Investigating pathways linking women's status and empowerment to skilled attendance at birth in Tanzania: A structural equation modeling approach.

Maternal and newborn mortality remain unacceptably high in sub-Saharan Africa where use of a skilled birth attendant (SBA) at delivery has remained low. Despite the recognized importance of women's empowerment as a key determinant of maternal and newborn health, evidence from sub-Saharan Africa is more limited. Using data from the 2010 Tanzania Demographic and Health Survey (n = 4,340), this study employs a robust method-structural equation modeling (SEM)-to investigate the complex and multidimensional pathways through which women's empowerment affects SBA use. The results show that women's education and household decision-making are positively associated with SBA use. However, not all empowerment dimensions have similar effects. Attitudes towards sex negotiation and violence as well as early marriage are not significant factors in Tanzania. Mediation analysis also confirms the indirect effect of education on SBA use only through household decision-making. The findings underscore the utility of structural equation modeling when examining complex and multidimensional constructs, such as empowerment, and demonstrate potential causal inference to better inform policy and programmatic recommendations.

Customer's self-audit to improve the technical quality of maternity care in Tabriz: a community trial.

Pregnant women have a major role to play in assessing and improving their own quality of care. This study in Tabriz, Islamic Republic of Iran, aimed to assess the effectiveness of an intervention for pregnant women-based on education and support groups and involvement in quality assessment activities-in order to improve the technical quality of public maternity care at public health centres. The intervention phase began in September 2011 and lasted 8 months. The outcome measure was health-care providers' degree of adherence to the Iranian maternity care standards. An intervention group of 92 pregnant women from 10 health centres was compared with a control group of 93 pregnant women from 11 centres. Logistic regression analysis showed that the self-assessed technical quality of maternity care received by the women was significantly better in the intervention that the control group for several of the standards concerning clinical examinations, maternal education and vitamin and mineral supplements.

Perinatal staff perceptions of safety and quality in their service.

BACKGROUND: Ensuring safe and appropriate service delivery is central to a high quality maternity service. With this in mind, over recent years much attention has been given to the development of evidence-based clinical guidelines, staff education and risk reporting systems. Less attention has been given to assessing staff perceptions of a service's safety and quality and what factors may influence that. In this study we set out to assess staff perceptions of safety and quality of a maternity service and to explore potential influences on service safety. METHODS: The study was undertaken within a new low risk metropolitan maternity service in Victoria, Australia with a staffing profile comprising midwives (including students), neonatal nurses, specialist obstetricians, junior medical staff and clerical staff. In depth open-ended interviews using a semi-structured questionnaire were conducted with 23 staff involved in the delivery of perinatal care, including doctors, midwives, nurses, nursing and midwifery students, and clerical staff. Data were analyzed using naturalistic interpretive inquiry to identify emergent themes. RESULTS: Staff unanimously reported that there were robust systems and processes in place to maintain safety and quality. Three major themes were apparent: (1) clinical governance, (2) dominance of midwives, (3) inter-professional relationships. Overall, there was a strong sense that, at least in this midwifery-led service, midwives had the greatest opportunity to be an influence, both positively and negatively, on the safe delivery of perinatal care. The importance of understanding team dynamics, particularly mutual respect, trust and staff cohesion, were identified as key issues for potential future service improvement. CONCLUSIONS: Senior staff, particularly midwives and neonatal nurses, play central roles in shaping team behaviors and attitudes that may affect the safety and quality of service delivery. We suggest that strategies targeting senior staff to enhance their performance in their roles, particularly in the training and teamwork role-modeling of the transitory junior workforce, are important for the development and maintenance of a high quality and safe maternity service.

Evolving global education standards for nurses and midwives.

More than a a decade ago nurse experts identified information critical for their practice in the 21st century, initiated by the increasing globalization of healthcare and nursing education. Much has happened since then. We know more about the healthcare needs of developing and developed countries, although solutions remain problematic. Although nurses continue to migrate, exaggerating developing country health issues, they are plagued by the variability in how they are educated. For example, some countries prepare nurses in high school, while in other countries nurses are educated in institutions of higher education. Recognizing this variability, nurse leaders have undertaken several efforts to address this variability. The purpose of this article is to highlight several issues associated with global education in general, describe current efforts in nursing and midwifery to strengthen nursing education, and discuss why these efforts are relevant to maternal-child nurses. This information is particularly relevant when one considers the contributions appropriately educated nurses and midwives can make as achieving select United Nations Millennium Development Goals.

Improving essential obstetric and newborn care in resource-poor countries.

Skilled birth attendance (SBA) and essential obstetric care (EOC) are key strategies for reducing maternal and newborn mortality and morbidity globally. Lack of adequately trained competent staff is a key barrier to achieving this. We assessed the effectiveness of a new package of 'Life Saving Skills - Essential Obstetric and Newborn Care Training' (LSS-EOC and NC) designed specifically around the UN signal functions in seven countries in sub-Saharan Africa. Among 600 healthcare providers (nurse-midwives, doctors, clinical officers and specialists), knowledge about the diagnosis and management of complications of pregnancy and childbirth as well as newborn care significantly increased (p < 0.001). There was measurable improvement in skills (p < 0.001), and participants expressed a high level of satisfaction with the training. The training package was found to meet the needs of healthcare providers, increased awareness of the need for evidence-based care and encouraged teamwork.

The association between women's perceptions of professional support and problems experienced on breastfeeding cessation: a Western Australian study.

A cross-sectional survey was used to determine the association among women's breastfeeding problems, their perceptions of support from midwives and child health nurses, and breastfeeding cessation in the first 10 weeks postbirth in a sample of Western Australian women (N = 2669). Primiparous women (75.8%) experienced significantly more problems that multiparous women (52.6%). Although 78.8% of all women agreed or strongly agreed that staff were helpful with feeding, 53.4% confirmed that different midwives offered different feeding advice; however, receiving different advice from midwives around feeding was not associated with breastfeeding cessation. Differences in breastfeeding cessation were associated with parity. Primiparous women's cessation was associated with experiencing any breastfeeding problems, unhelpful hospital midwives, and unhelpful information from child health nurses, whereas for multiparous women, this included 2 or more breastfeeding problems, not being able to choose when to feed, and unhelpful information from child health nurses.

Evaluation of a traditional birth attendant training programme in Bangladesh.

BACKGROUND AND CONTEXT: the 1997 Safe Motherhood Initiative effectively eliminated support for training traditional birth attendants (TBAs) in safe childbirth. Despite this, TBAs are still active in many countries such as Bangladesh, where 88% of deliveries occur at home. Renewed interest in community-based approaches and the urgent need to improve birth care has necessitated a re-examination of how provider training should be conducted and evaluated. OBJECTIVE: to demonstrate how a simple evaluation tool can provide a quantitative measure of knowledge acquisition and intended behaviour following a TBA training program. DESIGN: background data were collected from 45 TBAs attending two separate training sessions conducted by Bangladeshi non-governmental organization (NGO) Gonoshasthaya Kendra (GK). A semi-structured survey was conducted before and after each training session to assess the TBAs' knowledge and reported practices related to home-based management of childbirth. SETTING: two training sessions conducted in Vatshala and Sreepur in rural Bangladesh. PARTICIPANTS: 45 active TBAs were recruited for this training evaluation. FINDINGS: there were significant improvements following the training sessions regarding how TBAs reported they would: (a) measure blood loss, (b) handle an apneic newborn, (c) refer women with convulsions and (d) refer women who are bleeding heavily. A greater degree of improvement, and higher scores overall, were observed among TBAs with no prior training and with less birth experience. KEY CONCLUSIONS AND RECOMMENDATIONS FOR PRACTICE: as the Safe Motherhood community strives to improve safe childbirth care, the quality of care in pregnancy and childbirth for women who rely on less-skilled providers should not be ignored. These communities need assistance from governments and NGOs to help improve the knowledge and skill levels of the providers upon which they depend. Gonoshasthaya Kendra's extensive efforts to train and involve TBAs, with the aim of improving the quality of care provided to Bangladeshi women, is a good example of how to effectively integrate TBAs into safe motherhood efforts in resource-poor settings. The evaluation methodology described in this paper demonstrates how trainees' prior experiences and beliefs may affect knowledge acquisition, and highlights the need for more attention to course content and pedagogic style.

The high impact actions for nursing and midwifery. 7: Promoting normal birth.

There is significant variation in rates of Caesarean section between maternity units. Higher rates appear to be associated with older mothers and women from certain ethnic groups. However, taking these and other demographic factors into account does not explain the differences between trusts. This eighth article in this series on the high impact actions for nursing and midwifery looks at how midwives and nurses can help to avoid unnecessary Caesarean sections.

Use of the Optimality Index-United States in perinatal clinical research: a validation study.

The objective of this study was to assess the validity and observed effect size of a new instrument, the Optimality Index-United States (OI-US), for use in perinatal clinical research. Using a large, hospital-based, midwifery service clinical database that included complete obstetric data for 3425 women, we examined discriminant validity and the effects of two different scoring methods used with the OI-US. Discriminant validity was confirmed by comparing OI scores for women who remained low risk and did not require physician involvement in their care (OI score mean = 84%; standard deviation [SD] = 8%) compared to those whose condition changed to require physician involvement in their care (mean = 71%; SD = 10%; P < .001). Two methods of scoring the OI-US were compared, finding no significant difference and suggesting that the types of data available and the research question can drive this decision. Finally, effect size was calculated by two methods: Cohen's d (-1.4) and the effect size correlation (r = -0.548), the latter of which corresponds to a d of -1.3, both resulting in a similarly large effect size estimation. The OI-US is a new instrument that shows promise for use in perinatal clinical research, particularly when assessing more subtle clinical differences in outcomes between study groups.

Challenges for the adoption of evidence-based maternity care in Turkey.

Evidence-based medicine is an important tool for improving the quality of maternity care. However, getting providers to change their practices may not be an easy or rapid process, and other factors, in addition to knowledge of the literature, may be important. This study documents the current state of obstetric practices at three maternity hospitals in Istanbul, Turkey, and identifies attitudes, social pressures, and perceptions that, according to the theory of planned behavior, may pose challenges for adoption of evidence-based practices. Data were collected through interviews with administrators, examination of hospital statistics, provider and client interviews, and structured observations of maternity care. Practices that did not follow current guidelines included routine episiotomy, not allowing companionship during labor, use of procedures to speed up labor without indications, routine enema, restriction of mobility, restriction of oral fluids, supine position for delivery, and non-use of active management of the third stage of labor. The findings indicate that providers had negative attitudes about some recommended practices, while they had positive attitudes towards some ineffective and/or harmful practices. We identified social pressure to comply with practices recommended by supervisors and peers, as well as the belief that limited resources affect maternity care providers, opportunities to perform evidence-based procedures. An underlying problem was the failure to involve women in decision-making regarding their own maternity care. In addition to informing providers about the evidence, it seems necessary to develop standard protocols, improve physical conditions, and implement behavior interventions that take into account provider attitudes, social pressures, and beliefs.

Assessment of quality of care in postpartum wards of Shaheed Beheshti Medical Science University hospitals, 2004.

PURPOSE: Despite 77 per cent antenatal care coverage and 90 per cent skilled attendant at delivery, adjusted maternal mortality in Iran is 76 per 100,000 births. Low quality of maternal health services is one cause of maternal morbidity and mortality. However, few and limited studies have been devoted to the quality of postpartum care in Iran. This study aims to assess quality of care in postpartum wards of Shaheed Beheshti Medical Science University hospitals to show weakness and gaps areas in the care procedure for future improvement intervention programs. It is a descriptive study to assess quality of care in postpartum wards of Shaheed Beheshti Medical Science University hospitals, in 2003. DESIGN/METHODOLOGY/APPROACH: Using quota sampling, 60 healthy women were recruited for the study. Data were collected using three forms including a questionnaire with demographic and obstetrics questions, a check-list for the postpartum care and education quality assessment. Control of vital signs, uterus assessment, perineum assessment, leaving bed, urinary system assessment, digestive system assessment, breast examination, extremities assessment, psychological assessment, as well as education about perineum self-care, breast-feeding, infant care, education before discharge and educational method. Validity and reliability of the questionnaire and checklist were assessed prior to use. Data were analyzed using SPSS. FINDINGS: Results showed compatibility of provided postpartum care with the standards as follows: method of patient's education (52.68 per cent); control of vital signs (43.21 per cent); education about breast-feeding (26.06 per cent); care in getting out of bed (25.83 per cent); psychological care (19.36 per cent); urinary system assessment (16.66 per cent); education about perineum care (13.12 per cent); uterus assessment (10.6 per cent); digestive system assessment (9.69 per cent); patient's education before discharge (7.99 per cent); education about infant's care (7.81 per cent); perineum assessment (6.72 per cent); breast examination (1.11 per cent); and assessment of extremities (0.81 per cent). The study demonstrated that weak postpartum care was provided in 82 per cent of cases but also that mothers were satisfied with provided care in all domains of care. Mothers were very satisfied with facilities and less satisfied with personnel interaction with their visitors in hospital. There was no significant correlation between quality of services and clients' satisfaction (Spearman test, p < 0.05). ORIGINALITY/VALUE: For the first time in Iran, this study has evaluated quality of care in postpartum wards of hospitals based on the defined standards. The study provided a defined standard for postpartum care, which is necessary for regular monitoring and evaluation and so evidence-based intervention programs to improve the system of care. It was also postulated that mothers' satisfaction with care is not always a good indicator of services quality.

Vitamin D and the breastfed infant.

For infants and children, vitamin D deficiency causes a bone-deforming disease known as rickets. As breastfeeding rates have increased, so have the incidences of rickets. The current recommendation from the American Academy of Pediatrics, to supplement all breastfed infants with vitamin D, is controversial. The role of the nurse is to understand the vitamin D dilemma, promote breastfeeding, and prevent vitamin D deficiency rickets.