Maternal near-miss and death incidences - Frequencies, causes and the referral chain in Somaliland: A pilot study using the WHO near-miss approach.

Background Somaliland is a self-declared country with a population of 3.5 million. Most of its population reside in rural areas. The objective of this pilot near-miss study was to monitor the frequency and causes of maternal near-miss and deaths and the referral chain for women to access Skilled Birth Attendants (SBA). METHOD: A facility-based study of all maternal near-miss and mortality cases over 5months using the WHO near-miss tool in a main referral hospital. Reasons for bypassing the Antenatal Care facility (ANC) and late arrival to the referral hospital were investigated through verbal autopsy. RESULTS: One hundred and thirty-eight (138) women with severe maternal complications were identified: 120 maternal near-miss, 18 maternal deaths. There were more near-miss cases on arrival (74.2%) compared with events that developed inside the hospital (25.8%). Likewise, there were more maternal deaths (77.8%) on arrival than was the case during hospitalization (22.2%). The most common mode of referral among maternal near-miss events was family referrals (66.7%). Of 18 maternal deaths, 15 were family referrals. Reasons for bypassing ANC were as follows: lack of confidence in the service provided; lack of financial resources; and lack of time to visit ANC. Reasons for late arrival to the referral hospital were as follows: lack of knowledge and transportation; and poor communication. Conclusion and clinical implication: To increase the utilization of ANC might indirectly lower the number of near-miss and death events. Collaboration between ANC staff and referral hospital staff and a more comprehensive near-miss project are proposed.

'Partnerships are crucial': an evaluation of the Aboriginal Family Birthing Program in South Australia.

OBJECTIVES: To evaluate implementation and outcomes of the Aboriginal Family Birthing Program (AFBP), which provides culturally competent antenatal, intrapartum and early postnatal care for Aboriginal families across South Australia (SA). METHODS: Analysis of births to Aboriginal women in SA 2010-2012; interviews with health professionals and AFBP clients. RESULTS: Around a third of all Aboriginal women giving birth in SA 2010-2012 (n=486) attended AFBP services. AFBP women were more likely to be more socially disadvantaged, have poorer pregnancy health and to have inadequate numbers of antenatal visits than Aboriginal women attending other services. Even with greater social disadvantage and higher clinical complexity, pregnancy outcomes were similar for AFBP and other Aboriginal women. Interviews with 107 health professionals (including 20 Aboriginal Maternal and Infant Care (AMIC) workers) indicated differing levels of commitment to the model, with some lack of clarity about AMIC workers and midwives roles. Interviews with 20 AFBP clients showed they highly valued care from another Aboriginal woman. CONCLUSIONS: Despite challenges, the AFBP reaches out to women with the greatest need, providing culturally appropriate, effective care through partnerships. Implications for Public Health: Programs like the AFBP need to be expanded and supported to improve maternal and child health outcomes for Aboriginal families.

Las matronas y la detección de la violencia en el embarazo / Midwives and intimate partner violence during pregnancy

La violencia de género es un grave problema social en todo el mundo, por su gravedad y su elevada prevalencia. Puede provocar patologías, incapacidad e incluso la muerte, y tiene repercusiones sobre la salud física, psíquica, social y sexual-reproductiva de la mujer. Si la violencia se ejerce durante el embarazo, puede tener consecuencias no sólo para la mujer, sino también para el feto en desarrollo y el futuro hijo. Existen una serie de funciones mínimas que los profesionales deben desarrollar, como preguntar sobre violencia de género con regularidad, informar y remitir a las mujeres que la sufran a los recursos disponibles de la comunidad, registrar los casos y conocer la legislación vigente del país

Gender violence is a major social problem at global level due to its serious nature and prevalence. It can lead to pathologies, disabilities and even death, and has repercussions for women’s physical, mental, social and sexual/reproductive health. If it occurs during pregnancy it can have consequences not only for the woman but for the developing foetus and the future child. There are a series of minimum functions professionals can perform, such as asking regularly about gender violence, informing women who suffer it about and referring them to the resources available in the community, recording cases and being familiar with current legislation in the country

Integrated maternal and child health services in Mozambique: structural health system limitations overshadow its effect on follow-up of HIV-exposed infants.

BACKGROUND: The follow-up of HIV-exposed infants remains a public health challenge in many Sub-Saharan countries. Just as integrated antenatal and maternity services have contributed to improved care for HIV-positive pregnant women, so too could integrated care for mother and infant after birth improve follow-up of HIV-exposed infants. We present results of a study testing the viability of such integrated care, and its effects on follow-up of HIV-exposed infants, in Tete Province, Mozambique. METHODS: Between April 2009 and September 2010, we conducted a mixed-method, intervention-control study in six rural public primary healthcare facilities, selected purposively for size and accessibility, with random allocation of three facilities each for intervention and control groups. The intervention consisted of a reorganization of services to provide one-stop, integrated care for mothers and their children under five years of age. We collected monthly routine facility statistics on prevention of mother-to-child HIV transmission (PMTCT), follow-up of HIV-exposed infants, and other mother and child health (MCH) activities for the six months before (January-June 2009) and 13 months after starting the intervention (July 2009-July 2010). Staff were interviewed at the start, after six months, and at the end of the study. Quantitative data were analysed using quasi-Poisson models for significant differences between the periods before and after intervention, between healthcare facilities in intervention and control groups, and for time trends. The coefficients for the effect of the period and the interaction effect of the intervention were calculated with their p-values. Thematic analysis of qualitative data was done manually. RESULTS: One-stop, integrated care for mother and child was feasible in all participating healthcare facilities, and staff evaluated this service organisation positively. We observed in both study groups an improvement in follow-up of HIV-exposed infants (registration, follow-up visits, serological testing), but frequent absenteeism of staff and irregular supply of consumables interfered with healthcare facility performance for both intervention and control groups. CONCLUSIONS: Despite improvement in various aspects of the follow-up of HIV-exposed infants, we observed no improvement attributable to one-stop, integrated MCH care. Structural healthcare system limitations, such as staff absences and irregular supply of essential commodities, appear to overshadow its potential effects. Regular technical support and adequate basic working conditions are essential for improved performance in the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique.

[The functioning of feldsher-midwife stations].

The article presents the materials based on the statistical data and results of sociological survey. They characterize the condition of feldsher-midwife stations, their field of services, personnel issues and certain issues of everyday life of feldshers of Perm kray. The proposals concerning the development of feldsher-midwife stations functioning are analyzed. The comparative analysis with the data of similar survey of 1982 is done. The study results support the necessity to maintain and develop feldsher-midwife stations in the system of primary medical sanitary care of rural population, especially on the territories with low population density.

Pregnancy weight gain in Iranian women attending a cross-sectional study of public health centres in Rasht.

OBJECTIVE: to investigate pregnancy weight gain in a group of Iranian women who regularly attended urban public health centres for prenatal care in Rasht, Iran. DESIGN: an existing data study analysing routinely collected health-centre data. SETTING: six randomly selected health centres in urban areas in Rasht. PARTICIPANTS: 704 pregnant women aged 26.1+/-5.6 years who regularly attended health centres for prenatal care and delivered between June 2002 and May 2003. MEASUREMENTS: data on pre-pregnancy weight, height, total pregnancy weight gain, mother's age, smoking habit, parity, baby birth weight, mother's education and working status were extracted from the health records. The women were categorised based on their pre-pregnancy body mass index (BMI) as 'underweight', 'normal weight' and 'overweight' (and obese). Participants were also grouped on the basis of their years of schooling as 'low', 'intermediate' and 'high-education'; pregnancy weight gain was compared between groups and with recommended ranges. FINDINGS: weight gain below the lower cut-off recommended by the Institute of Medicine (IOM) were 64% and 67% in underweight and normal weight women, respectively. Baby birth weight and chance of low birth weight were negatively related to pre-pregnancy BMI and pregnancy weight gain. After controlling for the differences in parity, pre-pregnancy BMI, mothers' working status and age, highly educated women (>12 years schooling) gained more weight during pregnancy than women with an intermediate (5-12 years schooling) or lower level of education (< 5 years schooling). CONCLUSION: this study indicated that a considerable proportion of underweight and normal weight women had pregnancy weight gain below the lower cut off recommended by the IOM. These findings suggest that, in terms of pregnancy weight gain, prenatal care in the present health system is unsatisfactory. It would seem that a more effective nutritional education programme, especially for less educated pregnant women, is necessary.

Maternal and child health and family planning service utilization in Guatemala: implications for service integration.

Does the utilization of modern maternal and child health (MCH) services influence subsequent contraceptive use? The answer to this question holds important implications for proposals which advocate MCH and family planning service integration. This study uses data from the 1995/6 Guatemalan Demographic Health Survey and its 1997 Providers Census to test the influence of MCH service utilization on individual contraceptive use decisions. We use a full-information maximum likelihood regression model to control for unobserved heterogeneity. This model produces estimates of the MCH effect, independent of individual women's underlying receptiveness to MCH and contraceptive messages. The results of the analysis indicate that the intensity of MCH service use is indeed positively associated with subsequent contraceptive use among Guatemalan women, even after controlling for observed and unobserved individual- , household- , and community-level factors. Importantly, this finding holds even after controlling for the unobserved factors that 'predispose' some women to use both types of services. Simulations reveal that, for these Guatemalan women, key determinants such as age and primary schooling work indirectly through MCH service use to increase contraceptive utilization.

Deliveries in maternity homes in Norway: results from a 2-year prospective study.

BACKGROUND: The study aims to report the short-term outcome for the mothers and newborns for all pregnancies accepted for birth at maternity homes in Norway. METHODS: A 2-year prospective study of all mothers in labor in maternity homes, i.e. all births including women and newborns transferred to hospital intra partum or the first week post partum. RESULTS: The study included 1275 women who started labor in the maternity homes in Norway; 1% of all births in Norway during this period. Of those who started labor in a maternity home, 1217 (95.5%) also delivered there while 58 (4.5%) women were transferred to hospital during labor. In the post partum period there were 57 (4.7%) transferrals of mother and baby. Nine women had a vacuum extraction, one had a forceps and three had a vaginal breech (1.1% operative vaginal births in the maternity homes). Five babies (0.4%) had an Apgar score below 7 at 5 min. There were two (0.2%) neonatal deaths; both babies were born with a serious group B streptococcal infection. CONCLUSION: Midwives and general practitioners working in the districts can identify a low-risk population (estimated at 35%) of all pregnant women in the catchment areas who can deliver safely at the maternity homes in Norway. Only 4.5% of those who started labor in the maternity homes had to be transferred to hospital during labor.

Anaemia during pregnancy in southern Tanzania.

Anaemia in pregnancy is associated with maternal morbidity and mortality and is a risk factor for low birth-weight. Of 507 pregnant women recruited in a community, cross-sectional study in southern Tanzania, 11% were severely anaemic (<8 g haemoglobin/dl). High malarial parasitaemia [odds ratio (OR)=2.3] and iron deficiency (OR=2.4) were independent determinants of anaemia. Never having been married (OR=2.9) was the most important socio-economic predictor of severe anaemia. A subject recruited in the late dry season was six times more likely to be severely anaemic than a subject recruited in the early dry season. Compared with the women who were not identified as severely anaemic, the women with severe anaemia were more likely to present at mother-and-child-health (MCH) clinics early in the pregnancy, to seek medical attention beyond the MCH clinics, and to report concerns about their own health. Pregnancy-related food taboos in the study area principally restrict the consumption of fish and meat. Effective anti-malaria and iron-supplementation interventions are available but are not currently in place; improvements in the mechanisms for the delivery of such interventions are urgently required. Additionally, opportunities for contacting the target groups beyond the clinic environment need to be developed.

Coping with changing conditions: alternative strategies for the delivery of maternal and child health and family planning services in Dhaka, Bangladesh.

The door-to-door distribution of contraceptives and information on maternal and child health and family planning (MCH-FP) services, through bimonthly visits to eligible couples by trained fieldworkers, has been instrumental in increasing the contraceptive prevalence rate and immunization coverage in Bangladesh. The doorstep delivery strategy, however, is labour-intensive and costly. More cost-effective service delivery strategies are needed, not only for family planning services but also for a broader package of reproductive and other essential health services. Against this backdrop, operations research was conducted by the Centre for Health and Population Research at the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) from January 1996 to May 1997, in collaboration with government agencies and a leading national nongovernmental organization, with a view to developing and field-testing alternative approaches to the delivery of MCH-FP services in urban areas. Two alternative strategies featuring the withdrawal of home-based distribution and the delivery of basic health care from fixed-site facilities were tested in two areas of Dhaka. The clinic-based service delivery strategy was found to be a feasible alternative to the resource-intensive doorstep system in urban Dhaka. It did not adversely affect programme performance and it allowed the needs of clients to be addressed holistically through a package of essential health and family planning services.

Study of impact of nutrition & health day strategy on the coverage rates of supplementary nutrition and health interventions among the ICDS beneficiaries in a rural block of Madhya Pradesh.

To study the trends of beneficiary coverage (pregnant and lactating women and children less than two years of age) for utilization of supplementary nutrition and health services in a rural block before and after the launch of a strategy to converge Health & Integrated Child Development Services (ICDS) on a single day christened "Nutrition and Health Day" (NHD). It is a before and after intervention design in rural ICDS block Amarwada in district Chhindwada. As a part of intervention, NHD were organised on which convergent services of Health & ICDS were made available to the beneficiaries. On the weekly NHDs, uncooked supplementary nutrition for the week was distributed to pregnant and lactating mothers and children under two. The Health worker visited the Anganwadi Centre (AWC) and immunized children and pregnant women, distributed IFA, Vitamin A and provided health and nutrition education. The study assessed the impact of these interventions on the coverage rates of the services. Study was conducted between May 97 and March 98. The routine monitoring reports of the ICDS and Health System of the state government were used as study tools. The study sample comprised of AWC beneficiaries in the project area. The total population of the block was 89,476. Participation in the supplementary nutrition program (SNP) increased two to three folds in all categories of the target population. Immunization and Vitamin A coverage levels for children also showed an increase of about 3 and 5-8 times from baseline status respectively in a year's time. Among pregnant women, Tetanus Toxoid (TT) and Iron and Folic Acid (IFA) utilization rates have also shown two and five fold increase respectively.

Which resources pay for treatment? A model for estimating the informal economy of health.

The model proposed is a means for (i) documenting the resources a woman deploys to choose, seek, find, get and pay for treatment; (ii) comparing what she has/does with a neighbour facing similar symptoms and problems, and (iii) understanding which difference between them makes most difference to the way they manage illness. In a narrow economic perspective, only tangible items with easily enumerated values are called resources, and only the formal economy counts. This model allows assessment of the value of both formal and informal resources in the household system. It will not establish the absolute or market worth of households in the sample, but does offer a framework for comparing households which have the same access to a given set of treatment options when faced with the same symptoms. Its application improves the possibility of understanding which resources, or combinations of resources, make most difference to a household's capacity to seek and get the treatment it has decided it needs. The paper is one element of a multi-layered and multi-disciplinary study of 'The Informal Economy of Health in African Cities'. The overall project aims are (i) to map the cultural, infrastructural and clinical factors affecting the treatment-seeking behaviour of women in low-income urban areas; (ii) to compare their effect(s) on the management of symptoms of adult venereal infection (STD) and crisis symptoms in children under five. The project mapped the social context of illness management in a district of Kampala. Important dimensions of that context are: the infrastructure of the area, and the treatment options available in or around it; women's assessments of how good/kind/shameful/private/feasible/ appropriate those options are, and the social and physical signs which trigger the conclusion that a symptom is 'serious enough' to need treatment outside the home in the first place. The focus here is the value of resources mobilized after the 'serious enough' assessment has been made.

Availability of antenatal and perinatal care in an ICDS area.

PIP: During March-April 1991, in the Chaksu rural Integrated Child Development Services (ICDS) block near Jaipur, India, interviews were conducted with all lactating mothers living near the anganwadi centers of Kothoon, Shivdaspur, and Dehlala (subcenter level) and of Mahadevpura, Kareda-Khurz, and Sawai Jai Singh Pura (peripheral level) to determine availability of prenatal and perinatal care. 93.4% of the mothers were between 18 and 35 years old. 72.8% of all mothers received prenatal care with assistant nurse-midwives providing most of the prenatal care (39.7% of all mothers). 11% of mothers received their first prenatal care checkup during the first trimester. The figures for the second and third trimesters were 39.7% and 22.1%, respectively. 66.2% of all mothers received the tetanus toxoid (either 2 doses or a booster dose) during pregnancy. All mothers received labor and delivery care, mainly from untrained traditional birth attendants (54.4%) and from others (28.7%). 78.6% of deliveries occurred at home. 28.3% of mothers began breast feeding after 48 hours postpartum. Only 17.2% began breast feeding within 6 hours of birth. Only 11.7% received any postnatal care at all, with medical officers providing most of it (8.8% of all mothers). Most mothers did not receive any supplementary nutrition during pregnancy (64.7%) and during lactation (71.3%). Only 8.8% and 12.5% received supplementary nutrition regularly during pregnancy and during lactation, respectively. 50% of mothers received iron folic acid during pregnancy. Yet only 33.8% received it regularly. These findings suggest that prenatal checkups and complete tetanus toxoid immunization were adequate, but initiation of breast feeding and postnatal care were poor in this rural ICDS area.^ieng

[Health care organization and health in a region of Zaire]. / Organizzazione sanitaria e salute in una regione dello Zaire.

Kampene is a roughly 10,000 inhabitants village in Kivu, eastern region of Republic of Zaire. The equatorial rainforest in river Zaire basin surrounds it, far from the main and most crowded roads. Climate is warm and wet, rainfalls constant throughout ten months a years. Eighty seven per cent of the population of Kampene and of its administrative district (around 100,000 inhabitants) work in agriculture. Most of the remainder gets by on mineral search and mining (tin, cassiterite, gold). Health facilities and their organisation should be set up as according to Zaire Health Planning, worked out of 1977 Alma Ata Conference's guidelines on Primary Health Care, but actually they are hard to be implemented because of the wide territory, of the scattered settlements to be served, because of infrastructure and funds shortages. High children death ratio (roughly from 104 to 200/1000 altogether, short mean lifetimes and generally morbidity are caused by: parasitoses (malaria, filariasis, gut worms, bilharziosis, amebiasis), bacterial infections (breast feeding babies' toxic enteritis, tuberculosis, salmonellosis, shigellosis, gonococcosis, tetanus, epidemic meningitis), viral diseases (measles, poliomyelitis, virus B hepatitis, AIDS), protein-energy malnutrition, obstetric pathology (uterus fractures, ectopic pregnancy, obstructed labour). The management of Kampene Hospital is taken over by a Zaire-Italian team, according to the "Progetto Socio-Sanitario a Kampene", project carried out by Centro Volontari Marchigiani, a not-governmental organisation recognized and financed by Italian Foreign Office. The utilization of Kampene hospital wards has been investigated throughout 20 months (since 1/1/1986 to 31/8/1987) by working some parameters out: numbers of admissions, numbers of hospital days, man length of stay, bed occupancy rate, turnover index for bed. The utilisation of outpatient clinic has been investigated by means of the number of outpatients and outpatients per health operator ratio. Moreover the death rate for each ward has been appraised. These data show that wards and outpatient clinics are largely utilized; but a better redistribution of beds from Gynecology to Medicine and Pediatrics wards is suggested. The importance of a steady health team on the run stands out. Moreover the data stress the high death rates both of measles epidemics and protein-energy malnutrition (21.4% so far). In conclusion mother-child clinic is not yet satisfactory and should be better developed; protein-energy malnutrition urges food supply and deeper food consumption education projects to be supported.

PIP: The registry of patients at the hospital of Kampene, Zaire, covering the period 1986-87 was examined to determine the hospital's rate of utilization and accessibility, to evaluate mortality, and to ascertain the prevalence of infectious diseases. The 1986 data of the hospital laboratory indicated a high incidence of infectious and parasitic diseases: ancylostomiasis (33.6%); ascariasis (22.9%); schistosomiasis (3.4%); multiple intestinal parasitic infections (10.9%); malaria (43%), often chloroquine-resistant; filariasis (70.8%); and alcohol-acid resistant tuberculosis bacilli (15%). Sexually-transmitted diseases such as vaginitis (80%) were caused by polygamy, prostitution, and promiscuity, HIV serodiagnosis could not be performed because of a lack of equipment. A high infant mortality rate was caused by neonatal tetanus, toxic gastroenteritis, measles (5.1% lethality: 2 died out of 39 cases), and epidemic cerebrospinal meningitis. Malnutrition caused kwashiorkor and avitaminosis. 792 births were registered at the maternity ward in 1986: 52.8% were male and 47.2% were female; 48 (6.1%) were stillborn or died in the following days; 104 (13.1%) were born prematurely; and 24 (3.1%) were twins. Cesarean section was performed in 43 cases (5.4%). There was a total of 15,099 outpatient visits during a 1-year period. The bed occupancy rate of the surgical ward ranged between .7 and .8 during 1987. Recovery and hospitalization days per doctor or health assistant were very high compared to Italian standards. The lethality of malaria was a high 1.8%, but malnutrition rated even higher: 21.4%. The utilization of the hospital was high, Maternal-child protection measures, especially in the area of nutrition, require the training of community health workers and traditional birth attendants; however, cost-benefit considerations limit resources and the implementation of primary health care is curtailed by economic and cultural factors.

A household study of the pattern of utilization of mother and child health services in rural Greece and variation by socioeconomic status.

PIP: A household study of all families with children under age 6 in 3 villages in rural northwest Greece was conducted during August-September 1981. 94 mothers were interviewed about each of their children to find out who they had consulted seeking advice and care during pregnancy, for delivery, during the postnatal period, for child immunization, and in cases of mild or severe child illness. All 142 children were examined physically and developmentally. Information was also collected on the socioeconomic status of the family. Particular causes for concern were the findings that 30% of the mothers said they experienced at least 1 induced abortion; 5% had delivered without the help of any trained birth attendant; most of those who delivered in the district town (usually the more affluent) had not received postnatal care; 37% of the children had not seen a doctor during their 1st year of life either for sickness or for a developmental assessment. Only 41% of the children were fully immunized for their age, and 23% of those who should have begun their immunizations had not. Most of the 30 children who had been severely or chronically ill had bypassed the local doctor and sought services in the district town. There was clear variation in the pattern of health services use and socioeconomic status as shown by the availability of household facilities including water and electricity. The poorer mothers (30% of the sample) were more likely than the more affluent mothers to have delivered at home. Many had had the help of the local midwife, but those who had no help from a trained attendant came from poorer families. Postnatal care was provided to most (79%) of the families by the midwife. The poorer the family, the more likely that a sick child would be treated with a home remedy. Children from poor families were likely never to have seen a doctor and if a child did go, it was likely to be older at the time of the 1st visit. Very few poor families had ever consulted a specialist. Mothers who were better off were more likely to have delivered in the district town at a private clinic with an obstetrician. They were unlikely to have received any postnatal care. Their children were likely to be younger when 1st taken to the doctor for a routine developmental checkup, usually during the 1st year of life. Home remedies were less likely to be used for child illnesses. It is suggested that the experienced rural community midwife is providing excellent service to mothers from all social strata antenatally; in delivery and postnatal care for poorer mothers, and in informal child care for all. She is well-respected in the community and knows and is well-known to all the children. It is suggested that the trend for more affluent mothers to go to the town for private health care may undermine the crucial role of the midwife at the village level in rural Greece in protecting the health of the poor and less educated mother.^ieng