Improving health literacy through group antenatal care: results from a cluster randomized controlled trial in Ghana.

BACKGROUND: Although the majority of Ghanaian women receive antenatal care (ANC), many exhibit low health literacy by misinterpreting and incorrectly operationalizing ANC messages, leading to poor maternal and newborn health outcomes. Prior research in low-resource settings has found group antenatal care (G-ANC) feasible for women and providers. This study aims to determine the effect of G-ANC on increasing maternal health literacy. We hypothesized that pregnant women randomized into G-ANC would exhibit a greater increase in maternal health literacy than women in routine, individual ANC. METHODS: A 5-year cluster randomized controlled trial was conducted in 14 rural and peri-urban health facilities in the Eastern Region of Ghana. Facilities were paired based on patient volume and average gestational age at ANC enrollment and then randomized into intervention (G-ANC) vs. control (routine, individual ANC); 1761 pregnant women were recruited. Data collection occurred at baseline (T0) and post-birth (T2) using the Maternal Health Literacy scale, a 12-item composite scale to assess maternal health literacy. Logistic regression compared changes in health literacy from T0 to T2. RESULTS: Overall, women in both the intervention and control groups improved their health literacy scores over time (p < 0.0001). Women in the intervention group scored significantly higher on 3 individual items and on overall composite scores (p < 0.0001) and were more likely to attend 8 or more ANC visits. CONCLUSION: While health literacy scores improved for all women attending ANC, women randomized into G-ANC exhibited greater improvement in overall health literacy post-birth compared to those receiving routine individual care. Life-saving information provided during ANC must be presented in an understandable format to prevent women and newborns from dying of preventable causes. TRIAL REGISTRY: Ethical approval for the study was obtained from the Institutional Review Boards of the University of Michigan (HUM#00161464) and the Ghana Health Service (GHS-ERC: 016/04/19).

Implementation of Healthy Men Healthy Communities: A Health Promotion and Gender-Based Violence Prevention Program for Male South Sudanese Refugees in Uganda.

Men living in refugee settings are often exposed to violence, poverty, and social instability, which impacts physical and mental health and increases the risk of perpetrating sexual and gender-based violence. Healthy Men Healthy Communities was developed as a male-led health promotion program to address men's physical and mental health and their role in creating healthy relationships and families. Three community leaders from the settlements were trained to facilitate the program, which was implemented among six groups consisting of twelve men in each group. Pre/post surveys and feedback were collected among the facilitators and participants. Facilitators suggested culturally appropriate ways to present physical activities as a stress reduction technique and the importance of spacing out births. The small group setting facilitated open conversations on topics such as birth spacing and healthy partner communication. Participants experienced an increase in knowledge and confidence in practicing the program content, such as stress-reduction techniques and healthy communication strategies. Participants recommended additional topics such as fertility and sexually transmitted infections. The Healthy Men Healthy Communities program has the potential for wider implementation among male South Sudanese refugees to promote their health as well as the health of their families.

"With group antenatal care, pregnant women know they are not alone": The process evaluation of a group antenatal care intervention in Ghana.

BACKGROUND: An essential component to improving maternal and newborn outcomes is antenatal care. A trial of group antenatal care was implemented in Ghana where 7 health care facilities were randomized to be intervention sites and 7 control sites continued traditional antenatal care. Group antenatal care, where 10-14 women with similar due dates meet together for visits, includes traditional components such as risk assessment with increased opportunity for education and peer support. The study aim was to assess and report the process evaluation of the implementation of a group antenatal care intervention. METHODS: Process evaluation data were collected alongside intervention data and included both quantitative and qualitative data sources. Midwives at the health facilities which were randomized as intervention sites completed tracking logs to measure feasibility of the intervention. Research team members traveled to intervention sites where they conducted structured observations and completed fidelity and learning methods checklists to determine adherence to the model of group antenatal care delivery. In addition, midwives facilitating group antenatal care meetings were interviewed and focus groups were conducted with women participating in group antenatal care. RESULTS: In the majority of cases, midwives facilitating group antenatal care completed all components of the meetings with fidelity, following best practices such as sitting with the group rather than standing. Across 7 intervention sites, 7 groups (622 pregnant women) were documented in the tracking logs and of these participants, the majority (74%) attended more than half of the meetings, with 32% attending all 8 group meetings. Three themes were identified in both the midwife interviews and focus groups with pregnant women: 1) information sharing, 2) sense of community, and 3) time management challenges. An additional theme emerged from the focus groups with the women: women who had already given birth noticed a disconnect between what they learned and treatment received during labor and birth. CONCLUSION: This process evaluation determined that group antenatal care can be implemented with fidelity in low and middle-income countries. Time management was the biggest challenge, however both midwives and pregnant women found the model of care not only acceptable, but preferable to traditional care. The knowledge shared and sense of community built during the meetings was a valuable addition to the individual model of antenatal care.

Knowledge, attitudes, and practices of healthcare professionals on oral care of pregnant women in Brunei Darussalam.

OBJECTIVE: To examine nationwide the knowledge, attitudes, and practices of healthcare professionals on oral/dental care of pregnant women in Brunei Darussalam. MATERIALS AND METHODS: A descriptive cross-sectional study conducted using an online survey of eligible healthcare professionals in all Government Maternal and Child Health Care Clinics, Dental Clinics and Obstetrics and Gynecological Clinics in four hospitals covering the whole of Brunei Darussalam. Participants were given seven days to complete the survey. Sub-group analysis using Chi-square test for independence and one-way Analysis of Variance (ANOVA) was used to determine the significant association between domains of oral care practices and demographic factors. P values less than 0.05 was considered statistically significant. RESULTS: A total of 346 healthcare professionals participated in this online study. Most participants (94.3%) responded that they perceived oral health to be of high importance. However, less than two thirds of the participants (59.0%) included oral health questions during antenatal health assessments. Moreover, only 16.2% of participants frequently discussed the importance of oral care with their antenatal patients. CONCLUSIONS: In this survey, most healthcare professionals viewed oral health to be of high importance for prenatal/antenatal patients. However, not all put those views into practice with regard to oral care in pregnant women.

Measuring Fear of Childbirth Among a Diverse Population in the United States: A Revised Wijma Delivery Expectancy/Experience Scale (WDEQ-10).

INTRODUCTION: The current gold standard instrument used to measure fear of childbirth is the Wijma Delivery Expectancy/Experience Questionnaire (WDEQ). However, the existing scale is long, has translational challenges, and lacks data specific to experiences of a diverse population in the United States, making it challenging to assess how fear of childbirth impacts perinatal health care disparities. The objective of this study was to revise the WDEQ and analyze its reliability and validity for use in the United States. METHODS: The questionnaire was revised using qualitative data from a previously published study of fear of childbirth within a racially, ethnically, and economically diverse group of pregnant or postpartum people in the United States. Psychometric properties were analyzed in terms of construct validity, reliability, and factor analysis from a group of 329 participants. RESULTS: The revised and shortened 10 item WDEQ-10 comprises 3 subscales: fear of environmental factors, fear of death or injury, and fear of how they feel. The results indicate that the WDEQ-10 demonstrates good reliability and validity and confirmed the multidimensionality of fear of childbirth through a 3-factor solution. DISCUSSION: The WDEQ-10 is a readable and accessible instrument that will allow health care providers and researchers to accurately measure complex components of how pregnant people experience fear of childbirth.

Improving respectful maternity care through group antenatal care: findings from a cluster randomized controlled trial.

Background: Disrespect and patient mistreatment are identified as barriers to care-seeking and low uptake of facility-based deliveries. These mitigating factors have led to slow progress in the achievement of maternal and child health targets, especially in Ghana. Group antenatal care, as an alternative to individual antenatal was implemented to explore the impact on outcomes, including mothers' perception of respectful care. Methods: A cluster randomized controlled trial was conducted in 14 health facilities across four districts in the Easter Region of Ghana. These facilities were randomized to intervention or control using a matched pair. Data was collected at several timepoints: enrollment (Time 0), 34 weeks gestation to 3 weeks post-delivery (Time 1), 6 to 12 weeks post-delivery (Time 2), 5 to 8 months post-delivery (Time 3), and 11 to 14 months post-delivery (Time 4). Questions related to respectful care were asked at Time 2, while a focus group discussion (FGDs) was conducted as part of a process evaluation to examine participants' experiences about respectful maternity care. Results: The findings from the intervention group indicate that participants perceived higher levels of respect in comparison to the control group. Privacy and con dentiality were maintained. They believed they had been provided with adequate information, education, and counseling, empowering them to make informed decisions. Participants perceived a shortened waiting time and reduced discrimination in care provision. Generally, there were higher levels of satisfaction with antenatal care. Conclusion: The provision of respectful maternity care, which is essential to increasing healthcare utilization, has been demonstrated to correlate positively with group antenatal care.

Group Antenatal Care in Ghana: Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: While group antenatal care (ANC) has been delivered and studied in high-income countries for over a decade, it has only recently been introduced as an alternative to individual care in sub-Saharan Africa. Although the experimental design of the studies from high-resource countries have been scientifically rigorous, findings cannot be generalized to low-resource countries with low literacy rates and high rates of maternal and newborn morbidity and mortality. The Group Antenatal Care Delivery Project (GRAND) is a collaboration between the University of Michigan in the United States and the Dodowa Health Research Centre in Ghana. GRAND is a 5-year, cluster randomized controlled trial (RCT). Our intervention-group ANC-consists of grouping women by similar gestational ages of pregnancy into small groups at the first ANC visit. They then meet with the same group and the same midwife at the recommended intervals for care. OBJECTIVE: This study aims to improve health literacy, increase birth preparedness and complication readiness, and optimize maternal and newborn outcomes among women attending ANC at seven rural health facilities in the Eastern Region of Ghana. METHODS: Quantitative data will be collected at four time points using a secure web application for data collection and a database management tool. Data will be analyzed on an intention-to-treat basis to test the differences between the two arms: women randomized to group-based ANC and women randomized to routine individual ANC. We will conduct a process evaluation concurrently to identify and document patient, provider, and system barriers and facilitators to program implementation. RESULTS: The study was funded in September 2018. Recruitment and enrollment of participants and data collection started in July 2019. In November 2021, we completed participant enrollment in the study (n=1761), and we completed data collection at the third trimester in May 2022 (n=1284). Data collection at the additional three time points is ongoing: 6 weeks postpartum, 6 months postpartum, and 1 year postpartum. CONCLUSIONS: This study is significant and timely because it is among the first RCTs to be conducted to examine the effects of group ANC among low-literacy and nonliterate participants. Our findings have the potential to impact how clinical care is delivered to low-literacy populations, both globally and domestically, to improve maternal and newborn outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT04033003; https://clinicaltrials.gov/ct2/show/NCT04033003. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40828.

Perspectives of Doulas of Color on their Role in Alleviating Racial Disparities in Birth Outcomes: A Qualitative Study.

INTRODUCTION: The purpose of this study was to explore how doulas of color conceptualize both their work and how their racial and ethnic identities influence their work within the context of racial disparities in birth outcomes in the United States. METHODS: We conducted semistructured qualitative interviews with doulas of color who had attended at least 3 births as doulas. Participants were recruited from across the United States. The interviews were audio recorded and transcribed verbatim. Qualitative content analysis was used to derive themes from the transcribed interviews. RESULTS: Interviews were conducted with 8 doulas of color, ranging in age from 21 to 47 from across the United States. All participants were either current college students or had earned a college degree. Although many of the doulas identified as being of more than one racial or ethnic group, nearly all participants identified closely with being Black or African American first, and their other racial groups second. Four major themes emerged: relationship with the medical system, role of identity in the doulas' work, role of class, and divisions within the natural birth movement. DISCUSSION: The majority of doulas who participated in this study stated that their racial identity strongly influenced their work, particularly when working with women of the same race or ethnicity due to their shared identities. Several participants initially became doulas because of a desire to alleviate disparities in birth outcomes for women of color. This suggests a commitment on the part of the study participants to serving their communities and to bridging the gap between women of color and the health care system. Several participants also noted that they feel alienated by both the health care system and the mainstream natural birth community.

A pilot study to evaluate the effect of classroom-based high-fidelity simulation on midwifery students' self-efficacy in clinical lactation and perceived translation of skills to the care of the breastfeeding mother-infant dyad.

BACKGROUND: Midwives are expected to provide timely and skilled support to breastfeeding mothers, yet it is not clear whether and how midwifery students receive training in clinical lactation. The primary objective of this pilot study was to evaluate the impact of a classroom-based breastfeeding simulation on nurse-midwifery students' self-efficacy in lactation skills. The secondary objective was to describe students' exposure to breastfeeding patients in the classroom and in clinical settings. METHODS: A pilot study using a prospective cohort study design and convenience sampling was completed between September 2017 and April 2018. Two simulation-based workshops were developed for the classroom setting in alignment with breastfeeding-focused competencies for midwives and lactation professionals. The workshops were integrated into the nurse-midwifery curriculum at a US-based program. Two Self-Efficacy Surveys (defined, 7-point Likert Scale) were developed and used to measure baseline and continuing self-efficacy in breastfeeding skills among students. Two Practice Patterns instruments, adapted from the American Academy of Pediatrics breastfeeding curriculum, were used to define the setting, quantity, and types of nurse-midwifery students' breastfeeding-related exposures. Students participated in a one-hour focus group upon completion of the study. RESULTS: In this pilot study, nurse-midwifery student participants (N = 9) reported a 14% increase (P < .0001) in their perceived self-efficacy in basic and advanced clinical lactation skills after completing both workshops. The nurse-midwifery students reported dozens of encounters with diverse breastfeeding patients over a six-month period during which they performed a wide variety of clinical lactation skills. The focus group revealed most students (n = 5/9) would like more time to practice clinical lactation skills in a simulated environment and some indicated a desire to have more exposure to challenging versus common (n = 2/9) of breastfeeding concerns. CONCLUSIONS: In this work, we demonstrate the first high-fidelity lactation simulation in a classroom setting in a healthcare professional training program. Midwifery educators and researchers can adapt the framework and instruments presented in this pilot study to determine the effect of educational interventions on students' translation of skills to breastfeeding mother-infant dyads. Likewise, this is the first study to define the number and type of breastfeeding-related clinical exposures among nurse-midwifery students.

Outcomes of Expectant Management of Term Prelabor Rupture of Membranes.

OBJECTIVE: To assess rates of induction/augmentation of labor, maternal infection, neonatal outcomes, and time to birth when women were expectantly managed after term prelabor rupture of membranes (PROM) at home or in the hospital. DESIGN: Retrospective, descriptive study based on a review of data from a hospital midwifery service database and chart review. SETTING: A large Midwest hospital with 4,700 births annually. PARTICIPANTS: We used the cases of women who received midwifery care, experienced term PROM, and had singleton fetuses in the vertex position. METHODS: We conducted an analysis of maternal and neonatal outcomes with term PROM using data from a midwifery service quality improvement database. We compared characteristics and outcomes between management plans (immediate induction, expectant hospital, and expectant home) using chi-square, analysis of variance, and independent t-tests. RESULTS: PROM occurred in 281 (12%) of the 2,357 women cared for by the midwifery service between January 2016 and December 2018. One hundred fifty women (53.3%) opted to wait for labor onset at home, 102 (36.3%) were expectantly managed in the hospital, 21 (7.5%) were admitted for immediate induction of labor, and 8 (2.8%) were admitted for immediate cesarean birth. The rate of spontaneous labor onset was not significantly different between the two expectant management groups or between nulliparous and multiparous women. A total of 88 (34.9%) women who were expectantly managed ultimately had their labors induced. Rates of chorioamnionitis and endometritis were not significantly different between the expectant management groups in this study or compared with national averages. There was no difference in NICU admissions or Apgar scores below 7. The mean time from PROM to birth was significantly shorter in the expectant management in hospital group (27.3 hours) than in the expectant management at home group (33.5 hours). CONCLUSION: Expectant management at home or in the hospital is appropriate for low-risk pregnant women with term PROM. Women for whom this option is appropriate include those with term singleton fetuses in vertex presentation with reassuring fetal heart rates and confirmed clear amniotic fluid. Acceptable time frames for home management include up to 24 hours for women with negative group B streptococcus cultures and up to 12 hours for those with positive cultures.

Relational Decision-Making in the Context of Life-Limiting Fetal Anomalies: Two Cases of Anencephaly Diagnosis.

Life-limiting fetal diagnoses such as anencephaly require families to make decisions in which no options offered will lead to the desired outcome of a healthy newborn. Although informed choice and shared decision-making are important aspects of ethics regarding care choices, they have limitations. In this article, 2 cases of anencephaly diagnosis are presented, and a relational decision-making model of care is proposed as an alternative for aiding pregnant people and their families in making challenging choices in the context of perinatal care.

Midwifery students better approximate their self-efficacy in clinical lactation after reflecting in and on their performance in the LactSim OSCE.

BACKGROUND: Midwives are expected to support women with lactation initiation and maintenance. Midwifery students engaged in a simulation-based exercise (LactSim OSCE) where they role-played the clinician and the breastfeeding patient by wearing a high-fidelity breast model. We provided participants opportunities for reflecting in and on practice to compare their perceived self-confidence in clinical lactation skills to actual clinical performance. We also describe feasibility of implementing the LactSim OSCE with an emphasis on preparation and time spent on tasks during the OSCE. METHODS: Audio-video recordings from the LactSim OSCE were viewed and assessed using a technical skills checklist by an independent rater and by the study participants as part of the self-reflection. Mixed data on participants' self-efficacy in clinical lactation, experience with the LactSim OSCE, and self-assessment of clinical performance were collected in survey instruments and a focus group. Time spent on each component and clinical lactation skill during the LactSim OSCE was documented. RESULTS: Immediately following the LactSim OSCE, participants' confidence in clinical lactation was high (5.7/7), but after a guided video reflection exercise, their self-efficacy was 4.4/7. Participants spent approximately 2 of the allotted 10 min per case scenario discussing the OSCE logistics due to inadequate preparation. Participants spent approximately 2 min of the total encounter performing hands-on clinical lactation skills by touching, looking at, or using the high-fidelity breast model worn by their peer. CONCLUSION: We described the development and evaluation of the first simulated experience in clinical lactation with all three components of fidelity: conceptual, psychological, and physical. Multiple opportunities for reflecting on performance allowed the nurse-midwifery students to evaluate their competence in decision-making, technical, and counseling skills which resulted in a more realistic approximation of their perceived self-confidence in breastfeeding skills. Another innovation of this pilot work is the documentation of how long a learner spends on various tasks relevant to lactation support in a simulated encounter. Our findings highlight the importance of providing multiple opportunities for self-reflection using guided video reflection and checklists for objective self-assessment in the clinical lactation field.

Development and evaluation of a high-fidelity lactation simulation model for health professional breastfeeding education.

BACKGROUND: A key reason for premature cessation of breastfeeding is inadequate support from healthcare providers. Most physicians and nurses do not feel confident in their ability to support families with breastfeeding initiation or maintenance. Increasing health professional confidence in clinical lactation skills is key to improving maternal and child health outcomes. High-fidelity (realistic) simulators encourage learner engagement, resulting in increased clinical skills competency, confidence, and transfer to patient care. Lactation educators teach with low-fidelity cloth and single breast models. There are no high-fidelity breast simulators for health professional education in clinical lactation. DEVELOPMENT AND EVALUATION OF A HIGH-FIDELITY LACTATION SIMULATION MODEL: In this commentary we describe the development of a high-fidelity Lactation Simulation Model (LSM) and how physician residents, nurse-midwifery students, and clinical lactation experts provided feedback on LSM prototypes. LIMITATIONS: The user-testing described in this commentary does not represent comprehensive validation of the LSM due to small sample sizes and the significant conflict of interest. CONCLUSION: For breastfeeding rates to improve, mothers need support from their nurses, midwives, pediatricians, obstetricians and gynecologists, and all healthcare staff who interact with pregnant and lactating women. Clinical education with high-fidelity breastfeeding simulators could be the ideal learning modality for trainees and hospital staff to build confidence in clinical lactation skills. The ability of a high-fidelity breastfeeding simulator to increase a learner's lactation knowledge and psychomotor skills acquisition, retention, and transfer to patient care still needs to be tested.

A retrospective comparison of waterbirth outcomes in two United States hospital settings.

BACKGROUND: Water immersion during labor is an effective comfort measure; however, outcomes for waterbirth in the hospital setting have not been well documented. Our objective was to report the outcomes from two nurse-midwifery services that provide waterbirth within a tertiary care hospital setting in the United States. METHODS: This study is a retrospective, observational, matched comparison design. Data were collected from two large midwifery practices in tertiary care centers using information recorded at the time of birth for quality assurance purposes. Land birth cases were excluded if events would have precluded them from waterbirth (epidural, meconium stained fluid, chorioamnionitis, estimated gestational age < 37 weeks, or body mass index > 40). Neonatal outcomes included Apgar score and admission to the neonatal intensive care unit. Maternal outcomes included perineal lacerations and postpartum hemorrhage. RESULTS: A total of 397 waterbirths and 2025 land births were included in the analysis. There were no differences in outcomes between waterbirth and land birth for Apgar scores or neonatal intensive care admissions (1.8% vs 2.5%). Women in the waterbirth group were less likely to sustain a first- or second-degree laceration. Postpartum hemorrhage rates were similar for both groups. Similar results were obtained using a land birth subset matched on insurance, hospital location, and parity using propensity scores. DISCUSSION: In this study, waterbirth was not associated with increased risk to neonates, extensive perineal lacerations, or postpartum hemorrhage. Fewer women in the waterbirth group sustained first- or second-degree lacerations requiring sutures.

Timing and Outcomes of an Indication-Only Use of Intravenous Cannulation During Spontaneous Labor.

INTRODUCTION: In the United States, most women presenting in spontaneous labor undergo intravenous (IV) cannulation on admission to hospital labor and birth units. There is limited evidence for this routine practice in pregnant women at low risk for adverse outcomes during labor or birth. METHODS: A retrospective, exploratory, descriptive study of an indication-only practice of IV cannulation on admission for women presenting in spontaneous labor and cared for by a nurse-midwife service was performed. Descriptive data included the timing of IV cannula placement (admission, during labor or postpartum period, or not at all) and indications for placement. Maternal outcomes of interest were estimated blood loss, postpartum hemorrhage rates, and management; neonatal outcome was 5-minute Apgar scores. RESULTS: Records for 1069 women cared for by nurse-midwives who presented in spontaneous labor were reviewed. In this cohort, 445 (41.6%) had IV access established on admission, 325 (30.4%) had an IV cannula placed during labor or postpartum, and 299 (28%) never had IV access during their hospital stay. For the 325 women with IV cannulas placed after admission, 25 (7.7%) were placed urgently for excessive postpartum bleeding. Further analysis of the subset of women who had a postpartum hemorrhage after vaginal birth (defined as >500 mL estimated blood loss) indicated that urgent IV cannulation was not associated with a lower mean postpartum hemoglobin or hematocrit or an increase in blood transfusion rate when compared with women who had an IV cannula placed earlier in their labor course. DISCUSSION: Indication-only IV cannulation for women experiencing an uncomplicated labor and birth is a reasonable practice in settings where IV access can be established urgently if needed.

Certified Nurse-Midwives' Experiences With Provision of Prenatal Genetic Screening: A Case for Interprofessional Collaboration.

Prenatal genetic screening (GS) for the most common autosomal aneuploidies encompasses maternal serum screening (MSS) and noninvasive prenatal testing (NIPT, or cell-free fetal DNA testing). In the United States, most maternity care is provided by obstetrician-gynecologists; however, women are increasingly utilizing the services of certified nurse-midwives (CNMs). Currently, limited research exists on midwives' experiences with providing prenatal GS. Therefore, the purpose of this study was to explore CNMs' experiences in providing prenatal GS. A semistructured guide focused on MSS and NIPT was used to interview a convenience sample of 13 CNMs. Results were coded and analyzed using grounded theory to elicit overarching themes. Results were organized into 6 themes describing CNMs' prenatal GS provision: (1) clinical protocols; (2) patient education; (3) patient-CNM shared decision-making process; (4) testing initiation; (5) results delivery; and (6) follow-up coordination. Key influences on midwives' perspectives on offering prenatal GS included a noninterventionist approach to pregnancy and past experiences with false-positive MSS results. Participants had an understanding of prenatal GS that was appropriate to midwifery scope of practice. Results indicate that NIPT utilization is compatible with the midwifery philosophy of noninterventionism, although midwives had limited experiences with NIPT to date.

Determinants of postnatal care utilization in Tigray, Northern Ethiopia: A community based cross-sectional study.

INTRODUCTION: Globally, 289,000 women die from complications related to pregnancy, childbirth, or the postnatal period every year. Two-thirds of all maternal deaths occur during the first six weeks following birth and more than two thirds of newborn deaths occur during the first week of life, These statistics underscore the importance of postnatal care, an often neglected service according to the World Health Organization (WHO). The purpose of this study was to assess the factors associated with postnatal service utilization in the Tigray region of Ethiopia. METHODS: The study was a community-based, cross-sectional study. A multi-stage sampling method was used to select study districts randomly from the entire region. A total of 1,690 participants were selected using systematic random sampling. Participants were 18-49 years old, had given birth within the last six months, and were residents of the district for at least six months. Using SPSS version 20 means, frequencies, and percentages were calculated for the sub-group of participants who did attend postnatal care. Barriers to non-attendance of postatal care were analyzed using descriptive statistics. Bivariate analysis was undertaken to assess the association between demographic, obstetric, and knowledge regarding PNC and attendance at antenatal care. Variables with a P value, <0.05 were included in the multivariate logistic regression analysis to identify the determinant factors of postnatal care utilization. RESULT: Of the women surveyed, 132 (8%) obtained postnatal care. Women who did not receive postnatal care reported lack of awareness of the services (n = 1110, 73.3%). Most mothers who received postnatal care reported that they were aware of the service prior to the birth of their child (n = 101, 76.5%). Women were more likely to receive postnatal services if they lived in an urban area (odds ratio 1.96, 95% confidence interval 1.07, 3.59), had greater than a secondary education (OR 3.60, 95% CI 1.32,9.83), delivered by cesarean section (OR 2.88 95% CI 1.32,6.29), had four or more antenatal visits (OR 4.84, 95% CI 1.57,14.9), or had a planned pregnancy (OR 6.47, 95% CI 2.04,20.5). CONCLUSION: Postnatal care service utilization is very low in Tigray region. Interventions targeted at increasing women's awareness of the importance of postnatal services and improving accessibility, particularly in rural areas, is needed.

Where Are the Dads? A Pilot Study of a Dads-Only Session in Group Prenatal Care.

Despite suggestions that paternal engagement is one potential strategy to impact the multifaceted problem of infant mortality, fathers' involvement in prenatal care has received little attention or study. While there is evidence that fathers want information about assisting partners and caring for newborns, the best mechanism for providing this information is unknown. A pilot study was conducted using a father-only session designed to provide information in an informal, interactive setting within a model of group prenatal care. All 5 of the fathers approached agreed to participate. The fathers participating in this session indicated that the session was beneficial and found it to be a valuable addition to the group care model. Implications for health providers include identifying opportunities that allow fathers to share concerns and anxieties regarding care for partners and newborns. Implementing fathering activities into group prenatal care or developing other opportunities for fathers to be involved prenatally needs further investigation.

Achieving competency in vaginal examinations: The challenge of balancing student learning needs with best practice in maternity care.

Assessment of labor progress through vaginal digital examination (VE) remains one of the most challenging skills for midwifery students. As VE during labor has become a less frequent occurrence there are less opportunities for student midwives to gain mastery of the skill. Best practices for teaching and evaluating VE involve a step-wise, multi modal approach. More research is needed on how to standardize teaching for this essential skill.

Factors influencing use of family planning in women living in crisis affected areas of Sub-Saharan Africa: A review of the literature.

BACKGROUND: far too many women continue to die from pregnancy and childbirth related causes. While rates have decreased in the past two decades, some areas of the world such as sub-Saharan Africa continue to have very high maternal mortality rates. One intervention that has been demonstrated to decrease maternal mortality is use of family planning and modern contraception, yet rates of use in sub-Saharan countries with the highest rates of maternal death remain very low. AIM: to review available research and summarize the factors that inhibit or promote family planning and contraceptive use among refugee women and women from surrounding areas living in Sub-Saharan Africa. DESIGN: a review of the literature. DATA SOURCES: Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), OVID, power search, and PubMed databases. REVIEW METHODS: studies included were: (1) published in English from 2007 to present; (2) primary research; and (3) focused on family planning and contraceptive use among refugee women and women in surrounding areas. Findings were discussed within the framework of the Interaction Model of Client Health Behavior. FINDINGS: twelve studies met the inclusion criteria. Utilization of modern contraceptive methods was low. Women were socially influenced to avoid the use of contraceptives by husbands and others in the community. Reasons were a lack of trust in western medicine and the desire to have large families. Low socioeconomic status and proximity of family planning clinics were barriers to access. Women believed that health care providers were unqualified, many described being treated with disrespect in the health clinics. Knowledge and understanding of contraceptives was low; while most women knew different methods were available, there were many misconceptions. Believing that certain contraceptives cause death, infertility and side effects, contributed to fear of use. This lack of knowledge and fear, even with the desire to space and limit births, affected motivation to use contraception. CONCLUSIONS: developing new approaches to educating women, men (husbands), community leaders as well as healthcare providers is needed to address the multi-factorial issues that contribute to underuse of family planning services, thus contraceptive use. IMPLICATIONS FOR PRACTICE: while lack of access to family planning is a barrier to use, interventions that improve access must be affordable and include education regarding contraceptive methods, preferably from those within the community. However, education and access is not sufficient unless the issue of disrespect by healthcare providers is addressed. Respectful and culturally sensitive care for all women, regardless of socio-economic status or country of origin, must be provided by midwives and other women health providers.