Project20: Does continuity of care and community-based antenatal care improve maternal and neonatal birth outcomes for women with social risk factors? A prospective, observational study.

BACKGROUND: Social factors associated with poor childbirth outcomes and experiences of maternity care include minority ethnicity, poverty, young motherhood, homelessness, difficulty speaking or understanding English, migrant or refugee status, domestic violence, mental illness and substance abuse. It is not known what specific aspects of maternity care work to improve the maternal and neonatal outcomes for these under-served, complex populations. METHODS: This study aimed to compare maternal and neonatal clinical birth outcomes for women with social risk factors accessing different models of maternity care. Quantitative data on pregnancy and birth outcome measures for 1000 women accessing standard care, group practice and specialist models of care at two large, inner-city maternity services were prospectively collected and analysed using multinominal regression. The level of continuity of care and place of antenatal care were used as independent variables to explore these potentially influential aspects of care. Outcomes adjusted for women's social and medical risk factors and the service attended. RESULTS: Women who received standard maternity care were significantly less likely to use water for pain relief in labour (RR 0.11, CI 0.02-0.62) and have skin to skin contact with their baby shortly after birth (RR 0.34, CI 0.14-0.80) compared to the specialist model of care. Antenatal care based in the hospital setting was associated with a significant increase in preterm birth (RR 2.38, CI 1.32-4.27) and low birth weight (RR 2.31, CI 1.24-4.32), and a decrease in induction of labour (RR 0.65, CI 0.45-0.95) compared to community-based antenatal care, this was despite women's medical risk factors. A subgroup analysis found that preterm birth was increased further for women with the highest level of social risk accessing hospital-based antenatal care (RR 3.11, CI1.49-6.50), demonstrating the protective nature of community-based antenatal care. CONCLUSIONS: This research highlights how community-based antenatal care, with a focus on continuity of carer reduced health inequalities and improved maternal and neonatal clinical outcomes for women with social risk factors. The findings support the current policy drive to increase continuity of midwife-led care, whilst adding that community-based care may further improve outcomes for women at increased risk of health inequalities. The relationship between community-based models of care and neonatal outcomes require further testing in future research. The identification of specific mechanisms such as help-seeking and reduced anxiety, to explain these findings are explored in a wider evaluation.

How maternity waiting home use influences attendance of antenatal and postnatal care.

As highlighted in the International Year of the Nurse and the Midwife, access to quality nursing and midwifery care is essential to promote maternal-newborn health and improve survival. One intervention aimed at improving maternal-newborn health and reducing underutilization of pregnancy services is the construction of maternity waiting homes (MWHs). The purpose of this study was to assess whether there was a significant change in antenatal care (ANC) and postnatal care (PNC) attendance, family planning use, and vaccination rates before and after implementation of the Core MWH Model in rural Zambia. A quasi-experimental controlled before-and-after design was used to evaluate the impact of the Core MWH Model by assessing associations between ANC and PNC attendance, family planning use, and vaccination rates for mothers who gave birth to a child in the past 13 months. Twenty health care facilities received the Core MWH Model and 20 were identified as comparison facilities. Before-and-after community surveys were carried out. Multivariable logistic regression were used to assess the association between Core MWH Model use and ANC and PNC attendance. The total sample includes 4711 mothers. Mothers who used the Core MWH Model had better ANC and PNC attendance, family planning use, and vaccination rates than mothers who did not use a MWH. All mothers appeared to fare better across these outcomes at endline. We found an association between Core MWH Model use and better ANC and PNC attendance, family planning use, and newborn vaccination outcomes. Maternity waiting homes may serve as a catalyst to improve use of facility services for vulnerable mothers.

Determinants of postnatal care non-utilization among women in Demba Gofa rural district, southern Ethiopia: a community-based unmatched case-control study.

BACKGROUND: Maternal and neonatal mortality remain a significant problem across much of the developing world, especially in sub-Saharan Africa countries. In Ethiopia, most maternal and neonatal deaths occur during the postpartum period; this is a critical time for monitoring the health of women and newborns, but the most neglected period for care. In rural communities of Ethiopia, the utilization of postnatal care service is very low and evidence on which factors contribute to the non-utilization of postnatal care (PNC) is insufficient. Consequently, this study was designed to identify the determinants of postnatal service non-utilization among women who gave birth in Demba Gofa rural district, Southern Ethiopia. METHODS: A community-based unmatched case-control study was conducted among 186 cases (postnatal care non-utilizers) and 186 controls (postnatal care utilizers) in Demba Gofa rural district from March 1 to April 10, 2019. A previously tested interviewer-administered structured questionnaire was used for data collection. Binary logistic regression analysis was performed. In the final multivariable logistic regression analysis model, a p-value of less than 0.05 and an Adjusted Odd Ratio (AOR) with a 95% confidence interval (CI) was used to determine variables for postnatal care non-utilization. RESULTS: In this study, women who delivered recently were incorporated within 186 cases and 186 controls. Not knowing the availability of PNC services (AOR: 4.33, 95% CI: 1.71-10.99), having a home delivery (AOR: 7.06, 95% CI: 3.71-13.44), ANC non-attendance (AOR: 6.14, 95% CI: 3.01-12.50), unable to make an independent decision (AOR: 9.31, 95% CI: 3.29-26.35), and not participating in the Women's Development Army (WDA) (AOR: 5.09, 95% CI: 2.73-9.53) comprised the determinants which were assessed for non-utilization of postnatal care services. CONCLUSIONS: Encouraging institutional delivery along with integrated health education about postnatal care and postnatal danger signs, empowering women to execute independent decisions, accessing PNC services and strengthening participation in the Model Families will likely improve postnatal care service utilization in the district of Ethiopia.

Effects of a health education program targeted to Chinese women adhering to their cultural practice of doing the month: A randomized controlled trial.

BACKGROUND: "Doing the month" is a prevalent Chinese postpartum custom which is believed to restore health after delivery. However, some traditional practices are potentially harmful for women's health. OBJECTIVES: To examine the effect of an evidence-based health education program on Chinese postpartum women's adherence to traditional practices of doing the month and the effect of adherence to doing the month on maternal physiological and psychological health. METHODS: A randomized controlled trial was conducted. During December 2016-July 2017, we recruited postpartum women at a tertiary hospital. Women randomized to the intervention group received evidence-based health education within 1 week after returning home and received a second visit 1 month later. The control group received routine postpartum home visits. Adherence to doing the month was measured by the Adherence to Doing-the-Month Practices questionnaire (ADP). Maternal physical health was measured by the Chair Stand Test and Postpartum Symptom Checklist. Maternal psychological health was measured by the Edinburgh Postnatal Depression Scale (EPDS). Descriptive statistics, t-test, and chi-squared test were used to analyze the differences in scores and symptoms of the two groups. RESULTS: We recruited 124 eligible postpartum women and 108 of them (54 intervention group, 54 control group) completed this study. The ADP score of the intervention group was significantly lower than that of the control group (p < 0.001). The number of participants in the experimental group with poor appetite and indigestion was significantly lower than that of control group. No significant differences were found in numbers of symptoms and average EPDS scores between the 2 study groups (p > 0.05). CONCLUSIONS: Evidence-based health education can reduce postpartum women's adherence to some traditional practices of doing the month and improve women's physical health.

Trends in very early discharge from hospital for newborns under midwifery care in Ontario from 2003 to 2017: a retrospective cohort study.

BACKGROUND: Very early discharge from hospital is an element of Ontario midwifery care. Our aim in the present study was to describe the frequency of very early hospital discharge for newborns in Ontario midwifery care over time. METHODS: We conducted a retrospective population-based cohort study, including all midwife-attended singleton term cephalic newborns delivered by spontaneous vaginal birth at Ontario hospitals between April 2003 and February 2017. Our primary outcome was very early hospital discharge (< 6 h after birth) for newborns. Secondary outcomes were pediatric consultation before hospital discharge, phototherapy before hospital discharge and readmission for treatment of jaundice. We used generalized linear mixed models to estimate the relation between maternal, neonatal and hospital factors and very early discharge, while accounting for clustering by hospital. RESULTS: The study cohort included 101 852 newborns born at 89 hospitals. Between 2003/04 and 2016/17, the unadjusted rate of very early discharge decreased from 34.3% to 30.7%. This trend was not significant after adjustment for covariates (odds ratio 1.0, 95% confidence interval 0.99-1.0). Unadjusted rates of pediatric consultation, phototherapy and readmission for jaundice all rose slightly over the study period. Hospital-specific risk-adjusted frequencies of very early discharge ranged from 5% (n = 1479) to 83% (n = 3459) across the 75 Ontario hospitals with at least 100 newborns included in the study cohort. INTERPRETATION: Hospital-level factors contributed to the observed decrease in crude rates of very early discharge for midwifery clients. Wide variation in these rates across Ontario hospitals points to room for improvement to make more efficient use of health care resources by promoting optimal levels of very early discharge.

Warming the postpartum body as a form of postnatal care: An ethnographic study of medical injections and traditional health practices in Cambodia.

Postpartum care is a critical element for ensuring survival and health of mothers and newborns but is often inadequate in low- and middle-income countries due to barriers to access and resource constraints. Newly delivered mothers and their families often rely on traditional forms of postnatal care rooted in social and cultural customs or may blend modern and traditional forms of care. This ethnographic study sought to explore use of biomedical and traditional forms of postnatal care. Data were collected through unstructured observation and in-depth interviews with 15 mothers. Participants reported embracing traditional understandings of health and illness in the post-partum period centered on heating the body through diet, steaming, and other applications of heat, yet also seeking injections from private health care providers. Thematic analysis explored concepts related to transitioning forms of postnatal care, valuing of care through different lenses, and diverse sources of advice on postnatal care. Mothers also described concurrent use of both traditional medicine and biomedical postnatal care, and the importance of adhering to cultural traditions of postnatal care for future health. Maternal and newborn health are closely associated with postnatal care, so ensuring culturally appropriate and high-quality care must be an important priority for stakeholders including understand health practices that are evolving to include injections.

Delaying factors for maternal health service utilization in eastern Ethiopia: A qualitative exploratory study.

BACKGROUND: In Ethiopia, maternal health service utilization is still unacceptably low. The societal and cultural factors that constrain women from attending these services have not yet been sufficiently explored. Using qualitative methods, we aimed to explore the factors that delay maternal health service utilization in eastern Ethiopia. METHOD: A total of 13 audio-recorded focus group discussions were conducted comprising 88 participants. We conducted separate group discussions with reproductive aged women, mothers-in-law, traditional birth attendants, husbands, and Health Extension Workers to capture their knowledge, practices, feelings, thoughts and attitudes towards maternal health service utilization. The recorded sessions were transcribed into the local language and then translated into English for analysis. RESULT: The study identified a number of factors that may delay maternal health service utilization. Factors were grouped using the Three Delays model as a framework. Low level of awareness regarding need, poor involvement of husband, perceived absence of health problems, social power, community misperceptions and cultural restrictions, negative attitudes towards male midwives, acceptance of traditional birth attendants and poor social networking were Delay One factors. Lack of physical accessibility and high transportation costs were categorised as Delay Two factors for skilled birth care attendance. Perceived or experienced poor quality of care were categorised as Delay Three factors for both skilled birth and postnatal care utilization. CONCLUSION: Despite the ongoing government measures to improve maternal health service utilization in Ethiopia, numerous factors continue to contribute to delays in service use, which in turn contribute to high maternal mortality.

Mothers´ experiences in relation to a new Swedish postnatal home-based model of midwifery care-A cross-sectional study.

BACKGROUND: The goal of postnatal care is to provide the highest possible quality of care and medical safety with the least possible intervention in order to optimize health and wellbeing of the new family. The aim of the study was to describe mothers´ experiences in relation to a new postnatal home-based model of midwifery care. METHODS: The current study uses a cross-sectional mixed method design to assess a new postnatal home-based model of midwifery care in Sweden. Healthy women with an uncomplicated pregnancy and childbirth, and with a healthy baby answered an online questionnaire one week after birth. Data were collected during one year (2017-2018) and analyzed using descriptive and inferential statistics for quantitative data, and manifest content analysis for qualitative data. FINDINGS: In total, 180 mothers with one to six children were included. They were most likely to have been discharged between six and 12 h after childbirth (56%) and 90% reported that the time for their discharge was good. The postnatal check-ups included were telephone contact (100%), home visit(s) (94%) and hospital visit(s) (98%). Most mothers had a positive postnatal care experience from using the new postnatal model of midwifery care (mean VAS 8.74, Std. Deviation 1.438). For 75%, of the participants, home-based postnatal care would be preferred for their next childbirth. CONCLUSION: Home-based postnatal care is well accepted by mothers who were discharged early after childbirth. Mothers with a positive experience of the new postnatal model of midwifery care would prefer home-based postnatal care for their next childbirth. Midwifery care should include home-based postnatal care.

Factors associated with choice of antenatal, delivery and postnatal services between HIV positive and HIV negative women in Zambia.

BACKGROUND: Previous research has shown that developing countries account for the majority of maternal deaths around the world. Relatively high maternal mortality in developing countries has been linked to high HIV prevalence rates in these countries. Several studies have shown that women living with HIV are more vulnerable and are thus more likely to die during maternity than those who are not. Although there has been increased focus on this subject in contemporary research, the relationship between HIV status and maternal-care-utilization is not very well understood. It is not clear whether factors associated with professional maternal care utilization during antenatal, delivery and postnatal periods are similar for HIV positive and HIV negative women. It is also not known whether being HIV positive has an impact on the choice of care (professional care or traditional birth attendants). Thus the aim of this study is to investigate the differences in factors affecting choice of care during antenatal, delivery and postnatal periods between HIV positive and HIV negative women. We also investigate the effect of HIV positive status on choice of care. METHODS: By using the 2013-2014 Zambia Demographic Health Survey Data (ZDHS), we performed two different quantitative analyses. a) Regression analysis: to identify and compare factors associated with the likelihood of utilizing professional care during antenatal, at birth and postnatal periods between HIV positive and HIV negative women. b) Propensity score matching: to investigate the effect of being HIV positive on the choice of care (Professional care or TBAs). RESULTS: Our results show that reasons for choosing professional care during antenatal, at birth, and postnatal periods are the same for both HIV positive and HIV negative women. Further, we also showed that although the probability of utilizing professional care is slightly higher for HIV positive women, the difference is negligible. CONCLUSION: We demonstrated that in Zambia, utilization of professional care among HIV positive women is not particularly high. We also demonstrate that although institutional care is desirable and an ideal solution for HIV positive women, insisting on institutional care when the health facilities lack adequate trained personnel, drugs, and equipment is counterproductive.

Experiences of women, hospital clinicians and general practitioners with gestational diabetes mellitus postnatal follow-up: A mixed methods approach.

PROBLEM: Postnatal screening rates to detect type two diabetes following gestational diabetes are low. The quality of communication is an important element to consider in developing targeted strategies that support women in completing recommended follow-up care. AIMS: To explore the communication perspectives, practices and preferences of women, hospital clinicians and general practitioners, to determine strategies that may promote completion of recommended postnatal GDM follow-up, in Queensland Australia. METHOD: We used an exploratory, three-phase, mixed-methods approach, interpreted through intergroup communication theory. Phase one: convergent interviews explored perspectives of the communication experience in GDM care among new mothers (n = 13), hospital clinicians (n = 13) and general practitioners (n = 16). Phase two: a retrospective chart audit assessed current practice in postnatal discharge summaries of women (n = 86). Phase three: an online survey identified the preferences of general practitioners and hospital clinicians who provide maternity care in Queensland. Triangulation of the findings from the interviews, audit and surveys was used to clarify results and increase the robustness of the findings. RESULTS: Three themes: Seeking information, Written hospital discharge summary (discharge summary) and Clarity of follow-up requirements, provide direction for pragmatic strategies to promote follow-up. Practical recommendations include continued discussion about care with women from the point of GDM diagnosis into the postnatal period; discharge summaries that give primacy to diagnosis and ongoing treatment; and provision of explicit directions for recommended testing and timing. IMPLICATIONS: This research informs seven practical recommendations to help promote completion of recommended postnatal GDM follow-up.

Health care providers' adherence to immediate postpartum care guideline and associated factors among women who gave birth in Mekele public teaching hospitals, Tigray 2018.

OBJECTIVE: To assess health care providers adherence to immediate postpartum care and associated factors among women's who gave birth in Mekele teaching public hospitals, 2018. RESULTS: The Health care providers' complete adherence to immediate postpartum care guideline was 22.8%. Health care providers who have complete adherence to prenatal care guideline were 93.3% less likely to have incomplete adherence to immediate postpartum care guideline (AOR 95% CI 0.067 (0.036-0.125)).

Pre-lacteal feeding practice and associated factors among mothers having children less than two years of age in Aksum town, Tigray, Ethiopia, 2017: a cross-sectional study.

BACKGROUND: Pre-lacteal feeding has continued as a deep-rooted nutritional malpractice in developing countries. Pre-lacteal feeding is a barrier to the implementation of optimal breastfeeding practices and increases the risk of neonatal early-life diseases and mortality. Therefore, the aim of this study was to assess pre-lacteal feeding practice and associated factors among mothers having children less than 2 years of age in Aksum town, central Tigray, Ethiopia. METHODS: A community-based cross-sectional study was conducted to interview 477 mother-child pairs by systematic random sampling technique. Data were collected through interviewer-administered semi-structured questionnaires. Data were coded, entered, cleaned and edited using EPIDATA version 3.1 and export to SPSS Version 22.0 for analysis. To identify the significant variables binary logistic regression were employed. Variables with p-value < 0.05 at 95% CI in multivariate logistic regression were considered statistically significant. RESULT: The prevalence of pre-lacteal feeding in Aksum town was 10.1% (95% CI: 7.3%, 13%). Mothers with no previous birth (AOR: 2.93(95% CI:1.21,7.09)), birth spacing less than 24 (AOR: 2.88(95% CI: 1.15,7.25)), colostrum discarding (AOR: 6.72 (95% CI: 2.49,18.12)), less than four anti natal care follow up (AOR: 10.55 (95% CI: 4.78,23.40)), those who underwent cesarean section (AOR: 4.38 (95% CI:1.72,11.12)) and maternal believe on purported advantage of pre-lacteal feeding (AOR: 3.36 (95%CI: 1.62,6.96)) were more likely to practice pre-lacteal feeding to their infants. CONCLUSIONS: Pre-lacteal feeding is still practiced in the study area. Childbirth spacing, colostrum discarding, antenatal Care follow up, maternal belief in pre-lacteal feeding was contributing factors for practicing of pre-lacteal feeding. Coordination and sustaining the existing strategies and approaches are recommended to give emphasis on the nutritional value of colostrum and anti-natal care follow up.

Association between skilled maternal healthcare and postpartum contraceptive use in Ethiopia.

BACKGROUND: The postpartum period provides an important opportunity to address unmet need for contraception and reduce short birth intervals. This study aims to assess the association between skilled maternal healthcare and postpartum contraceptive use in Ethiopia. METHODS: Data for this analysis come from the 2011 to 2016 Ethiopian Demographic and Health Surveys (EDHS) and include nearly 5000 married women of reproductive age with a recent birth. Multivariate logistic regression was conducted to investigate the relationship between skilled maternal healthcare and postpartum contraceptive use. RESULTS: Between rounds of the 2011 and 2016 EDHS, the postpartum contraceptive prevalence increased from 15 to 23% and delivery in public facilities, use of skilled birth assistance, and skilled antenatal care also grew. In both survey rounds, educated women had approximately twice the odds of postpartum contraceptive use, compared with non-educated women, while an initially significant relationship between wealth and postpartum contraceptive use diminished in significance by 2016. Women with a desire to limit future pregnancy had five to six times the odds of postpartum contraceptive use in both survey rounds, and women in 2016 - unlike those in 2011 - with a desire to delay pregnancy were significantly more likely to use contraception (adjusted odds ratio (AOR) = 4.38, 95% CI: 1.46-13.18) compared to women who wanted another child soon. In 2011, no statistically significant associations were found between any maternal healthcare and postpartum contraceptive use. In contrast, in 2016, postpartum contraceptive use was significantly associated with an institutional delivery (AOR = 1.71, 95% confidence interval (CI): 1.12-2.62) and skilled antenatal care (AOR = 2.41, 95% CI: 1.41-4.10). No significant relationship was observed in either survey round between postpartum contraceptive use and skilled delivery or postnatal care. CONCLUSIONS: A comparison of postpartum women in the 2011 and 2016 EDHS reveals increased use of both contraception and skilled maternal healthcare services and improved likelihood of contraceptive use among women with an institutional delivery or antenatal care, perhaps as a result of increased attention to postpartum family planning integration. Additionally, results suggest postpartum women are now using contraception to space future pregnancies, with the potential to help women achieve more optimal birth intervals.

Comparison of Support for Breastfeeding Beyond 12 Months of Age from Conventional and Alternative Pediatric Primary Care Providers.

OBJECTIVE: Conventional medicine pediatric care providers (e.g., pediatricians) have been shown to be influential in women's decisions to initiate and sustain breastfeeding. Alternative pediatric care providers (e.g., naturopaths and chiropractors) may also provide breastfeeding support, but this has not been the subject of prior research. Our objective was to compare breastfeeding mothers' perceptions of support from these two provider types in a large sample of women who breastfed for more than 12 months. METHODS: We conducted a cross-sectional study of 49,091 U.S. women through online questionnaire distributed through peer breastfeeding groups. We used log-binomial regression to compare those who used an alternative pediatric healthcare provider to care for their child to those who used a conventional provider on perceptions of support and key factors influencing the decision to breastfeed for more than 12 months. RESULTS: Those who used an alternative provider were more likely to discuss breastfeeding (Adj RR = 1.25, 95% CI 1.17-1.33), feel comfortable discussing breastfeeding (Adj RR = 1.17; 95% CI 1.15-1.19), and feel supported by the provider (Adj RR = 1.25; 95% CI 1.23-1.28). However, providers' recommendations were not important factors in these women's decision to breastfeed beyond 12 months of age. CONCLUSIONS: Mothers who used an alternative care provider as their child's primary source of healthcare rated the provider's breastfeeding support more favorable than those who used a conventional provider (usually a pediatrician). Improving breastfeeding support may be one way to retain families in conventional pediatric primary care, and thereby, ensure children receive comprehensive, evidence-based care.

The fourth trimester: a critical transition period with unmet maternal health needs.

After childbirth, most American women are not scheduled for follow-up care for 6 weeks, and this visit is poorly attended. Many new mothers feel unprepared for the common health issues they encounter and are uncertain of whom to contact. To improve care, the 4th Trimester Project is bringing together mothers, health care providers, and other stakeholders to explore what families need most from birth to 12 weeks postpartum. Eighty-seven individuals convened in March 2016 in Chapel Hill, NC. Four major topic areas emerged: (1) the intense focus on women's health prenatally is unbalanced by infrequent and late postpartum care; (2) medical practice guidelines often do not align with women's experiences and constraints; (3) validation of women as experts of their infants and elevating their strengths as mothers is necessary to achieve health goals; and (4) mothers need comprehensive care, which is difficult to provide because of numerous system constraints. Considerations for improving postpartum services include enabling more convenient care for families that is holistic, culturally appropriate, conversation based, and equitable. Maternal health issues in the fourth trimester intersect and can compound one another. Enhanced collaboration among health care providers may improve the focus of clinical interactions to address the interrelated health issues most important to women.

Factors influencing utilisation of maternal health services by adolescent mothers in Low-and middle-income countries: a systematic review.

BACKGROUND: Adolescent mothers aged 15-19 years are known to have greater risks of maternal morbidity and mortality compared with women aged 20-24 years, mostly due to their unique biological, sociological and economic status. Nowhere Is the burden of disease greater than in low-and middle-income countries (LMICs). Understanding factors that influence adolescent utilisation of essential maternal health services (MHS) would be critical in improving their outcomes. METHODS: We systematically reviewed the literature for articles published until December 2015 to understand how adolescent MHS utilisation has been assessed in LMICs and factors affecting service utilisation by adolescent mothers. Following data extraction, we reported on the geographical distribution and characteristics of the included studies and used thematic summaries to summarise our key findings across three key themes: factors affecting MHS utilisation considered by researcher(s), factors assessed as statistically significant, and other findings on MHS utilisation. RESULTS: Our findings show that there has been minimal research in this study area. 14 studies, adjudged as medium to high quality met our inclusion criteria. Studies have been published in many LMICs, with the first published in 2006. Thirteen studies used secondary data for assessment, data which was more than 5 years old at time of analysis. Ten studies included only married adolescent mothers. While factors such as wealth quintile, media exposure and rural/urban residence were commonly adjudged as significant, education of the adolescent mother and her partner were the commonest significant factors that influenced MHS utilisation. Use of antenatal care also predicted use of skilled birth attendance and use of both predicted use of postnatal care. However, there may be some context-specific factors that need to be considered. CONCLUSIONS: Our findings strengthen the need to lay emphasis on improving girl child education and removing financial barriers to their access to MHS. Opportunities that have adolescents engaging with health providers also need to be seized. These will be critical in improving adolescent MHS utilisation. However, policy and programmatic choices need to be based on recent, relevant and robust datasets. Innovative approaches that leverage new media to generate context-specific dis-aggregated data may provide a way forward.

Maternal and newborn care practices in Sierra Leone: a mixed methods study of four underserved districts.

Despite recent progress, Sierra Leone's lifetime risk of maternal death remains high (1 in 21), as does neonatal mortality (35 per 1000 live births). We present findings on maternal and neonatal care practices from a mixed methods study conducted in four districts during July­August 2012. We conducted a household cluster survey with data on maternal and newborn care practices collected from women ages 15­49 years who had ever given birth. We also conducted focus group discussions and in-depth interviews in two communities in each of the four districts. Participants included pregnant women, mothers of young children, older caregivers, fathers, community health volunteers, traditional birth attendants (TBAs) and health workers. We explored personal experiences and understandings of pregnancy, childbirth, the newborn period and social norms. Data analysis was conducted using STATA (quantitative) and thematic analysis using Dedoose software (qualitative). Antenatal care was high (84.2%, 95% CI: 82.0­86.3%), but not timely due to distance, transport, and social norms to delay care-seeking until a pregnancy is visible, particularly in the poorer districts of Kambia and Pujehun. Skilled delivery rates were lower (68.9%, 95% CI: 64.8­72.9%), particularly in Kambia and Tonkolili where TBAs are considered effective. Clean cord care, delaying first baths and immediate breastfeeding were inadequate across all districts. Timely postnatal checks were common among women with facility deliveries (94.1%, 95% CI: 91.9­96.6%) and their newborns (94.5%, 95% CI: 92.5­96.5%). Fewer women with home births received postnatal checks (53.6%, 95% CI: 46.2­61.3%) as did their newborns (75.8%, 95% CI: 68.9­82.8%). TBAs and practitioners are well-respected providers, and traditional beliefs impact many behaviours. Challenges remain with respect to maternal and neonatal health in Sierra Leone; these were likely exacerbated by service interruptions during the 2014­2016 Ebola Virus Disease epidemic. The reasons behind existing practices must be examined to identify appropriate strategies to improve maternal and newborn survival.

[The Professional Practice of Midwives in Home-based Postnatal Care: A Literature Analysis]. / Die berufliche Praxis von Hebammen in der ambulanten Wochenbettbetreuung: eine Literaturanalyse.

Due to the reduction of the length of stay in hospital, postnatal care today takes place primarily in the ambulant sector. Midwives provide the health care and support young families. This literature study examines home-based postnatal care from the perspectives of midwives with the aim of exploring how midwives provide postnatal care and what influencing factors exist. A systematic literature search was conducted. Studies that integrated the perceptions of midwives during their work in home-based postpartum care were included. A thematic analysis of the selected articles was undertaken. Besides monitoring the health and well-being of mother and child, the focus of postnatal care is on psychosocial aspects and on support and advice on issues concerning the new situation and structural changes in the family. However, midwives do not always feel sufficiently prepared for dealing with complex psychosocial issues and require extra knowledge and better access to information. Besides temporal limitations of midwives, continuity of care as well as different care approaches are also relevant. Home-based postnatal care constitutes complex professional procedures during an important period of life of women and their families. Besides ensuring continuity of care, appropriate knowledge resources and midwifery skills are required. The development of theory-guided concepts, improved training and further training programmes as well as a clearly defined provider contract can support the professional behaviour patterns of midwives.

Social Determinants and Health Disparities Associated With Outcomes of Women of Childbearing Age Who Receive Public Health Nurse Home Visiting Services.

OBJECTIVE: To examine the associations between social and behavioral determinants of health (SBDH), health disparities, and the outcomes of women who received public health nurse home visits for pregnancy and parenting support. DESIGN: Observational exploratory data analysis and comparative outcome evaluation. SETTING: An extant dataset from women served in a Midwestern U.S. state, including demographics and Omaha System problems, signs/symptoms, interventions, and outcome assessments. PARTICIPANTS: Women (N = 4,263) with an average age of 23.6 years (SD = 6.1); 21.4% were married, and 39.1% were White. METHODS: An evaluation dataset was constructed that included all women of childbearing age, their demographics, and outcome assessments. A summative SBDH Index based on Institute of Medicine-recommended instruments was computed based on sign/symptom data. Visualizations were developed using Microsoft Excel, and outcome significance statistics were computed using SPSS version 22 and SAS version 9.4. RESULTS: Outcome evaluation showed positive, significant changes from baseline after public health nurse intervention. Visualization showed variable concentrations of problem-specific signs/symptoms by SBDH Index subgroups. There were between-group differences in overall outcome attainment across SBDH Index subgroups. Compared with White women, minority women had greater improvement; however, despite these gains overall minority final ratings were lower. CONCLUSION: An informatics approach showed that SBDH are important factors for understanding a comprehensive and holistic view of health and health care outcomes. There is potential to use large datasets to further explore intervention effectiveness and progress toward health equity related to SBDH.