Una concepción integral del parto humanizado en Cuba / A Holistic Concept of Humanized Childbirth in Cuba

Introducción: El sistema de salud cubano ha logrado bajos índices de mortalidad materna e infantil, lo que constituye un logro tanto para el sistema de salud como para el sistema socioeconómico; pero al tomar en consideración que el parto establece el principio de la vida, su humanización constituye una necesidad inaplazable. Objetivo: caracterizar el parto humanizado en Cuba. Métodos: Se realizó una revisión bibliográfica sistemática para desarrollar un análisis crítico reflexivo del contenido de documentos. La búsqueda fue realizada en las bases de datos SciELO y Google académico. Tras la identificación de los estudios pre-seleccionados, se llevó a cabo la lectura de los títulos, resumen y palabras clave, comprobando la pertinencia con el estudio. Conclusión: De este análisis teórico surgen presunciones con relación al proceso de parto en el contexto de las maternidades cubanas, donde existen profesionales de la salud con un nivel científico y un dominio tecnológico elevado para garantizar un resultado satisfactorio en el binomio madre-hijo pero se precisa la inclusión del componente humanizador e integral(AU)

Introduction: The Cuban health system has achieved low rates of maternal and infant mortality, which is an achievement of both the health system and the socioeconomic system; but when taking into consideration that childbirth constitutes the beginning of life, its humanization constitutes an unplayable need. Objective: To characterize humanized childbirth in Cuba. Methods: We carried out a systematic bibliographic review to grow a reflexive critical analysis of the content of documents in SciELO and Google academic databases. After the identification of the pre-selected studies, we studied titles, abstracts and keywords for verifying the relevance for our study. Conclusion: This theoretical analysis brings assumptions regarding the birthing process in the context of Cuban maternity wards where health professionals with high scientific level and high technological expertise domain to guarantee a satisfactory result in the mother-child binomial but inclusion of the humanizing and integral component is required in order to provide better quality care(AU)

Vitamin K supplementation to prevent hemorrhagic morbidity and mortality of newborns in India and China.

BACKGROUND: Vitamin K deficiency bleeding (VKDB) can cause prolonged and bleeding (intracranial hemorrhage) among newborns, which can be life-threatening or lead to long-term morbidity. The aim of this review article is to reiterate empirical evidence to support the argument that vitamin K should be mandatory for newborns in India and China, as well as in other countries with a high burden of neonatal deaths. DATA SOURCES: Studies were integrated from the PubMed/MEDLINE database search, as well as related literature available elsewhere. RESULTS: Both India and China have been slow in adopting an effective program for administering vitamin K injections to newborns to prevent VKDB-related morbidity and mortality. VKDB cases in China and India have shown inadequate attention to routine use of vitamin K by injection. CONCLUSIONS: While no reliable data are publicly available, the issue of VKDB is at last receiving some attention from the Chinese public health system as well as the Indian government. In both countries, routine vitamin K administration to newborns would prove to be a cost-effective intervention to reduce preventable neonatal morbidity and mortality. VKDB is a global neonatal care issue, including countries where parental resistance is preventing babies from defense against this life-threatening condition.

INEQUITY ISSUES AND MOTHERS' PREGNANCY, DELIVERY AND EARLY-AGE SURVIVAL EXPERIENCES IN ENDE DISTRICT, INDONESIA.

Indonesia's infant mortality rates are among the highest in South-East Asia, and there are substantial variations between its sub-national regions. This qualitative study aims to explore early mortality-related health service provision and gender inequity issues based on mothers' pregnancy, delivery and early-age survival experience in Ende district, Nusa Tenggara Timur province. Thirty-two mothers aged 18-45 years with at least one birth in the previous five years were interviewed in depth in May 2013. The results show most mothers have little knowledge about the danger signs for a child's illness. Mothers with early-age deaths generally did not know the cause of death. Very few mothers had received adequate information on maternal and child health during their antenatal and postnatal visits to the health facility. Some mothers expressed a preference for using a traditional birth attendant, because of their ready availability and the more extensive range of support services they provide, compared with local midwives. Unprofessional attitudes displayed by midwives were reported by several mothers. As elsewhere in Indonesia, the power of health decision-making lies with the husband. Policies aimed at elevating mothers' roles in health care decision-making are discussed as measures that would help to improve early-age survival outcomes. Widening the public health insurance distribution, especially among poorer mothers, and equalizing the geographical distribution of midwives and health facilities are recommended to tackle geographical inequities and to increase early-age survival in Ende district.

A qualitative study exploring newborn care behaviours after home births in rural Ethiopia: implications for adoption of essential interventions for saving newborn lives.

BACKGROUND: Ethiopia is among seven high-mortality countries which have achieved the fourth millennium development goal with over two-thirds reduction in under-five mortality rate. However, the proportion of neonatal deaths continues to rise and recent studies reported low coverage of the essential interventions saving newborn lives. In the context of low uptake of health facility delivery, it is relevant to explore routine practices during home deliveries and, in this study, we explored the sequence of immediate newborn care practices and associated beliefs following home deliveries in rural communities in Ethiopia. METHODS: Between April-May 2013, we conducted 26 semi-structured interviews and 2 focus group discussions with eligible mothers, as well as a key informant interview with a local expert in traditional newborn care practices in rural Basona woreda (district) near the urban town of Debrebirhan, 120 km from Addis Ababa, Ethiopia. RESULTS: The most frequently cited sequence of newborn care practices reported by mothers with home deliveries in the rural Basona woreda was to tie the cord, immediately bath then dry the newborn, practice 'Lanka mansat' (local traditional practice on newborns), give pre-lacteal feeding and then initiate breastfeeding. For 'Lanka mansat', the traditional birth attendant applies mild pressure inside the baby's mouth on the soft palate using her index finger. This is performed believing that the baby will have 'better voice' and 'speak clearly' later in life. CONCLUSION: Coverage figures fail to tell the whole story as to why some essential interventions are not practiced and, in this study, we identified established norms or routines within the rural communities that determine the sequence of newborn care practices following home births. This might explain why some mothers delay initiation of breastfeeding and implementation of other recommended essential interventions saving newborn lives. An in-depth understanding of established routines is necessary, and community health extension workers require further training and negotiation skills in order to change the behaviour of mothers in practicing essential interventions while respecting local values and norms within the communities.

Reproductive health in indigenous Chihuahua: giving birth 'alone like the goat'.

INTRODUCTION: Indigenous peoples in the state of Chihuahua, Mexico, are known to outsiders as the Tarahumaras. The Tarahumaras are one of the few cultural groups known to have no traditional birth attendants, and Tarahumara women often give birth alone and outdoors. Currently, little is known about this group, their health status or their culture. OBJECTIVE: The objective of this study was to assess the state of reproductive health outcomes, risks, protective factors, beliefs and behaviors in the Tarahumara population. DESIGN: This paper reports on the qualitative results of a mixed methods study, comprised of focus groups, interviews, participatory exploratory methods, ethnographic observation and household surveys investigating the reproductive health status of the Tarahumara peoples and contextual factors influencing it. Qualitative data is presented, supported by preliminary quantitative findings. RESULTS: This study supports speculation that the Tarahumara population is burdened by severe maternal health problems. The sample size was too small to definitively assess risk factors for the outcome of maternal mortality, but qualitative findings point to some important contextual issues that contribute to participants' perceptions of susceptibility to and severity of the problem, their reproductive health beliefs and behaviors, and barriers to behavior change. Major issues included disparities in biomedical knowledge, trust between non-indigenous providers and indigenous patients, and structural issues including access to medical facilities and infrastructure. CONCLUSION: Qualitative data is drawn upon to make recommendations and identify lessons applicable to similar situations where cultural minorities suffer serious health inequities. This study underscores the importance of needs and assets assessment, as it reveals unique contextual factors that must be taken into account in intervention design. Also, collaborative partnership with community members and leaders proved to be invaluable in the research, warranting further collaboration by both governmental and non-governmental groups attempting to improve the health of this population. This becomes especially important when making and enforcing health policy.

Facility-based delivery and maternal and early neonatal mortality in sub-Saharan Africa: a regional review of the literature.

Regional variability in facility-based delivery (FBD) rates in sub-Saharan Africa (SSA) is not well understood, nor is the relationship between FBD and national maternal and early neonatal mortality rates. A systematic literature review identified studies documenting the factors associated with FBD, stratified by region. Rates of skilled birth attendance, facility delivery, maternal mortality, and early neonatal mortality were compared across nations and regions. 70 articles met inclusion criteria, reflecting wide variability in the number, type, and quality of studies by region. Within-country differences were most pronounced in nations where multiple studies were conducted. Correlation between FBD and maternal mortality rates throughout SSA was -0.69 (p=.008), and the correlation between facility delivery rates and early neonatal mortality rates was -0.41 (p=0.08). This study demonstrates the need to attend to regional differences both across and within SSA nations if facility delivery rates are to be improved to reduce maternal and early neonatal mortality.

Neonatal care in the home in northern rural Honduras: a qualitative study of the role of traditional birth attendants.

Traditional birth attendants (TBAs) have limited ability to reduce maternal mortality, but may be able to have a significant impact on neonatal survival. This qualitative study explores TBAs' (possessive) experience with neonatal care in a rural Honduran community. In 6 semistructured focus groups, TBAs described services they routinely provide to newborns. Using Atlas.ti, Version 6.0. (ATLAS.ti Scientific Software Development GmbH, University of Berlin), transcripts were coded by bilingual researchers and analyzed by thematic content. TBAs demonstrated limited knowledge of newborn physiology, yet were aware of many internationally recommended practices. Despite attempts to follow recommendations, all TBAs expressed difficulty due to resource constraints. TBAs were strong advocates of immediate breast-feeding and skin-to-skin care, but they did not demonstrate knowledge regarding delayed bathing and thermal care. Most TBAs stated that a sick neonate could be identified immediately at birth; thus, infections or other illnesses developed in later days may be missed. TBAs did not believe they could have averted neonatal complications or deaths that had occurred under their care. For most healthy newborns, TBAs are the primary providers until the 2-month vaccine visit at the healthcare clinic. Improved TBA training focused on infection symptomotology, physiology, and thermoregulation for newborns may increase opportunities for improved health and timely referrals to healthcare facilities.

The quest for equity in Latin America: a comparative analysis of the health care reforms in Brazil and Colombia.

INTRODUCTION: Brazil and Colombia have pursued extensive reforms of their health care systems in the last couple of decades. The purported goals of such reforms were to improve access, increase efficiency and reduce health inequities. Notwithstanding their common goals, each country sought a very different pathway to achieve them. While Brazil attempted to reestablish a greater level of State control through a public national health system, Colombia embraced market competition under an employer-based social insurance scheme. This work thus aims to shed some light onto why they pursued divergent strategies and what that has meant in terms of health outcomes. METHODS: A critical review of the literature concerning equity frameworks, as well as the health care reforms in Brazil and Colombia was conducted. Then, the shortfall inequality values of crude mortality rate, infant mortality rate, under-five mortality rate, and life expectancy for the period 1960-2005 were calculated for both countries. Subsequently, bivariate and multivariate linear regression analyses were performed and controlled for possibly confounding factors. RESULTS: When controlling for the underlying historical time trend, both countries appear to have experienced a deceleration of the pace of improvements in the years following the reforms, for all the variables analyzed. In the case of Colombia, some of the previous gains in under-five mortality rate and crude mortality rate were, in fact, reversed. CONCLUSIONS: Neither reform seems to have had a decisive positive impact on the health outcomes analyzed for the defined time period of this research. This, in turn, may be a consequence of both internal characteristics of the respective reforms and external factors beyond the direct control of health reformers. Among the internal characteristics: underfunding, unbridled decentralization and inequitable access to care seem to have been the main constraints. Conversely, international economic adversities, high levels of rural and urban violence, along with entrenched income inequalities seem to have accounted for the highest burden among external factors.

The status of maternal and newborn care services in Sierra Leone 8 years after ceasefire.

OBJECTIVE: To conduct a needs assessment for emergency obstetric care (EmOC) to address the unacceptably high maternal and newborn mortality indices in Sierra Leone 8 years after the end of the civil war. METHODS: From June to August 2008, a cross-sectional survey was conducted of health facilities in Sierra Leone offering delivery services. Assessment tools were local adaptations of tools developed by the Averting Maternal Death and Disability program at Columbia University, New York, USA. RESULTS: There were enough comprehensive EmOC (CEmOC) facilities in the country but they were poorly distributed. There were no basic EmOC (BEmOC) facilities. Few facilities (37% of hospitals and 2% of health centers) were able to perform assisted vaginal delivery (AVD), and 3 potentially BEmOC facilities did not meet the standard only because they did not perform AVD. Severe shortages in staff, equipment, and supplies, and unsatisfactory supply of utilities severely hampered the delivery of quality EmOC services. Demand for maternity and newborn services was low, which may have been related to the poor quality and the high/unpredictable out-of-pocket cost of such services. CONCLUSION: Significant increases in the uptake of institutional delivery services, the linkage of remote health workers to the health system, and the recruitment of midwives, in addition to rapid expansion in the training of health workers (including training in midwifery and obstetric surgery skills), are urgently needed to improve the survival of mothers and newborns.

'Closing the Gap': how maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women.

CONTEXT: The reproductive health outcomes for Aboriginal and Torres Strait Islander mothers and infants are significantly poorer than they are for other Australians; they worsen with increasing remoteness where the provision of services becomes more challenging. Australia has committed to 'Overcoming Indigenous Disadvantage' and 'Closing the Gap' in health outcomes. ISSUES: Fifty-five per cent of Aboriginal and Torres Strait Islander birthing women live in outer regional and remote areas and suffer some of the worst health outcomes in the country. Not all of these women are receiving care from a skilled provider, antenatally, in birth or postnatally while the role of midwives in reducing maternal and newborn mortality and morbidity is under-utilised. The practice of relocating women for birth does not address their cultural needs or self-identified risks and is contributing to these outcomes. An evidence based approach for the provision of maternity services in these areas is required. Australian maternal mortality data collection, analysis and reporting is currently insufficient to measure progress yet it should be used as an indicator for 'Closing the Gap' in Australia. LESSONS LEARNED: A more intensive, coordinated strategy to improve maternal infant health in rural and remote Australia must be adopted. Care needs to address social, emotional and cultural health needs, and be as close to home as possible. The role of midwives can be enabled to provide comprehensive, quality care within a collaborative team that includes women, community and medical colleagues. Service provision should be reorganised to match activity to need through the provision of caseload midwives and midwifery group practices across the country. Funding to embed student midwives and support Aboriginal and Torres Strait Islander women in this role must be realised. An evidence base must be developed to inform the provision of services in these areas; this could be through the testing of the Rural Birth Index in Australia. The provision of primary birthing services in remote areas, as has occurred in some Inuit and New Zealand settings, should be established. 'Birthing on Country' that incorporates local knowledge, on-site midwifery training and a research and evaluation framework, must be supported.