1%. Met need for EmONC was 12.2%. Among 201 maternal deaths in EmONC facilities, 69 were due to indirect causes. The intrapartum and very early neonatal death rate was 39 deaths per 1000 live births. CONCLUSION: The study showed low availability of EmONC services and underutilization of the available services. Further investigation is needed to evaluate the effect of the current policy of user fees exemption for deliveries and prenatal care in Guinea.

Local initiatives to access emergency obstetric and neonatal care in Burkina Faso.

OBJECTIVE: To describe the various local initiatives to access emergency obstetric and neonatal care in Burkina Faso. METHODS: An existing framework was used to review the three processes for local initiatives: emergence, formulation, and implementation. Multiple case studies were conducted, followed by literature review and semi-structured interviews with key informants. RESULTS: Sixteen districts had implemented local initiatives, including cost sharing, free care for women and children, and free care for delivery and cesareans. Most districts (n=10) had implemented the cost-sharing intervention. These initiatives were initiated by local actors as well as nongovernmental organizations. The profile of those involved led to different ways of handling the emergence and formulation processes. At implementation, these initiatives faced many issues including late payment of contributions, low involvement of local governments, and equity in participation. CONCLUSION: There are some issues in the implementation and sustainability of the local initiatives. Although many initiatives exist, these are unable to fully address the financial barriers to care. However, these initiatives highlight context-based financial barriers that must be taken into account to accelerate universal access to health care.

Maternal Intimate Partner Violence Victimization Before and During Pregnancy and Postbirth Child Welfare Contact: A Population-Based Assessment.

We conducted a population-based prospective cohort study to help elucidate the predictive relationship between a maternal prebirth self-reported history of intimate partner violence (IPV) and any postbirth reported allegation to Child Protective Services (CPS) by age 2. We linked data from the 2009-2010 Alaska Pregnancy Risk Assessment Monitoring System with CPS data through 2012. Among this cohort, we found that 8.0%w self-reported experiencing IPV 12 months prior or during pregnancy, and 8.0%w of the offspring experienced at least one CPS report of alleged maltreatment during the study period. The predictive relationship varied by maternal educational attainment. Among mothers with 12+ years education completed, the odds of a CPS report were 3.9 times compared to those with no IPV, while among mothers with <12 years education completed, no association was noted. These results suggest that for a subset of Alaskan families, maternal history of IPV is a strong independent predictor of future CPS contact.

Providing hope: midwifery teaching in Bangladesh.

Bangladesh is recognised as a resource-poor country that has made some very positive steps to reducing maternal mortality over the last decade. However the death rate of women directly caused by pregnancy and childbirth still remains much higher than countries such as the UK, often due to lack of access to good quality and affordable basic health care. In this article, Anna Kent writes of her experiences teaching obstetric emergency clinical skills to Bangladesh's first ever student midwives. The students were recruited from rural villages to complete a three-year fully funded Midwifery Diploma Programme at one of seven education centres across the country. The goal of the programme is for the students to eventually return and practise as midwives in their home communities, enabling greater access for women to good quality basic health care, directly reducing maternal mortality across Bangladesh.

Strategies to increase demand for maternal health services in resource-limited settings: challenges to be addressed.

BACKGROUND: Universal health access will not be achieved unless women are cared for in their own communities and are empowered to take decisions about their own health in a supportive environment. This will only be achieved by community-based demand side interventions for maternal health access. In this review article, we highlight three common strategies to increase demand-side barriers to maternal healthcare access and identify the main challenges that still need to be addressed for these strategies to be effective. DISCUSSION: Common demand side strategies can be grouped into three categories:(i) Financial incentives/subsidies; (ii) Enhancing patient transfer, and; (iii) Community involvement. The main challenges in assessing the effectiveness or efficacy of these interventions or strategies are the lack of quality evidence on their outcome and impact and interventions not integrated into existing health or community systems. However, what is highlighted in this review and overlooked in most of the published literature on this topic is the lack of knowledge about the context in which these strategies are to be implemented. We suggest three challenges that need to be addressed to create a supportive environment in which these demand-side strategies can effectively improve access to maternal health services. These include: addressing decision-making norms, engaging in intergenerational dialogue, and designing contextually appropriate communication strategies.

Maternal and Perinatal Health in Umbria region in 2012.

BACKGROUND: Pregnancy and childbirth still involve risk for pregnant women and their babies and health in the perinatal period remains an important public health priority. This study addresses the question of perinatal health in Umbria region. METHODS: Data were obtained from the administrative source of the regional Standard Certificate of Live Births in Umbria in 2012. We used population data, which merges data from each mother and her baby for a total of 7964 records. To describe perinatal health we considered pathological pregnancy, fetal growth defect, birth weight, gestational age, Apgar scores at 5 minutes and stillbirth such as indicators of Maternal and Neonatal Health in according with population characteristics and risk factors (maternal age, parity, mothers' educational level and mothers' country of birth). RESULTS: In Umbria, in 2012 we have: - 29 stillbirths corresponding to a rate of stillbirths of 3.52 ‰ (stillbirths per 1000 births) - a perinatal mortality rate ( stillbirths and deaths in the first week of life) of 4.9 per 1000 live births and stillbirths - an Infant mortality rate (within the first year of life) of 2.5 per 1000 live births The 1.4 % of infants underwent neonatal resuscitation. This percentage detects an indicative Apgar score of important neonatal suffering (0-3) in the 1% of neonates. The frequency of infants with birth weight less than 2500 grams (LBW) was 6.4 %, with higher values ​​in females (7.3%) than males (2.7%). The frequency of infants with birth weight less than 1500 grams is 0.8%. The preterm birth (<37 weeks of gestation) rate is 6.3% of the total: 5.6% are pregnancies among the 32 and 36 weeks of gestation and 0.7% are pregnancies under the 32nd week of gestation. The pathological pregnancies are 7.9% and the Fetal Growth Restriction (FGR) is 2.7%. The health perinatal indicators considered were different in different population subgroups. The most representative population was Italian women (76.8%), with maternal age between 25-34 years (56.4%), primiparous (61.9%) and mothers with medium education levels (48.1%). CONCLUSIONS: Results highlight the existence of differences in perinatal health. Worse maternal condition and neonatal status were observed especially for less advantaged social classes (i.e., foreign or poorly educated). Such inequalities should be examined in all areas of public policy and public services, to ensure equal opportunity for all.