Barriers and enablers to the provision of postnatal newborn care at community health centres in Sikka district, East Nusa Tenggara province, Indonesia.

OBJECTIVE: This study examined routine newborn care practices provided in the postnatal ward of primary health care facilities, known as Puskesmas, in Sikka District of eastern Indonesia The newborn mortality rate in this region is higher than the national rate despite an increasing proportion of facility based births, suggesting suboptimal quality of newborn care. DESIGN: We employed a mixed methods study combining qualitative and quantitative approaches, in four purposively sampled Puskesmas. Nine mothers, twelve midwives, and four key informants were interviewed on the provision and experience of postnatal care, and an audit of postnatal care processes, including observation of routine postnatal check-up was conducted. The data were analyzed using framework analysis and standard descriptive statistics. FINDINGS: Despite appropriate regulation, national guidance on postnatal care and adequate financing that supported continuity of supplies and equipment, postnatal care practices, including counselling around newborn danger signs, did not meet the national guidelines in any of the Puskesmas in this study. Postnatal care was a low priority, the responsibility often given to new graduates on voluntary placements with little job security, who were insufficiently trained or supervised. In addition, inadequate water and sanitation in postnatal care wards deterred women from staying for the recommended postnatal observation period. CONCLUSION: Despite strong support for postnatal care at the policy level, at the implementation level postnatal newborn care is not prioritised by midwives. Under-functioning infrastructure and inadequate planning and budgeting for postnatal check-ups are major challenges to the provision of care in the postnatal wards.

Challenges in Implementing Community-Based Healthcare Teams in a Low-Income Country Context: Lessons From Ethiopia's Family Health Teams.

BACKGROUND: Addressing chronic diseases and intra-urban health disparities in low- and middle-income countries (LMICs) requires new health service models. Team-based healthcare models can improve management of chronic diseases/complex conditions. There is interest in integrating community health workers (CHWs) into these teams, given their effectiveness in reaching underserved populations. However healthcare team models are difficult to effectively implement, and there is little experience with team-based models in LMICs and with CHW-integrated models more generally. Our study aims to understand the determinants related to the poor adoption of Ethiopia's family health teams (FHTs); and, raise considerations for initiating CHW-integrated healthcare team models in LMIC cities. METHODS: Using the Consolidated Framework for Implementation Research (CFIR), we examine organizational-level factors related to implementation climate and readiness (work processes/incentives/resources/leadership) and system-level factors (policy guidelines/governance/financing) that affected adoption of FHTs in two Ethiopian cities. Using semi-structured interviews/focus groups, we sought implementation perspectives from 33 FHT members and 18 administrators. We used framework analysis to deductively code data to CFIR domains. RESULTS: Factors associated with implementation climate and readiness negatively impacted FHT adoption. Failure to tap into financial, political, and performance motivations of key stakeholders/FHT members contributed to low willingness to participate, while resource constraints restricted capacity to implement. Workload issues combined with no financial incentives/perceived benefit contributed to poor adoption among clinical professionals. Meanwhile, staffing constraints and unavailability of medicines/supplies/transport contributed to poor implementation readiness, further decreasing willingness among clinical professionals/managers to prioritize non-clinic based activities. The federally-driven program failed to provide budgetary incentives or tap into political motivations of municipal/health centre administrators. CONCLUSION: Lessons from Ethiopia's challenges in implementing its FHT program suggest that LMICs interested in adopting CHW-integrated healthcare team models should closely consider health system readiness (budgets, staffing, equipment/medicines) as well as incentivization strategies (financial, professional, political) to drive organizational change.

The salt between the beans: a qualitative study of the role of auxiliary midwives in a hard-to-reach area of Myanmar.

BACKGROUND: Auxiliary Midwives (AMWs) are unpaid volunteer health workers assisting qualified paid midwives in maternal and child health care mainly in hard-to-reach areas of Myanmar. This paper describes the relationship between AMWs and the health system in providing maternal and child services as perceived by the community, AMWs themselves and health care providers in one remote township of Myanmar. METHOD: A qualitative study was conducted in Ngape Township, Myanmar. A total of 15 focus group discussions with midwives, AMWs, community members and mothers were conducted. Ten key informant interviews were performed with national, district and township level health planners and implementers of maternal and child health services. Thematic analysis was done using the ATLAS.ti software. RESULTS: AMWs occupy a unique position between the community and the health sector in the study township. The relationship and trust with the community is built upon prolonged presence providing health care, skill building and fulfilling community expectations. Health care providers' expectations to provide only preventive care, health promotion and education and childbirth care are often exceeded in reality when emergencies occur in hard-to-reach areas. This challenge to handle emergency situations with no support and limited skills and training is considered as most difficult by the AMWs. This mismatch of service provision expectations by both the community and other health care providers has put AMWs in a position which they describe as being the "salt between the beans" an essential ingredient but often invisible between the beans. CONCLUSION: The trust and relationship developed by AMWs over four decades of community practice serving as the mediator role is an untapped resource that can facilitate future community-based maternal and child health interventions in Myanmar.

Adapting the 2015 Mother-Baby Friendly Birth Facility Guidelines for Semi-nomadic Pastoralist Communities in Laikipia and Samburu Counties of Kenya.

Purpose To adapt the 2015 International Federation of Gynecologists and Obstetricians (FIGO), International Confederation of Midwives (ICM), White Ribbon Alliance (WRA), International Pediatric Association (IPA), and WHO auspiced Guidelines on Mother-Baby Friendly Facilities to a particular sub-population; seminomadic pastoralist communities of Laikipia and Samburu Counties, Kenya. We anticipate an increased utilization of childbirth services by improving their acceptability. Description We drafted a Pastoralist Friendly Birthing Facility Checklist based on the FIGO/ICM/WRA/IPA/WHO guidelines and previous research in this context. We employed mixed methods to finalise the adaptation: a workshop with 27 local stakeholders; interviews with ten health planners and skilled birth attendants (SBAs); and ten focus group discussions (FGDs) with health committee members, community health workers, mothers and traditional birth attendants (TBAs). A facility audit of dispensaries across five group ranches was also undertaken. Assessment The final Checklist was divided into: characteristics of care and the environment; care during labour and birth; post-partum care; and community staff relationships. It was endorsed by the Ministries of Health in the relevant counties, and by women, SBAs and TBAs. No facility currently satisfies all the criteria specified in the Checklist. Conclusion The FIGO/ICM/WRA/IPA/WHO Guidelines were successfully adapted and can be used to ensure health facilities meet the needs of pastoralist women.

Service providers' experiences of disrespectful and abusive behavior towards women during facility based childbirth in Addis Ababa, Ethiopia.

BACKGROUND: Disrespect and abuse (D&A) of women during childbirth by the attending staff in health facilities has been widely reported in many countries. Although D&A in labor rooms is recognized as a deterrent to maternal health service utilization, approaches to defining, classifying, and measuring D&A are still at an early stage of development. This study aims to enhance understanding of service providers' experiences of D&A during facility based childbirth in health facilities in Addis Ababa. METHODS: A facility based cross-sectional study was conducted in August 2013 in one hospital and three health centers. A total of 57 health professionals who had assisted with childbirth during the study period completed a self-administered questionnaire. Service providers' personal observations of mistreatment during childbirth and their perceptions of respectful maternity care (RMC) were assessed. Data were entered into and analyzed using SPSS version 16 software. RESULTS: The majority (83.7%) of participants were aged <30 years (mean = 27.25 ± 5.45). Almost half (43.9%) were midwives, and 77.2% had less than five years experience as a health professional. Work load was reported to be very high by 31.6% of participants, and 28% rated their working environment as poor or very poor. Almost half (50.3%) of participants reported that service providers do not generally obtain women's consent prior to procedures. One-quarter (25.9%) reported having ever witnessed physical abuse (physical force, slapping, or hitting) in their health facility. They also reported observing privacy violations (34.5%), and women being detained against their will (18%). Violations of women's rights were self-reported by 14.5% of participants. More than half (57.1%) felt that they had been disrespected and abused in their work place. The majority of participants (79.6%) believed that lack of respectful care discourages pregnant women from coming to health facilities for delivery. CONCLUSIONS: The study findings indicate that most service providers from these facilities had witnessed disrespectful practices during childbirth, and recognized that such practices have negative consequences for service utilization. These findings can help decision makers plan for interventions to improve RMC taking account of the provider perspective.

The potential of task shifting selected maternal interventions to auxiliary midwives in Myanmar: a mixed-method study.

BACKGROUND: An estimated 282 women die for every 100,000 live births in Myanmar, most due to preventable causes. Auxiliary Midwives (AMWs) in Myanmar are responsible for providing a package of care during pregnancy and childbirth to women in rural hard to reach areas where skilled birth attendants (Midwives) are not accessible. This study aims to examine the role of AMWs in Myanmar and to assess the current practices of three proposed essential maternal interventions (oral supplement distribution to pregnant women; administration of misoprostol to prevent postpartum haemorrhage; management of puerperal sepsis with oral antibiotics) in order to facilitate a formal integration of these tasks to AMWs in Myanmar. METHODS: A mixed methods study was conducted in Magwe Region, Myanmar involving a survey of 262 AMWs, complemented by 15 focus group discussions with midwives (MWs), AMWs, mothers and community members, and 10 key informant interviews with health care providers at different levels within the health care system. RESULTS: According to current government policy, AMWs are responsible for identifying pregnant women, screening for danger signs and facilitating early referral, provision of counselling on nutrition and birth preparedness for women in hard-to-reach areas. AMWs also assist at normal deliveries and help MWs provide immunization services. In practice, they also provide oral supplements to pregnant women (84%), provide antibiotics to mothers during the puerperium (43%), and provide misoprostol to prevent postpartum haemorrhage (41%). The current practices of AMWs demonstrate the potential for task shifting on selected essential maternal interventions. However, to integrate these interventions into formal practice they must be complemented with appropriate training, clear guidelines on drug use, systematic recording and reporting, supportive monitoring and supervision and a clear political commitment towards task shifting. CONCLUSION: With the current national government's commitment towards one AMW in one village, this study highlights the potential for shifting specific maternal lifesaving tasks to AMWs.

Walking Together: Towards a Collaborative Model for Maternal Health Care in Pastoralist Communities of Laikipia and Samburu, Kenya.

Purpose In 2009 the Kenyan Government introduced health system reforms to address persistently high maternal and newborn mortality including deployment of skilled birth attendants (SBAs) to health facilities in remote areas, and proscription of births attended by traditional birth attendants (TBAs). Despite these initiatives, uptake of SBA services remains low and inequitably distributed. This paper describes the development of an SBA/TBA collaborative model of maternal health care for pastoralist communities in Laikipia and Samburu. Description A range of approaches were used to generate a comprehensive understanding of the maternal and child health issues affecting these pastoralist communities including community and government consultations, creation of a booklet and film recognising the contributions of both TBAs and SBAs that formed the basis of subsequent discussions, and mixed methods research projects. Based on the knowledge and understanding collectively generated by these approaches we developed an evidence-based, locally acceptable and feasible model for SBA/TBA collaborative care of women during pregnancy and childbirth. Assessment The proposed collaborative care model includes: antenatal and post-natal care delivered by both SBAs and TBAs; TBAs as birth companions who support women and SBAs; training TBAs in recognition of birth complications, nutrition during pregnancy and following birth, referral processes, and family planning; training SBAs in respectful maternity care; and affordable, feasible redesign of health facility infrastructure and services so they better meet the identified needs of pastoralist women and their families. Conclusion The transition from births predominantly attended by TBAs to births attended by SBAs is likely to be a gradual one, and an interim SBA/TBA collaborative model of care has the potential to maximise the safety of pastoralist women and babies during the transition phase, and may even accelerate the transition itself.

Determinants of knowledge of critical danger signs, safe childbirth and immediate newborn care practices among auxiliary midwives: a cross sectional survey in Myanmar.

OBJECTIVES: The re-emergence of community-based health workers such as the auxiliary midwives (AMWs) in Myanmar, who are local female volunteers, has been an important strategy to address global health workforce shortages. The Myanmar government recommends one AMW for every village. The aim of this study is to investigate the current knowledge of critical danger signs and practices for safe childbirth and immediate newborn care of AMWs to inform potential task shifting of additional healthcare responsibilities. METHODS: A cross-sectional survey was conducted from July 2015 to June 2016 in three hard-to-reach areas in Myanmar. Face-to-face interviews were conducted using a pretested questionnaire. RESULTS: Among 262 AMWs participating in the study, only 8% of AMWs were able to identify at least 80% of 20 critical danger signs. Factors associated with greater knowledge of critical danger signs included older age over 35 years (adjusted OR (AOR) 2.19, 95% CI 0.99 to 4.83), having received refresher training within the last year (AOR 2.20, 95% CI 1.21 to 4.01) and receiving adequate supervision (AOR 5.04, 95% CI 2.74 to 9.29). Those who employed all six safe childbirth and immediate newborn care practices were more likely to report greater knowledge of danger signs (AOR 2.81, 95% CI 1.50 to 5.26), adequate work supervision (AOR 3.18 95% CI 1.62 to 6.24) and less education (AOR 0.44, 95% CI 0.23 to 0.88). CONCLUSION: The low level of knowledge of critical danger signs and reported practices for safe childbirth identified suggest that an evaluation of the current AMW training and supervision programme needs to be revisited to ensure that existing practices, including recognition of danger signs, meet quality care standards before new interventions are introduced or new responsibilities given to AMWs.

Factors influencing place of delivery for pastoralist women in Kenya: a qualitative study.

BACKGROUND: Kenya's high maternal mortality ratio can be partly explained by the low proportion of women delivering in health facilities attended by skilled birth attendants (SBAs). Many women continue to give birth at home attended by family members or traditional birth attendants (TBAs). This is particularly true for pastoralist women in Laikipia and Samburu counties, Kenya. This paper investigates the socio-demographic factors and cultural beliefs and practices that influence place of delivery for these pastoralist women. METHODS: Qualitative data were collected in five group ranches in Laikipia County and three group ranches in Samburu County. Fifteen in-depth interviews were conducted: seven with SBAs and eight with key informants. Nineteen focus group discussions (FGDs) were conducted: four with TBAs; three with community health workers (CHWs); ten with women who had delivered in the past two years; and two with husbands of women who had delivered in the past two years. Topics discussed included reasons for homebirths, access and referrals to health facilities, and strengths and challenges of TBAs and SBAs. The data were translated, transcribed and inductively and deductively thematically analysed both manually and using NVivo. RESULTS: Socio-demographic characteristics and cultural practices and beliefs influence pastoralist women's place of delivery in Laikipia and Samburu counties, Kenya. Pastoralist women continue to deliver at home due to a range of factors including: distance, poor roads, and the difficulty of obtaining and paying for transport; the perception that the treatment and care offered at health facilities is disrespectful and unfriendly; lack of education and awareness regarding the risks of delivering at home; and local cultural values related to women and birthing. CONCLUSIONS: Understanding factors influencing the location of delivery helps to explain why many pastoralist women continue to deliver at home despite health services becoming more accessible. This information can be used to inform policy and program development aimed at increasing the proportion of facility-based deliveries in challenging settings.

Community and provider perceptions of traditional and skilled birth attendants providing maternal health care for pastoralist communities in Kenya: a qualitative study.

BACKGROUND: Kenya has a high burden of maternal and newborn mortality. Consequently, the Government of Kenya introduced health system reforms to promote the availability of skilled birth attendants (SBAs) and proscribed deliveries by traditional birth attendants (TBAs). Despite these changes, only 10% of women from pastoralist communities are delivered by an SBA in a health facility, and the majority are delivered by TBAs at home. The aim of this study is to better understand the practices and perceptions of TBAs and SBAs serving the remotely located, semi-nomadic, pastoralist communities of Laikipia and Samburu counties in Kenya, to inform the development of an SBA/TBA collaborative care model. METHODS: This descriptive qualitative study was undertaken in 2013-14. We conducted four focus group discussions (FGDs) with TBAs, three with community health workers, ten with community women, and three with community men. In-depth interviews were conducted with seven SBAs and eight key informants. Topic areas covered were: practices and perceptions of SBAs and TBAs; rewards and challenges; managing obstetric complications; and options for SBA/TBA collaboration. All data were translated, transcribed and thematically analysed. RESULTS: TBAs are valued and accessible members of their communities who adhere to traditional practices and provide practical and emotional support to women during pregnancy, delivery and post-partum. Some TBA practices are potentially harmful to women e.g., restricting food intake during pregnancy, and participants recognised that TBAs are unable to manage obstetric complications. SBAs are acknowledged as having valuable technical skills and resources that contribute to safe and clean deliveries, especially in the event of complications, but there is also a perception that SBAs mistreat women. Both TBAs and SBAs identified a range of challenges related to their work, and instances of mutual respect and informal collaborations between SBAs and TBAs were described. CONCLUSIONS: These findings clearly indicate that an SBA/TBA collaborative model of care consistent with Kenyan Government policy is a viable proposition. The transition from traditional birth to skilled birth attendance among the pastoralist communities of Laikipia and Samburu is going to be a gradual one, and an interim collaborative model is likely to increase the proportion of SBA assisted deliveries, improve obstetric outcomes, and facilitate the transition.

Knowledge, attitudes and practices of traditional birth attendants in pastoralist communities of Laikipia and Samburu counties, Kenya: a cross-sectional survey.

INTRODUCTION: Current efforts to reduce maternal and newborn mortality focus on promoting institutional deliveries with skilled birth attendants (SBAs), and discouraging deliveries at home attended by traditional birth attendants (TBAs). In rural Kenya, semi-nomadic pastoralist communities are underserved by the formal health system, experience high maternal and neonatal mortality, and rely primarily on TBAs for delivery care, despite Government proscription of TBA-assisted births. This study examined the knowledge, attitude and practices of TBAs serving these communities to assess the potential for collaboration between TBAs and SBAs. METHODS: A cross-sectional, interviewer-administered survey was conducted among 171 TBAs from Maasai and Samburu pastoralist communities in Laikipia and Samburu counties, Kenya, as part of a larger mixed-methods study in partnership with a local service provider. RESULTS: BAs were relatively elderly (mean age 59.6 years), and attended an average of 5-6 deliveries per year. A minority (22.2%) had received formal training. They provided antenatal, intra-partum and post-partum care. Most TBA care was non-interventionist, but not necessarily consistent with best practice. Most had encountered birth complications, but knowledge regarding management of complications was sub-optimal. Most had previously referred at least one woman to a health facility (80.1%), were key participants in decision making to refer women (96.5%), and had been present at an institutional delivery (54.4%). CONCLUSION: TBAs continue to be key providers of maternal and neonatal healthcare in regions where the formal health system has poor coverage or acceptability. Strengthening existing TBA/SBA collaborations could improve both community links to the formal health system, and the quality of care provided to pastoralist women, while remaining consistent with current Government policy.

Provider perspectives on the enabling environment required for skilled birth attendance: a qualitative study in western Nepal.

OBJECTIVES: In Nepal, where difficult geography and an under-resourced health system contribute to poor health care access, the government has increased the number of trained skilled birth attendants (SBAs) and posted them in newly constructed birthing centres attached to peripheral health facilities that are available to women 24 h a day. This study describes their views on their enabling environment. METHODS: Qualitative methods included semi-structured interviews with 22 SBAs within Palpa district, a hill district in the Western Region of Nepal; a focus group discussion with ten SBA trainees, and in-depth interviews with five key informants. RESULTS: Participants identified the essential components of an enabling environment as: relevant training; ongoing professional support; adequate infrastructure, equipment and drugs; and timely referral pathways. All SBAs who practised alone felt unable to manage obstetric complications because quality management of life-threatening complications requires the attention of more than one SBA. CONCLUSIONS: Maternal health guidelines should account for the provision of an enabling environment in addition to the deployment of SBAs. In Nepal, referral systems require strengthening, and the policy of posting SBAs alone, in remote clinics, needs to be reconsidered to achieve the goal of reducing maternal deaths through timely management of obstetric complications.

The influence of protein fractions from bovine colostrum digested in vivo and in vitro on human intestinal epithelial cell proliferation.

Colostrum consists of a number of biologically active proteins and peptides that influence physiological function and development of a neonate. The present study investigated the biological activity of peptides released from first day bovine colostrum through in vitro and in vivo enzymatic digestion. This was assessed for proliferative activity using a human intestinal epithelial cell line, T84. Digestion of the protein fraction of bovine colostrum in vitro was conducted with the enzymes pepsin, chymosin and trypsin. Pepsin and chymosin digests yielded protein fractions with proliferative activity similar to that observed with undigested colostrum and the positive control foetal calf serum (FCS). In contrast trypsin digestion significantly (P<0·05) decreased colostral proliferative activity when co-cultured with cells when compared with undigested colostrum. The proliferative activity of undigested colostrum protein and abomasal whey protein digesta significantly increased (P<0·05) epithelial cell proliferation in comparison to a synthetic peptide mix. Bovine colostrum protein digested in vivo was collected from different regions of the gastrointestinal tract (GIT) in newborn calves fed either once (n=3 calves) or three times at 12-h intervals (n=3 calves). Digesta collected from the distal duodenum, jejunum and colon of calves fed once, significantly (P<0·05) stimulated cell proliferation in comparison with comparable samples collected from calves fed multiple times. These peptide enriched fractions are likely to yield candidate peptides with potential application for gastrointestinal repair in mammalian species.

"How often? How much? Where from?" knowledge, attitudes, and practices of mothers and health workers to iron supplementation program for children under five in rural Tamil Nadu, south India.

Iron deficiency anemia (IDA) affects 70% of under-5 children in India. The primary prevention strategy is regular iron supplementation. Little is known about what helps families adhere to daily iron supplementation. Our study explored the knowledge, attitudes, and practices of mothers and village health workers (VHWs) involved in a community health program in one hill district of Tamil Nadu. We conducted 30 semistructured interviews and 3 group discussions involving mothers, VHWs, and community stakeholders. Knowledge of IDA was widespread, yet no children were receiving the iron supplementation as recommended. The main determinants to adherence included the perception of its need, the ease of access, and the activity of VHWs. Preventive care requiring daily supplements is challenging. Our study suggests that increasing community awareness of mild anemia, simplifying dosage instructions, and further strengthening the supportive environment for VHWs would help in reducing the prevalence of IDA.

How the integration of traditional birth attendants with formal health systems can increase skilled birth attendance.

BACKGROUND: Forty years of safe motherhood programming has demonstrated that isolated interventions will not reduce maternal mortality sufficiently to achieve MDG 5. Although skilled birth attendants (SBAs) can intervene to save lives, traditional birth attendants (TBAs) are often preferred by communities. Considering the value of both TBAs and SBAs, it is important to review strategies for maximizing their respective strengths. OBJECTIVES: To describe mechanisms to integrate TBAs with the health system to increase skilled birth attendance and examine the components of successful integration. METHOD: A systematic review of interventions linking TBAs and formal health workers, measuring outcomes of skilled birth attendance, referrals, and facility deliveries. RESULTS: Thirty-three articles met the selection criteria. Mechanisms used for integration included training and supervision of TBAs, collaboration skills for health workers, inclusion of TBAs at health facilities, communication systems, and clear definition of roles. Impact on skilled birth attendance depended on selection of TBAs, community participation, and addressing barriers to access. Successful approaches were context-specific. CONCLUSIONS: The integration of TBAs with formal health systems increases skilled birth attendance. The greatest impact is seen when TBA integration is combined with complementary actions to overcome context-specific barriers to contact among SBAs, TBAs, and women.