' It is a question of determination': a case study of monitoring and evaluation of integrated family planning services in urban areas of Togo.

Background: Integrating family planning into postabortion and postpartum services can increase contraceptive use and decrease maternal and child death; however, little information exists on the monitoring and evaluation of such programs. This article draws on research completed by the EngenderHealth's AgirPF project in three urban areas of Togo on the extent to which monitoring and evaluation systems of health services, which operated within the AgirPF project area in Togo, captured integrated family planning services. Methods: This mixed methods case study used 25 health facility assessments with health service record review in hospitals, large community clinics, a dispensary, and private clinics and 41 key informant interviews with health faculty, individuals working at reproductive health organizations, individuals involved in reproductive health policy and politics, health care workers, and health facility directors. Results: The study found the reporting system for health care was labor intensive and involved multiple steps for health care workers. The system lacked a standardized method to record family planning services as part of other health care at the patient level, yet the Ministry of Health required integrated family planning services to be reported on district and partner organization reporting forms. Key informants suggested improving the system by using computer-based monitoring, streamlining the reporting process to include all necessary information at the patient level, and standardizing what information is needed for the Ministry of Health and partner organizations. Conclusion: Future research should focus on assessing the best methods for recording integrated health services and task shifting of reporting. Recommendations for future policy and programming include consolidating data for reproductive health indicators, ensuring type of information needed is captured at all levels, and reducing provider workload for reporting.

The Effect of Prior Work Experiences on the Preparation and Employment of Early-Career Midwives.

INTRODUCTION: Strategic recruitment, preparation, distribution, and retention of US midwives requires a solid body of knowledge about midwives' education and workforce experiences. Although half of US midwifery education programs currently require or prefer prior registered nurse (RN) employment, data are lacking about whether and how these criteria influence efforts to scale up the workforce to meet reproductive care workforce shortages and maldistributions. METHODS: This cross-sectional research used an online survey, developed using the framework of Social Cognitive Career Theory. Early-career midwives were contacted through the American College of Nurse-Midwives electronic mailing list and social media during the fall of 2016. Statistical analysis allowed for linkage of data related to the following constructs: personal characteristics, prior RN employment, educational experiences, employment situations, career perceptions, and future plans. RESULTS: All participants (N = 244) were certified nurse-midwives. Compared with those without prior RN employment, midwives with prior RN employment were more likely to enroll part-time in distance programs and complete single majors or degrees. During enrollment, the 2 groups experienced the same degree of mentorship and cultural support and were similarly likely to attend 30 births and to pass the certification examination on first attempt. In the workforce, those with prior RN employment were 6 years older and more likely to work full-time. The 2 groups demonstrated no significant differences in their career perspectives or future career plans. DISCUSSION: Despite anecdotal concerns about training midwives who lack RN work experience, an individual without prior RN employment offers the workforce an employee who completes midwifery education at a younger age, may be educated more quickly, and is more likely to have earned a dual major or degree. Those with prior RN employment are more likely to work full-time. Both groups may offer benefits to education and the workforce.

Recognition of and Response to neonatal intrapartum-related complications in home-birth settings in Bangladesh.

Intrapartum-related complications (previously called 'birth asphyxia') are a significant contributor to deaths of newborns in Bangladesh. This study describes some of the perceived signs, causes, and treatments for this condition as described by new mothers, female relatives, traditional birth attendants, and village doctors in three sites in Bangladesh. Informants were asked to name characteristics of a healthy newborn and a newborn with difficulty in breathing at birth and about the perceived causes, consequences, and treatments for breathing difficulties. Across all three sites 'no movement' and 'no cry' were identified as signs of breathing difficulties while 'prolonged labour' was the most commonly-mentioned cause. Informants described a variety of treatments for difficulty in breathing at birth, including biomedical and, less often, spiritual and traditional practices. This study identified the areas that need to be addressed through behaviour change interventions to improve recognition of and response to intrapartum-related complications in Bangladesh.

An evaluation of equitable access to a community-based maternal and newborn health program in rural Ethiopia.

INTRODUCTION: The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) aimed to promote equitable access to safe childbirth and postnatal care through a community-based educational intervention. This study evaluates the extent to which MaNHEP reached women who are socially and materially disadvantaged and, thus, at high risk for inadequate access to care. METHODS: The data used in this analysis are from MaNHEP's cross-sectional 2010 baseline and 2012 endline surveys of women who gave birth in the prior year. A logistic regression model was fit to examine the effects of sociodemographic characteristics on participation in the MaNHEP program. Descriptive statistics of select characteristics by birth and postnatal care provider were also calculated to explore trends in services use. RESULTS: Using data from the endline survey (N = 1019), the regression model showed that age, parity, education, and geographic residence were not significantly associated with MaNHEP exposure. However, women who were materially disadvantaged were still less likely to have participated in the program than their better-off counterparts. From the baseline survey (N = 1027) to the endline survey, women's use of skilled and semiskilled providers for birth care and postnatal care increased substantially, while use of untrained providers or no provider decreased. These shifts were greater for women with less personal wealth than for women with more personal wealth. DISCUSSION: MaNHEP appears to have succeeded in meeting its equity goals to a degree. However, this study also supports the intractable relationship between wealth inequality and access to maternal and newborn health services. Strategies targeting the poor in diverse contexts may eventually prove consistently effective in equitable services delivery. Until that time, a critical step that all maternal and newborn health programs can take is to monitor and evaluate to what extent they are reaching disadvantaged groups within the populations they serve.

Knowledge and skills retention among frontline health workers: community maternal and newborn health training in rural Ethiopia.

INTRODUCTION: We examined the degree to which the skills and knowledge of health workers in Ethiopia were retained 18 months after initial maternal and newborn health training and sought to identify factors associated with 18-month skills assessment performance. METHODS: A nonexperimental, descriptive design was employed to assess 18-month skills performance on the topics of Prevent Problems Before Baby Is Born and Prevent Problems After Baby Is Born. Assessment was conducted by project personnel who also received the maternal and newborn health training and additional training to reliably assess health worker performance. RESULTS: Among the 732 health workers who participated in maternal and newborn health training in 6 rural districts of the Amhara and Oromia regions of Ethiopia (including pretesting before training and a posttraining posttest), 75 health extension workers (78%) and 234 guide team members (37%) participated in 18-month posttest. Among health extension workers in both regions, strong knowledge retention was noted in 10 of 14 care steps for Prevent Problems Before Baby Is Born and in 14 of 16 care steps of Prevent Problems After Baby Is Born. Lower knowledge retention was observed among guide team members in the Amhara region. Across regions, health workers scored lowest on steps that involved nonaction (eg, do not give oxytocin). Educational attainment and age were among the few variables found to significantly predict test performance, although participants varied substantially by other sociodemographic characteristics. DISCUSSION: Results demonstrated an overall strong retention of knowledge and skills among health extension workers and highlighted the need for improvement among some guide team members. Refresher training and development of strategies to improve knowledge of retention of low-performing steps were recommended.

Factors shaping interactions among community health workers in rural Ethiopia: rethinking workplace trust and teamwork.

INTRODUCTION: Worldwide, a shortage of skilled health workers has prompted a shift toward community-based health workers taking on greater responsibility in the provision of select maternal and newborn health services. Research in mid- and high-income settings suggests that coworker collaboration increases productivity and performance. A major gap in this research, however, is the exploration of factors that influence teamwork among diverse community health worker cadres in rural, low-resource settings. The purpose of this study is to examine how sociodemographic and structural factors shape teamwork among community-based maternal and newborn health workers in Ethiopia. METHODS: A cross-sectional survey was conducted with health extension workers, community health development agents, and traditional birth attendants in 3 districts of the West Gojam Zone in the Amhara region of Ethiopia. Communities were randomly selected from Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) sites; health worker participants were recruited using a snowball sampling strategy. Fractional logit modeling and average marginal effects analyses were carried out to identify the influential factors for frequency of work interactions with each cadre. RESULTS: One hundred and ninety-four health workers participated in the study. A core set of factors-trust in coworkers, gender, and cadre-were influential for teamwork across groups. Greater geographic distance and perception of self-interested motivations were barriers to interactions with health extension workers, while greater food insecurity (a proxy for wealth) was associated with increased interactions with traditional birth attendants. DISCUSSION: Interventions that promote trust and gender sensitivity and improve perceptions of health worker motivations may help bridge the gap in health services delivery between low- and high-resource settings. Inter-cadre training may be one mechanism to increase trust and respect among diverse health workers, thereby increasing collaboration. Large-scale, longitudinal research is needed to understand how changes in trust, gender norms, and perceptions of motivations influence teamwork over time.

The effect of community maternal and newborn health family meetings on type of birth attendant and completeness of maternal and newborn care received during birth and the early postnatal period in rural Ethiopia.

INTRODUCTION: Maternal and newborn deaths occur predominantly in low-resource settings. Community-based packages of evidence-based interventions and skilled birth attendance can reduce these deaths. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) used community-level health workers to conduct prenatal Community Maternal and Newborn Health family meetings to build skills and care-seeking behaviors among pregnant women and family caregivers. METHODS: Baseline and endline surveys provided data on a random sample of women with a birth in the prior year. An intention-to-treat analysis, plausible net effect calculation, and dose-response analysis examined increases in completeness of care (mean percentage of 17 maternal and newborn health care elements performed) over time and by meeting participation. Regression models assessed the relationship between meeting participation, completeness of care, and use of skilled providers or health extension workers for birth care-controlling for sociodemographic and health service utilization factors. RESULTS: A 151% increase in care completeness occurred from baseline to endline. At endline, women who participated in 2 or more meetings had more complete care than women who participated in fewer than 2 meetings (89% vs 76% of care elements; P < .001). A positive dose-response relationship existed between the number of meetings attended and greater care completeness (P < .001). Women with any antenatal care were nearly 3 times more likely to have used a skilled provider or health extension worker for birth care. Women who had additionally attended 2 or more meetings with family members were over 5 times as likely to have used these providers, compared to women without antenatal care and who attended fewer than 2 meetings (odds ratio, 5.19; 95% confidence interval, 2.88-9.36; P < .001). DISCUSSION: MaNHEP's family meetings complemented routine antenatal care by engaging women and family caregivers in self-care and care-seeking, resulting in greater completeness of care and more highly skilled birth care.

A regional comparison of distribution strategies and women's awareness, receipt, and use of misoprostol to prevent postpartum hemorrhage in rural Amhara and Oromiya regions of Ethiopia.

INTRODUCTION: In Ethiopia, postpartum hemorrhage is a leading cause of maternal death. The Maternal Health in Ethiopia Partnership (MaNHEP) project developed a community-based model of maternal and newborn health focusing on birth and early postpartum care. Implemented in the Amhara and Oromiya regions, the model included misoprostol to prevent postpartum hemorrhage. This article describes regional trends in women's use of misoprostol; their awareness, receipt, and use of misoprostol at project's endline; and factors associated with its use. METHODS: The authors assessed trends in use of misoprostol using monthly data from MaNHEP's quality improvement database; and awareness, receipt, use, and correct use of misoprostol using data from MaNHEP's endline survey of 1019 randomly sampled women who gave birth during the year prior to the survey. RESULTS: Misoprostol use increased rapidly and was relatively stable over 20 months, but regional differences were stark. At endline, significantly more women in Oromiya were aware of misoprostol compared with women who resided in Amhara (94% vs 59%); significantly more had received misoprostol (80% vs 35%); significantly more had received it during pregnancy (93% vs 48%); and significantly more had received it through varied sources. Most women who received misoprostol used it (> 95%) irrespective of age, parity, or education. Factors associated with use were Oromiya residence (odds ratio [OR] 9.48; 95% confidence interval [CI], 6.78-13.24), attending 2 or more Community Maternal and Newborn Health (CMNH) family meetings (OR 2.62; 95% CI, 1.89-3.63), receiving antenatal care (OR 1.67; 95% CI, 1.08-2.58) and being attended at birth by a skilled provider or trained health extension worker, community health development agent, or traditional birth attendant versus an untrained caregiver or no one. Correct use was associated with having attended 2 or more CMNH family meetings (OR 2.02; 95% CI, 1.35-3.03). DISCUSSION: Multiple distribution channels increase women's access to misoprostol. Most women who have access to misoprostol use it. Early distribution to pregnant women who are educated to use misoprostol appears to be safe and unrelated to choice of birthplace.

Strengthening maternal and newborn health in rural Ethiopia: early results from frontline health worker community maternal and newborn health training.

OBJECTIVE: to describe early results from the Community Maternal and Newborn Health (CMNH) training programme of the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) project. DESIGN: a non-experimental, descriptive design was employed to assess training implementation. SETTING: six rural districts of Amhara and Oromiya regions, Ethiopia. PARTICIPANTS: 91 Health Extension Workers (HEWs) and 626 Guide Team members including Traditional Birth Attendants (TBAs) and volunteer Community Health Promoters (vCHPs). INTERVENTION: CMNH is one aspect of a broader strategy to improve maternal and newborn health at the community level in rural areas of Ethiopia where pregnant women have limited access to health facilities. MEASUREMENTS: performance testing of HEWs, TBAs, and vCHPs was conducted to assess transfer of knowledge and skills from CMNH Master Trainer level to CMNH Trainer level, and from CMNH Trainer level to CMNH Guide Team (GT) level on the topic areas of Prevent Problems before Baby is Born and Prevent Problems after Baby is Born. FINDINGS: post-training performance scores were significantly higher than immediate pre-training scores for Amhara and Oromiya regions on both topic areas (p<0.001). For HEWs and GT members, respectively, average scores increased over 250% and 300% for Prevent Problems before Baby is Born, and over 300% and 400% for Prevent Problems after Baby is Born. KEY CONCLUSIONS: CMNH was successful in transferring knoweldge to HEWs at the CMNH Trainer level and to Guide Team members at the community level. In order for gains to be realised and sustained, the CMNH programme will be nested within an enabling environment created through behaviour change communication to increase demand for CMNH services, emphasising evidence-based maternal and newborn care practices, teamwork among frontline health workers, and an enhanced role of HEWs in provision of safe care during pregnancy, birth, and the early postnatal period.

Traditional birth attendant training for improving health behaviours and pregnancy outcomes.

BACKGROUND: Between the 1970s and 1990s, the World Health Organization promoted traditional birth attendant (TBA) training as one strategy to reduce maternal and neonatal mortality. To date, evidence in support of TBA training is limited but promising for some mortality outcomes. OBJECTIVES: To assess the effects of TBA training on health behaviours and pregnancy outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 June 2012), citation alerts from our work and reference lists of studies identified in the search. SELECTION CRITERIA: Published and unpublished randomised controlled trials (RCT), comparing trained versus untrained TBAs, additionally trained versus trained TBAs, or women cared for/living in areas served by TBAs. DATA COLLECTION AND ANALYSIS: Three authors independently assessed study quality and extracted data in the original and first update review. Three authors and one external reviewer independently assessed study quality and two extracted data in this second update. MAIN RESULTS: Six studies involving over 1345 TBAs, more than 32,000 women and approximately 57,000 births that examined the effects of TBA training for trained versus untrained TBAs (one study) and additionally trained TBA training versus trained TBAs (five studies) are included in this review. These studies consist of individual randomised trials (two studies) and cluster-randomised trials (four studies). The primary outcomes across the sample of studies were perinatal deaths, stillbirths and neonatal deaths (early, late and overall).Trained TBAs versus untrained TBAs: one cluster-randomised trial found a significantly lower perinatal death rate in the trained versus untrained TBA clusters (adjusted odds ratio (OR) 0.70, 95% confidence interval (CI) 0.59 to 0.83), lower stillbirth rate (adjusted OR 0.69, 95% CI 0.57 to 0.83) and lower neonatal death rate (adjusted OR 0.71, 95% CI 0.61 to 0.82). This study also found the maternal death rate was lower but not significant (adjusted OR 0.74, 95% CI 0.45 to 1.22).Additionally trained TBAs versus trained TBAs: three large cluster-randomised trials compared TBAs who received additional training in initial steps of resuscitation, including bag-valve-mask ventilation, with TBAs who had received basic training in safe, clean delivery and immediate newborn care. Basic training included mouth-to-mouth resuscitation (two studies) or bag-valve-mask resuscitation (one study). There was no significant difference in the perinatal death rate between the intervention and control clusters (one study, adjusted OR 0.79, 95% CI 0.61 to 1.02) and no significant difference in late neonatal death rate between intervention and control clusters (one study, adjusted risk ratio (RR) 0.47, 95% CI 0.20 to 1.11). The neonatal death rate, however, was 45% lower in intervention compared with the control clusters (one study, 22.8% versus 40.2%, adjusted RR 0.54, 95% CI 0.32 to 0.92).We conducted a meta-analysis on two outcomes: stillbirths and early neonatal death. There was no significant difference between the additionally trained TBAs versus trained TBAs for stillbirths (two studies, mean weighted adjusted RR 0.99, 95% CI 0.76 to 1.28) or early neonatal death rate (three studies, mean weighted adjusted RR 0.83, 95% CI 0.68 to 1.01).  AUTHORS' CONCLUSIONS: The results are promising for some outcomes (perinatal death, stillbirth and neonatal death). However, most outcomes are reported in only one study. A lack of contrast in training in the intervention and control clusters may have contributed to the null result for stillbirths and an insufficient number of studies may have contributed to the failure to achieve significance for early neonatal deaths. Despite the additional studies included in this updated systematic review, there remains insufficient evidence to establish the potential of TBA training to improve peri-neonatal mortality.

Determinants of place of birth decisions in uncomplicated childbirth in Bangladesh: an empirical study.

OBJECTIVE: to test the predictive value of women's self-identified criteria in place of birth decisions in the event of uncomplicated childbirth in a setting where facility based skilled birth attendants are available. DESIGN: a retrospective, cross-sectional study was conducted in two phases. The first phase used data from in-depth interviews. The second phase used data from semi-structured questionnaires. SETTING: the service area of Matlab, Bangladesh. PARTICIPANTS: women 18-49 years who had an uncomplicated pregnancy and delivery resulting in a live birth. FINDINGS: a women's intention about where to deliver during pregnancy, her perception of labour progress, the availability of transportation at the time of labour, and the close proximity of a dai to the household were independent predictors of facility-based SBA use. Marital age was also significant predictor of use. KEY CONCLUSIONS: the availability of delivery services does not guarantee use and instead specific considerations and conditions during pregnancy and in and around the time of birth influence the preventive health seeking behaviour of women during childbirth. Our findings have implications for birth preparedness and complication readiness initiatives that aim to strengthen timely use of SBAs for all births. Demand side strategies to reduce barriers to health seeking, as part of an overall health system strengthening approach, are needed to meet the Millennium Development 5 goal.

Women's social networks and birth attendant decisions: application of the network-episode model.

This paper examines the association of women's social networks with the use of skilled birth attendants in uncomplicated pregnancy and childbirth in Matlab, Bangladesh. The network-episode model was applied to determine if network structure variables (density/kinship homogeneity/strength of ties) together with network content (endorsement for or against a particular type of birth attendant) explain the type of birth attendant used by women above and beyond the variance explained by women's individual attributes. Data were collected by interviewing a representative sample of 246 women, 18-45 years of age, using survey and social network methods between October and December 2008. Logistic regression models were used to examine the associations. Results suggest that the structural properties of networks did not add to explanatory value but instead network content or the perceived advice of network members add significantly to the explanation of variation in service use. Testing aggregate network variables at the individual level extends the ability of the individual profile matrix to explain outcomes. Community health education and mobilization interventions attempting to increase demand for skilled attendants need to reflect the centrality of kinship networks to women in Bangladesh and the likelihood of women to heed the advice of their network of advisors with regard to place of birth.

Effectiveness of an integrated approach to reduce perinatal mortality: recent experiences from Matlab, Bangladesh.

BACKGROUND: Improving perinatal health is the key to achieving the Millennium Development Goal for child survival. Recently, several reviews suggest that scaling up available effective perinatal interventions in an integrated approach can substantially reduce the stillbirth and neonatal death rates worldwide. We evaluated the effect of packaged interventions given in pregnancy, delivery and post-partum periods through integration of community- and facility-based services on perinatal mortality. METHODS: This study took advantage of an ongoing health and demographic surveillance system (HDSS) and a new Maternal, Neonatal and Child Health (MNCH) Project initiated in 2007 in Matlab, Bangladesh in half (intervention area) of the HDSS area. In the other half, women received usual care through the government health system (comparison area). The MNCH Project strengthened ongoing maternal and child health services as well as added new services. The intervention followed a continuum of care model for pregnancy, intrapartum, and post-natal periods by improving established links between community- and facility-based services. With a separate pre-post samples design, we compared the perinatal mortality rates between two periods--before (2005-2006) and after (2008-2009) implementation of MNCH interventions. We also evaluated the difference-of-differences in perinatal mortality between intervention and comparison areas. RESULTS: Antenatal coverage, facility delivery and cesarean section rates were significantly higher in the post- intervention period in comparison with the period before intervention. In the intervention area, the odds of perinatal mortality decreased by 36% between the pre-intervention and post-intervention periods (odds ratio: 0.64; 95% confidence intervals: 0.52-0.78). The reduction in the intervention area was also significant relative to the reduction in the comparison area (OR 0.73, 95% CI: 0.56-0.95; P = 0.018). CONCLUSION: The continuum of care approach provided through the integration of service delivery modes decreased the perinatal mortality rate within a short period of time. Further testing of this model is warranted within the government health system in Bangladesh and other low-income countries.

A comparison of excessive postpartum blood loss estimates among three subgroups of women attending births in Matlab, Bangladesh.

OBJECTIVE: Postpartum hemorrhage (PPH) is the leading cause of maternal death and disability worldwide. Recognition depends on subjective visual quantification. This study sought to assess and compare the thresholds for excessive postpartum blood loss reported by skilled birth attendants (SBA), traditional birth attendants (TBA), and laywomen in Matlab, Bangladesh. METHOD: Data from six questions asking about excessive blood loss in the postpartum period were analyzed using analysis of variance (ANOVA), Hochberg test, Kruskal-Wallis and standard descriptive statistics. RESULTS: Thresholds for excessive blood loss estimated by laywomen and TBAs exceed biomedical standards for PPH. Skilled birth attendant reports are consistent with the definition of severe acute PPH. CONCLUSION: Further research on locally validated blood collection devices, in birth kits, for diagnostic aid or referral indication is needed. Areas where coverage and uptake of skilled birth attendance are low should be targeted due to the number of home births attended by TBAs and laywomen in such settings. PRECIS: A comparison of excessive postpartum blood loss estimates among skilled birth attendants, traditional birth attendants and laywomen in Matlab, Bangladesh.

60 Million non-facility births: who can deliver in community settings to reduce intrapartum-related deaths?

BACKGROUND: For the world's 60 million non-facility births, addressing who is currently attending these births and what effect they have on birth outcomes is a key starting point toward improving care during childbirth. OBJECTIVE: We present a systematic review of evidence for the effect of community-based cadres-community-based skilled birth attendants (SBAs), trained traditional birth attendants (TBAs), and community health workers (CHWs)-in improving perinatal and intrapartum-related outcomes. RESULTS: The evidence for providing skilled birth attendance in the community is low quality, consisting of primarily before-and-after and quasi-experimental studies, with a pooled 12% reduction in all cause perinatal mortality (PMR) and a 22%-47% reduction in intrapartum-related neonatal mortality (IPR-NMR). Low/moderate quality evidence suggests that TBA training may improve linkages with facilities and improve perinatal outcomes. A randomized controlled trial (RCT) of TBA training showed a 30% reduction in PMR, and a meta-analysis demonstrated an 11% reduction in IPR-NMR. There is moderate evidence that CHWs have a positive impact on perinatal-neonatal outcomes. Meta-analysis of CHW packages (2 cluster randomized controlled trials, 2 quasi-experimental studies) showed a 28% reduction in PMR and a 36% reduction in early neonatal mortality rate; one quasi-experimental study showed a 42% reduction in IPR-NMR. CONCLUSION: Skilled childbirth care is recommended for all pregnant women, and community strategies need to be linked to prompt, high-quality emergency obstetric care. CHWs may play a promising role in providing pregnancy and childbirth care, mobilizing communities, and improving perinatal outcomes in low-income settings. While the role of the TBA is still controversial, strategies emphasizing partnerships with the health system should be further considered. Innovative community-based strategies combined with health systems strengthening may improve childbirth care for the rural poor, help reduce gross inequities in maternal and newborn survival and stillbirth rates, and provide an effective transition to higher coverage for facility births.

Cultural theories of postpartum bleeding in Matlab, Bangladesh: implications for community health intervention.

Early recognition can reduce maternal disability and deaths due to postpartum haemorrhage. This study identified cultural theories of postpartum bleeding that may lead to inappropriate recognition and delayed care-seeking. Qualitative and quantitative data obtained through structured interviews with 149 participants living in Matlab, Bangladesh, including women aged 18-49 years, women aged 50+ years, traditional birth attendants (TBAs), and skilled birth attendants (SBAs), were subjected to cultural domain. General consensus existed among the TBAs and lay women regarding signs, causes, and treatments of postpartum bleeding (eigenvalue ratio 5.9, mean competence 0.59, and standard deviation 0.15). Excessive bleeding appeared to be distinguished by flow characteristics, not colour or quantity. Yet, the TBAs and lay women differed significantly from the SBAs in beliefs about normalcy of blood loss, causal role of the retained placenta and malevolent spirits, and care practices critical to survival. Cultural domain analysis captures variation in theories with specificity and representativeness necessary to inform community health intervention.

Women's descriptions of postpartum health problems: preliminary findings from Matlab, Bangladesh.

Complications of childbirth kill more than 500,000 women each year. Postpartum hemorrhage (PPH) is the leading cause of death. Because nearly half the women who give birth at home in developing countries are cared for by unskilled attendants, it is critical to understand how women and their caregivers recognize bleeding and decide to seek help when needed. Using an approach that combined systematic qualitative data collection and multivariate analysis, we identified local cultural theories that women and traditional birth attendants in rural Bangladesh use to recognize and care for postpartum problems, including PPH. These preliminary findings will be used to further explore cultural norms related to PPH and their possible modes of transmission. The overall approach may be used to develop or improve birth preparedness and complication readiness, a core global safe motherhood intervention.

Transition to skilled birth attendance: is there a future role for trained traditional birth attendants?

A brief history of training of traditional birth attendants (TBAs), summary of evidence for effectiveness of TBA training, and consideration of the future role of trained TBAs in an environment that emphasizes transition to skilled birth attendance are provided. Evidence of the effectiveness of TBA training, based on 60 studies and standard meta-analytic procedures, includes moderate-to-large improvements in behaviours of TBAs relating to selected intrapartum and postnatal care practices, small significant increases in women's use of antenatal care and emergency obstetric care, and small significant decreases in perinatal mortality and neonatal mortality due to birth asphyxia and pneumonia. Such findings are consistent with the historical focus of TBA training on extending the reach of primary healthcare and a few programmes that have included home-based management of complications of births and the newborns, such as birth asphyxia and pneumonia. Evidence suggests that, in settings characterized by high mortality and weak health systems, trained TBAs can contribute to the Millennium Development Goal 4--a two-thirds reduction in the rate of mortality of children aged less than 14 years by 2015--through participation in key evidence-based interventions.

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.

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.