Effectiveness of interventions based on patient empowerment in the control of type 2 diabetes in sub-Saharan Africa: A review of randomized controlled trials.

Background: It is estimated that 1.6 million deaths worldwide were directly caused by diabetes in 2016, and the burden of diabetes has been increasing rapidly in low- and middle-income countries. This study reviews existing interventions based on patient empowerment and their effectiveness in controlling diabetes in sub-Saharan Africa. Method: PubMed, MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO and Global Health were searched through August 2018, for randomized controlled trials of educational interventions on adherence to the medication plan and lifestyle changes among adults aged 18 years and over with type 2 diabetes. Random-effects meta-analysis was used. Results: Eleven publications from nine studies involving 2743 participants met the inclusion criteria. The duration of interventions with group education and individual education ranged from 3 to 12 months. For six studies comprising 1549 participants with meta-analysable data on glycaemic control (HbA1c), there were statistically significant differences between intervention and control groups: mean difference was -0.57 [95% confidence interval (CI) -0.75, -0.40] (P < .00001, I2 = 27%). Seven studies with meta-analysable data on blood pressure showed statistically significant differences between groups in favour of interventions. Subgroup analyses on glycaemic control showed that long-term interventions were more effective than short-term interventions and lifestyle interventions were more effective than diabetes self-management education. Conclusion: This review supports the findings that interventions based on patient empowerment may improve glycaemia (HbA1c) and blood pressure in patients with diabetes. The long-term and lifestyle interventions appear to be the most effective interventions for glycaemic control.

[Evaluation of Maternal and Neonatal Health Services sein Guinea-Conakry and Togo.] / Évaluation de la qualité des services de santé maternelle et néonatale en Guinée-Conakry et au Togo.

INTRODUCTION: The quality of mother and child healthcare remains a challenge for low and middle income countries. Quality interventions that allow a reduction of maternal and infantile mortality require the services of qualified personnel. The objective of this study is to present the results of analysis of the status of human healthcare resources and the quality of healthcare (technical, interpersonal, organisational) they provide to mothers and neonates in Guinea and Togo. METHODS: Data were derived from Guinea and Togo case studies with embedded levels of analysis. Participants were: maternal and neonatal health care resources (MNCHR), health care beneficiaries, community members. Data collection methods comprised: observations of MNHCR clinical practice; interviews (beneficiaries, health care establishment and educational institution personnel); and focus groups (men, women, community leaders, students). Analysis consisted of qualitative analysis of the content of interviews and focus groups and quantitative analysis of quality scores. RESULTS: The observations revealed a low level of health care quality for all criteria. Non-technical quality varied according to: the health establishment and level of experience, the MNHCR qualifications, specialisation and basic training. Geographic and financial accessibility, maternal and neonatal health care personnel capacities, continuity and extent of their services are unsatisfactory. CONCLUSION: Recommendations target the establishment of public policies to reinforce MNHCR capacities, standard to define their practice, and organisation and work environment. Conclusions could be used as benchmarks for other countries from Sub-Saharan Africa.

[Construction of a common vision of nurses and midwives training in Democratic Republic of the Congo.] / Construire une vision commune de la formation des infirmières et sages-femmes en République Démocratique du Congo.

OBJECTIVE: To present the activities that facilitate the development of a public policy by public health and higher and university education ministry stakeholders - based on a common vision of nurses and midwives training in Democratic Republic of the Congo (DRC). METHODS: An operational research using different methods applied by experts called ?policy brokers? according to a framework covering the advocacy mechanisms (Advocacy Coalition Framework) designed to promote the development of a public policy. The population comprised 2 types of common interest groups (coalitions), derived from 3 systems (sociocultural-legal, educational, professional), involved in the choice of the ?secondary AND higher? or ?secondary OR higher? training profile for the concerned professionals. The methods comprised: workshops (discussion, training, restitution, validation, negotiation, scientific, reflection group meetings), training activities (programme development, training of nursing and midwives trainers-supervisors) and a variety of media coverage and marketing activities. RESULTS: The nurses and midwives profiles required in the DRC have been established. The levels required for their training have been validated and defined by a common vision of the two ministries concerned. A formal consultation framework was set up to launch the required reform for the review of these two professional's profiles. CONCLUSION: The public policy experts' activities based on the advocacy framework are complex, lengthy and time-consuming. In DRC, a Ministerial decree is currently being finalized to address the creation of a formal consultation framework concerning the training and utilisation of human health resources.

Understanding factors affecting collaboration between midwives and other health care professionals in a birth center and its affiliated Quebec hospital: a case study.

BACKGROUND: A better understanding of the processes of collaboration between midwives who work in the birthing centers, and hospital-based obstetricians, family physicians and nurses may promote cooperation among professionals providing maternity care in both institutions. The aim of this research was to explore the barriers and facilitators of the interprofessional and interorganizational collaboration between midwives in birthing centers and other health care professionals in hospitals in Quebec. METHODS: A case study design was adopted. Data were collected through semi-structured interviews with midwives, multidisciplinary professionals and administrators, through direct observation of activities in maternity units and field notes, and a variety of organizational and policy documents and archives. A qualitative thematic analysis method was used for analyzing transcribed verbatim. RESULTS: The study suggests the close intertwinement between interactional, organizational and systemic factors in regard to barriers and opportunities for collaboration between midwives in birthing centers, and physicians and nurses in hospitals in Quebec. At interactional level, our findings show a conflict in scope of midwifery practice, myth about midwives, pre-judgment, and lack of communication skills between health care providers in the studied birthing center and hospital. At the organizational level, this investigation shows that although midwives have complete access to the hospital with which a formal agreement was signed, they were not integrated in hospital because of lack of interest of midwives and differences in philosophy and scope of practice among healthcare professionals as well as the culture of organizations. At a systemic level, in spite of excessive demand for midwifery care, there are not enough midwives to cover these demands. CONCLUSION: Maternity care professionals require taking a collaborative approach in working and the boundaries of responsibility need to be redrawn. The inter-professional collaborative work between midwives and other maternity care professionals is crucial to improve access and women's choices for maternity care in Canada. Although having collaborative and multidisciplinary teamwork is a goal of maternity care systems, it is hard to achieve.

Diagnosis, Prevalence, Awareness, Treatment, Prevention, and Control of Hypertension in Cameroon: Protocol for a Systematic Review and Meta-Analysis of Clinic-Based and Community-Based Studies.

BACKGROUND: Hypertension holds a unique place in population health and health care because it is the leading cause of cardiovascular disease and the most common noncommunicable condition seen in primary care worldwide. Without effective prevention and control, raised blood pressure significantly increases the risk of stroke, myocardial infarction, chronic kidney disease, heart failure, dementia, renal failure, and blindness. There is an urgent need for stakeholders-including individuals and families-across the health system, researchers, and decision makers to work collaboratively for improving prevention, screening and detection, diagnosis and evaluation, awareness, treatment and medication adherence, management, and control for people with or at high risk for hypertension. Meeting this need will help reduce the burden of hypertension-related disease, prevent complications, and reduce the need for hospitalization, costly interventions, and premature deaths. OBJECTIVE: This review aims to synthesize evidence on the epidemiological landscape and control of hypertension in Cameroon, and to identify elements that could potentially inform interventions to combat hypertension in this setting and elsewhere in sub-Saharan Africa. METHODS: The full search process will involve several steps, including selecting relevant databases, keywords, and Medical Subject Headings (MeSH); searching for relevant studies from the selected databases; searching OpenGrey and the Grey Literature Report for gray literature; hand searching in Google Scholar; and soliciting missed publications (if any) from relevant authors. We will select qualitative, quantitative, or mixed-methods studies with data on the epidemiology and control of hypertension in Cameroon. We will include published literature in French or English from electronic databases up to December 31, 2016, and involving adults aged 18 years or older. Both facility and population-based studies on hypertension will be included. Two reviewers of the team will independently search, screen, extract data, and assess the quality of selected studies using suitable tools. Selected studies will be analyzed by narrative synthesis, meta-analysis, or both, depending on the nature of the data retrieved in line with the review objectives. RESULTS: This review is part of an ongoing research program on disease prevention and control in the context of the dual burden of communicable and noncommunicable diseases in Africa. The first results are expected in 2017. CONCLUSIONS: This review will provide a comprehensive assessment of the burden of hypertension and control measures that have been designed and implemented in Cameroon. Findings will form the knowledge base relevant to stakeholders across the health system and researchers who are involved in hypertension prevention and control in the community and clinic settings in Cameroon, as a yardstick for similar African countries. TRIAL REGISTRATION: PROSPERO registration number: CRD42017054950; http://www.crd.york.ac.uk/PROSPERO/ display_record.asp?ID=CRD42017054950 (Archived by WebCite at http://www.webcitation.org/6qYSjt9Jc).

A case study evaluation of an intervention aiming to strengthen the midwifery professional role in Morocco: anticipated barriers to reaching outcomes.

BACKGROUND: In order to reduce the high maternal mortality ratio, Morocco is strongly committed to strengthen its midwifery professional role. This study aimed to identify barriers that could potentially hinder an action plan to strengthen the midwifery professional role from achieving desired outcomes. We used a conceptual framework, which is derived from Hatem-Asmar's (1997) framework on the interaction of educational, professional, and sociocultural systems in which a professional role evolves and from Damschroder et al's (2009) framework for the implementation analysis. METHODS: This paper builds on a qualitative case study on the factors affecting the action plan's implementation process that also revealed rich data about anticipated barriers to reaching outcomes. Data were collected through training sessions, field observations, documents, focus groups (n=20), and semistructured interviews (n=11) with stakeholders pertaining to the three systems under study. Content analysis was used to identify themes related to barriers. RESULTS: Seven barriers that may compromise the achievement of desired results were found. They relate to the legal framework, social representations, and media support in the sociocultural system and the practice environment, networks and communication mechanisms, and characteristics related to the role and the readiness in the professional system. CONCLUSION: Disregarding sociocultural and professional system level, barriers may impede efforts to strengthen the midwife's role and to provide qualified midwives who can improve the quality of maternal care. Making changes in the educational system cannot be thought of as an isolated process. Its success is closely tied with multiple contextual factors pertaining to the two other systems. Activities recommended to address these barriers may have great potential to build a competent midwifery workforce that contributes to positive maternal and neonatal health outcomes.

Analyzing barriers and facilitators to the implementation of an action plan to strengthen the midwifery professional role: a Moroccan case study.

BACKGROUND: As part of a national strategy for reaching Millennium Development Goals 4 and 5 in Morocco, an action plan covering three systems (sociocultural, educational and professional) was developed to strengthen midwives' professional role in order to contribute to high quality maternity care. This study aimed to understand the implementation process by identifying the characteristics of this intervention and the dimensions of the three-systems which could act as barriers to/facilitators of the implementation process. We used a conceptual framework that builds on Hatem-Asmar's model that describes change in a health professional role; and on the Consolidated Framework for Implementation Research for our analysis. METHODS: An embedded case study with three levels of analysis was conducted during June and July 2010. Data were collected through 11 semi-structured interviews, 20 focus groups, training session observations and documents. A purposive sample of 106 multi-stakeholders from two Moroccan regions (health professionals, academic staff, students, medical administrative officers and health programmers) and one international consultant were recruited. A thematic analysis was conducted using QDA Miner. RESULTS: Data showed a failure to carry out the plan as intended. Seventeen barriers and seven facilitators were identified. Misalignment of the values, methods, actors and targets of the sociocultural system with the values, methods and actors of the educational and professional systems, on one hand, and with the intervention, on the other hand, were likely the greatest impediments to implementing the plan. The bureaucratic structure and lack of readiness of the sociocultural system were among the most influential barriers to: dissemination of information, involvement of key actors in the process and readiness of the educational system. The main facilitators were the values promoted related to human rights, and the national and international policies to strengthen midwifery and reduce maternal mortality. The plan was perceived as beneficial, but complex and externally driven. CONCLUSIONS: The findings suggest that successful implementation requires redesigning the implementation strategy to adapt to the factors identified in our study. The results would be very useful to health planners seeking the expansion of such an intervention to other developing countries looking to strengthen midwives' role and to improve maternity health care services.

Mental Health Disorders Among Women Victims of Conflict-Related Sexual Violence in the Democratic Republic of Congo.

To assess the effects of sexual violence (SV) in armed conflicts on women's mental health, on its own and in conjunction with reproductive health issues such as fistula or chronic pelvic pain (CPP). A cross-sectional population-based study of 320 women living in Goma, the Democratic Republic of Congo, aged 15 to 45 years, was conducted. Women who experienced conflict-related sexual violence (CRSV) were compared with those who experienced non-conflict-related sexual violence (NCRSV) and those who never experienced such acts. Data were gathered through individual interviews by local staff using standardized questionnaires. The outcomes investigated were post-traumatic stress disorder (PTSD) symptoms severity and psychological distress symptoms (PDS) severity. Experience of SV in either context was associated with more severe PDS (p < .0001). Only CRSV was associated with more severe PTSD symptoms (p < .0001). Women who suffered from fistula or CPP also had a higher PDS score mean (p < .0001 and p = .007) and a higher PTSD symptoms score mean (p < .0001, for both reproductive health issues). Multivariate analyses showed that compared with women who never experienced SV and never suffered from fistula or CPP, those who experienced CRSV and suffered from fistula or CPP had the most severe PDS and PTSD symptoms after adjustment for potential confounders. The differences in PDS and PTSD symptoms severity were all significant (p < .0001). Psychological and physical health care are urgently needed for women who experienced CRSV, particularly those with additional issues of fistula or CPP. Current interventions should simultaneously seek to improve both reproductive and mental health.

Birth Preparedness and Complication Readiness (BPCR) interventions to reduce maternal and neonatal mortality in developing countries: systematic review and meta-analysis.

BACKGROUND: Birth Preparedness and Complication Readiness (BPCR) interventions are widely promoted by governments and international agencies to reduce maternal and neonatal health risks in developing countries; however, their overall impact is uncertain, and little is known about how best to implement BPCR at a community level. Our primary aim was to evaluate the impact of BPCR interventions involving women, families and communities during the prenatal, postnatal and neonatal periods to reduce maternal and neonatal mortality in developing countries. We also examined intervention impact on a variety of intermediate outcomes important for maternal and child survival. METHODS: We conducted a systematic review and meta-analysis of randomized trials of BPCR interventions in populations of pregnant women living in developing countries. To identify relevant studies, we searched the scientific literature in the Pubmed, Embase, Cochrane library, Reproductive health library, CINAHL and Popline databases. We also undertook manual searches of article bibliographies and web sites. Study inclusion was based on pre-specified criteria. We synthesised data by computing pooled relative risks (RR) using the Cochrane RevMan software. RESULTS: Fourteen randomized studies (292 256 live births) met the inclusion criteria. Meta-analyses showed that exposure to BPCR interventions was associated with a statistically significant reduction of 18% in neonatal mortality risk (twelve studies, RR = 0.82; 95% CI: 0.74, 0.91) and a non-significant reduction of 28% in maternal mortality risk (seven studies, RR = 0.72; 95% CI: 0.46, 1.13). Results were highly heterogeneous (I2 = 76%, p < 0.001 and I2 = 72%, p = 0.002 for neonatal and maternal results, respectively). Subgroup analyses of studies in which at least 30% of targeted women participated in interventions showed a 24% significant reduction of neonatal mortality risk (nine studies, RR = 0.76; 95% CI: 0.69, 0.85) and a 53% significant reduction in maternal mortality risk (four studies, RR = 0.47; 95% CI: 0.26, 0.87).Pooled results revealed that BPCR interventions were also associated with increased likelihood of use of care in the event of newborn illness, clean cutting of the umbilical cord and initiation of breastfeeding in the first hour of life. CONCLUSIONS: With adequate population coverage, BPCR interventions are effective in reducing maternal and neonatal mortality in low-resources settings.

Fistula and other adverse reproductive health outcomes among women victims of conflict-related sexual violence: a population-based cross-sectional study.

BACKGROUND: Sexual violence (SV) is being used widely as a weapon of war. However, few studies have investigated its health effects. The objective of the present study is to investigate the relationship between sexual violence and several serious reproductive health conditions including fistula. METHODS: We conducted a cross-sectional study among 320 women living in Goma, the Democratic Republic of Congo. We assessed the association of four outcomes: fistula, chronic pelvic pain, desire for sex, and desire for children, with SV in two contexts: conflict-related and nonconflict-related. Two groups of women: those who experienced conflict-related sexual violence (CRSV) and those who experienced nonconflict-related sexual violence (NCRSV), were compared with women who had not experienced SV. Data were collected by trained interviewers using a standard questionnaire. RESULTS: Compared with women who did not experience SV, after adjustment for potential confounders, women who experienced CRSV were significantly more likely to have fistula (OR = 11.1, 95% CI [3.1-39.3]), chronic pelvic pain (OR = 5.1, 95% CI [2.4-10.9]), and absence of desire for sex (OR = 3.5, 95% CI [1.7-6.9]) and children (OR = 3.5, 95% CI [1.6-7.8]). Women who experienced NCRSV were more likely to report absence of desire for children (OR = 2.7, 95% CI [1.1-6.5]), and seemed more likely to report chronic pelvic pain (OR = 2.3, 95% CI [0.95-5.8]), although the difference was not statistically significant. Women who experienced NCRSV did not have higher odds for fistula and absence of sexual desire. CONCLUSION: Conflict-related sexual violence can contribute to women's adverse reproductive health outcomes. Its impact is more devastating than that of NCRSV.

Antenatal psychosomatic programming to reduce postpartum depression risk and improve childbirth outcomes: a randomized controlled trial in Spain and France.

BACKGROUND: Postpartum depression (PPD) and poor childbirth outcomes are associated with poverty; these variables should be addressed by an adapted approach. The aim of this research was to evaluate the impact of an antenatal programme based on a novel psychosomatic approach to pregnancy and delivery, regarding the risk of PPD and childbirth outcomes in disadvantaged women. METHODS: A multi-centre, randomized, controlled trial comparing a novel to standard antenatal programme. Primary outcome was depressive symptoms (using EPDS) and secondary outcome was preterm childbirth (fewer 37 weeks). The sample comprised 184 couples in which the women were identified to be at PPD risk by validated interview. The study was conducted in three public hospitals with comparable standards of perinatal care. Women were randomly distributed in to an experimental group (EG) or a control group (CG), and evaluated twice: during pregnancy (T1) and four weeks post-partum (T2). At T2, the variables were compared using the chi square test. Data analysis was based on intention to treat. The novel programme used the Tourné psychosomatic approach focusing on body awareness sensations, construction of an individualized childbirth model, and attachment. The 10 group antenatal sessions each lasted two hours, with one telephone conversation between sessions. In the control group, the participants choose the standard model of antenatal education, i.e., 8 to 10 two-hour sessions focused on childbirth by obstetrical prophylaxis. RESULTS: A difference of 11.2% was noted in postpartum percentages of PPD risk (EPDS ≥ 12): 34.3% (24) in EG and 45.5% (27) in CG (p = 0.26). The number of depressive symptoms among EG women decreased at T2 (intragroup p = 0.01). Premature childbirth was four times less in EG women: three (4.4%) compared to 13 (22.4%) among CG women (p = 0.003). Birth weight was higher in EG women (p = 0.01). CONCLUSIONS: The decrease of depressive symptoms in women was not conclusive. However, because birth weight was higher and the rate of preterm childbirth was lower in the EG, our results suggest that the psychosomatic approach may be more helpful to the target population than the standard antenatal programs.

Perception of humanization of birth in a highly specialized hospital: let's think differently.

Our goal for this article was to identify the perceptions of health care professionals, administrators, and women concerning the humanization of childbirth care in a tertiary hospital. A single-case study design and a qualitative approach were used. We collected data through semistructured interviews, participant observation, field notes, and a questionnaire. The humanization of birth in a tertiary hospital is identifiable by several key characteristics such as personalization, recognition of women's rights, human caring, women's advocacy and companionship, and a balance between medical care and comfort, safety, and humanity.

Understanding childbirth practices as an organizational cultural phenomenon: a conceptual framework.

Understanding the main values and beliefs that might promote humanized birth practices in the specialized hospitals requires articulating the theoretical knowledge of the social and cultural characteristics of the childbirth field and the relations between these and the institution. This paper aims to provide a conceptual framework allowing examination of childbirth practices through the lens of an organizational culture theory. A literature review performed to extrapolate the social and cultural factors contribute to birth practices and the factors likely overlap and mutually reinforce one another, instead of complying with the organizational culture of the birth place. The proposed conceptual framework in this paper examined childbirth patterns as an organizational cultural phenomenon in a highly specialized hospital, in Montreal, Canada. Allaire and Firsirotu's organizational culture theory served as a guide in the development of the framework. We discussed the application of our conceptual model in understanding the influences of organizational culture components in the humanization of birth practices in the highly specialized hospitals and explained how these components configure both the birth practice and women's choice in highly specialized hospitals. The proposed framework can be used as a tool for understanding the barriers and facilitating factors encountered birth practices in specialized hospitals.

Cognitive-behavioral therapy versus other PTSD psychotherapies as treatment for women victims of war-related violence: a systematic review.

Although war-trauma victims are at a higher risk of developing PTSD, there is no consensus on the effective treatments for this condition among civilians who experienced war/conflict-related trauma. This paper assessed the effectiveness of the various forms of cognitive-behavioral therapy (CBT) at lowering PTSD and depression severity. All published and unpublished randomized controlled trials studying the effectiveness of CBT at reducing PTSD and/or depression severity in the population of interest were searched. Out of 738 trials identified, 33 analysed a form of CBTs effectiveness, and ten were included in the paper. The subgroup analysis shows that cognitive processing therapy (CPT), culturally adapted CPT, and narrative exposure therapy (NET) contribute to the reduction of PTSD and depression severity in the population of interest. The effect size was also significant at a level of 0.01 with the exception of the effect of NET on depression score. The test of subgroup differences was also significant, suggesting CPT is more effective than NET in our population of interest. CPT as well as its culturallyadapted form and NET seem effective in helping war/conflict traumatised civilians cope with their PTSD symptoms. However, more studies are required if one wishes to recommend one of these therapies above the other.

The facilitating factors and barriers encountered in the adoption of a humanized birth care approach in a highly specialized university affiliated hospital.

BACKGROUND: Considering the fact that a significant proportion of high-risk pregnancies are currently referred to tertiary level hospitals; and that a large proportion of low obstetric risk women still seek care in these hospitals, it is important to explore the factors that influence the childbirth experience in these hospitals, particularly, the concept of humanized birth care.The aim of this study was to explore the organizational and cultural factors, which act as barriers or facilitators in the provision of humanized obstetrical care in a highly specialized, university-affiliated hospital in Quebec province, in Canada. METHODS: A single case study design was chosen. The study sample included 17 professionals and administrators from different disciplines, and 157 women who gave birth in the hospital during the study. The data was collected through semi-structured interviews, field notes, participant observations, a self-administered questionnaire, documents, and archives. Both descriptive and qualitative deductive content analyses were performed and ethical considerations were respected. RESULTS: Both external and internal dimensions of a highly specialized hospital can facilitate or be a barrier to the humanization of birth care practices in such institutions, whether independently, or altogether. The greatest facilitating factors found were: caring and family- centered model of care, professionals' and administrators' ambient for the provision of humanized birth care besides the medical interventional care which is tailored to improve safety, assurance, and comfort for women and their children, facilities to provide a pain-free birth, companionship and visiting rules, dealing with the patients' spiritual and religious beliefs. The most cited barriers were: the shortage of health care professionals, the lack of sufficient communication among the professionals, the stakeholders' desire for specialization rather than humanization, over estimation of medical performance, finally the training environment of the hospital leading to the presence of too many health care professionals, and consequently, a lack of privacy and continuity of care. CONCLUSION: The argument of medical intervention and technology at birth being an opposing factor to the humanization of birth was not seen to be an issue in the studied highly specialized university affiliated hospital.

Facilitators and barriers in the humanization of childbirth practice in Japan.

BACKGROUND: Humanizing birth means considering women's values, beliefs, and feelings and respecting their dignity and autonomy during the birthing process. Reducing over-medicalized childbirths, empowering women and the use of evidence-based maternity practice are strategies that promote humanized birth. Nevertheless, the territory of birth and its socio-cultural values and beliefs concerning child bearing can deeply affect birthing practices. The present study aims to explore the Japanese child birthing experience in different birth settings where the humanization of childbirth has been identified among the priority goals of the institutions concerned, and also to explore the obstacles and facilitators encountered in the practice of humanized birth in those centres. METHODS: A qualitative field research design was used in this study. Forty four individuals and nine institutions were recruited. Data was collected through observation, field notes, focus groups, informal and semi-structured interviews. A qualitative content analysis was performed. RESULTS: All the settings had implemented strategies aimed at reducing caesarean sections, and keeping childbirth as natural as possible. The barriers and facilitators encountered in the practice of humanized birth were categorized into four main groups: rules and strategies, physical structure, contingency factors, and individual factors. The most important barriers identified in humanized birth care were the institutional rules and strategies that restricted the presence of a birth companion. The main facilitators were women's own cultural values and beliefs in a natural birth, and institutional strategies designed to prevent unnecessary medical interventions. CONCLUSIONS: The Japanese birthing institutions which have identified as part of their mission to instate humanized birth have, as a whole, been successful in improving care. However, barriers remain to achieving the ultimate goal. Importantly, the cultural values and beliefs of Japanese women regarding natural birth is an important factor promoting the humanization of childbirth in Japan.

Improving quality and safety in maternity care: the contribution of midwife-led care.

This article draws on findings from a recent Cochrane systematic review of midwife-led care and discusses its contribution to the safety and quality of women's care in the domains of safety, effectiveness, woman-centeredness, and efficiency. According to the Cochrane review, women who received models of midwife-led care were nearly eight times more likely to be attended at birth by a known midwife, were 21% less likely to experience fetal loss before 24 weeks' gestation, 19% less likely to have regional analgesia, 14% less likely to have instrumental birth, 18% less likely to have an episiotomy, and significantly more likely to have a spontaneous vaginal birth, initiate breastfeeding, and feel in control. In addition to normalizing and humanizing birth, the contribution of midwife-led care to the quality and safety of health care is substantial. The implications are that policymakers who wish to improve the quality and safety of maternal and infant care, particularly around normalizing and humanizing birth, should consider midwife-led models of care and how financing of midwife-led services can support this. Suggestions for future research include exploring why fetal loss is reduced under 24 weeks' gestation in midwife-led models of care, and ensuring that the effectiveness of midwife-led models of care on mothers' and infants' health and well-being are assessed in the longer postpartum period.

Humanized birth in high risk pregnancy: barriers and facilitating factors.

The medical model of childbearing assumes that a pregnancy always has the potential to turn into a risky procedure. In order to advocate humanized birth in high risk pregnancy, an important step involves the enlightenment of the professional's preconceptions on humanized birth in such a situation. The goal of this paper is to identify the professionals' perception of the potential obstacles and facilitating factors for the implementation of humanized care in high risk pregnancies. Twenty-one midwives, obstetricians, and health administrator professionals from the clinical and academic fields were interviewed in nine different sites in Japan from June through August 2008. The interviews were audio taped, and transcribed with the participants' consent. Data was subsequently analyzed using content analysis qualitative methods. Professionals concurred with the concept that humanized birth is a changing and promising process, and can often bring normality to the midst of a high obstetric risk situation. No practice guidelines can be theoretically defined for humanized birth in a high risk pregnancy, as there is no conflict between humanized birth and medical intervention in such a situation. Barriers encountered in providing humanized birth in a high risk pregnancy include factors such as: the pressure of being responsible for the safety of the mother and the fetus, lack of the women's active involvement in the decision making process and the heavy burden of responsibility on the physician's shoulders, potential legal issues, and finally, the lack of midwifery authority in providing care at high risk pregnancy. The factors that facilitate humanized birth in a high risk include: the sharing of decision making and other various responsibilities between the physicians and the women; being caring; stress management, and the fact that the evolution of a better relationship and communication between the health professional and the patient will lead to a stress-free environment for both. Humanized birth in a high risk pregnancy is something that goes beyond just curing women of their illnesses. It can be considered as a token of caring, and continued support, which positively consolidates the doctor-patient relationship. As yet, it has not been described as a practiced guideline, due to its ever-changing complexities.

QUARITE (quality of care, risk management and technology in obstetrics): a cluster-randomized trial of a multifaceted intervention to improve emergency obstetric care in Senegal and Mali.

BACKGROUND: Maternal and perinatal mortality are major problems for which progress in sub-Saharan Africa has been inadequate, even though childbirth services are available, even in the poorest countries. Reducing them is the aim of two of the main Millennium Development Goals. Many initiatives have been undertaken to remedy this situation, such as the Advances in Labour and Risk Management (ALARM) International Program, whose purpose is to improve the quality of obstetric services in low-income countries. However, few interventions have been evaluated, in this context, using rigorous methods for analyzing effectiveness in terms of health outcomes. The objective of this trial is to evaluate the effectiveness of the ALARM International Program (AIP) in reducing maternal mortality in referral hospitals in Senegal and Mali. Secondary goals include evaluation of the relationships between effectiveness and resource availability, service organization, medical practices, and satisfaction among health personnel. METHODS/DESIGN: This is an international, multi-centre, controlled cluster-randomized trial of a complex intervention. The intervention is based on the concept of evidence-based practice and on a combination of two approaches aimed at improving the performance of health personnel: 1) Educational outreach visits; and 2) the implementation of facility-based maternal death reviews. The unit of intervention is the public health facility equipped with a functional operating room. On the basis of consent provided by hospital authorities, 46 centres out of 49 eligible were selected in Mali and Senegal. Using randomization stratified by country and by level of care, 23 centres will be allocated to the intervention group and 23 to the control group. The intervention will last two years. It will be preceded by a pre-intervention one-year period for baseline data collection. A continuous clinical data collection system has been set up in all participating centres. This, along with the inventory of resources and the satisfaction surveys administered to the health personnel, will allow us to measure results before, during, and after the intervention. The overall rate of maternal mortality measured in hospitals during the post-intervention period (Year 4) is the primary outcome. The evaluation will also include cost-effectiveness.