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Maternal and Newborn Mortality: Community Opinions on Why Pregnant Women and Newborns Are Dying In Natikiri, Mozambique.

Authors:
  • Lurio University

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Background and objective: maternal and neonatal mortality rates in Mozambique are high, due to insufficient numbers of qualified health workers, lack of equipment and materials, referral system deficiency, difficulties to access health services and gender issues. This study assesses the barriers to health care access, regular attendance at ante natal consultations, institutional delivery and postnatal and neonatal follow-up. This is part of the baseline study for an implementation research project to reduce maternal and neonatal mortality in Natikiri, Nampula, Mozambique. Methods: descriptive mixed study with two components: 1) data analysis from primary sources (interviews and focus group discussions with community members, health professionals) in the catchment area of Marrere health center and hospital, in Natikiri; 2) data analysis of secondary sources (national and international literature). Results: 300 people were surveyed and 11 focal group discussions were held. Respondents were asked why they thought pregnant women and newborns were dying in their community. Local community members and health professionals some reasons: 1. Long walking distances required to reach health services. 2. Unsafe travel conditions for women. Available online: https://edupediapublications.org/journals/index.php/IJR/ P a g e | 224 3. Poor treatment in health facilities including illicit payments and bribes. 4. Long waits to be attended to. 5. Poor training and lack of knowledge of health professionals. 6. Health professionals neglecting patients and not giving family centered care. 7. Teenage pregnancies and short spacing of pregnancies. 8. Inability of women to make informed decisions about family planning. 9. Home births without trained support and traditional methods of treatment. 10. Myths and cultural taboos about pregnancy and newborn care. 11. Women and community limited knowledge about women and adolescent girls' health. 12. Need of "mother's house waiting" near the hospital for pregnant women. 13. Weak government policies and little funding to support maternal and child health care. Discussion: literature review identified several factors causing delay in pregnant women and newborns' appropriate care. These poor quality determinants on primary and secondary health care, for pregnant and newborn, can be grouped into three delays: (1) the decision to seek care by pregnant woman and woman who have delivered; 2) accessing and arriving at the health center; 3) receiving quality health care. Conclusion: local community members and health professionals were asked to state what they thought would be the best way to intervene. These ideas were then discussed further at a conference with health professionals and government representatives. Six intervention strategies to address identified problems were decided on and will be the basis for the ongoing implementation research project. They were: 1. Expanding family planning especially with adolescents. 2. Community based transport system for pregnant women. 3. Strengthening maternal and child health services by training maternity personnel in obstetrical emergency care and neonatal resuscitation. 4. Providing four quality prenatal visits. 5. Providing quality cesarean deliveries. 6. Supporting the Mozambican Government's campaign against bribery.
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Maternal and Newborn Mortality: Community Opinions on
Why Pregnant Women and Newborns Are Dying In Natikiri,
Mozambique.
Belo C,
1
Pires P,
2
Josaphat J,
3
Siemens R,
4
Rooke E,
5
Spence-Gress C.
6
ABSTRACT
Background and objective: maternal and neonatal mortality rates in Mozambique are
high, due to insufficient numbers of qualified health workers, lack of equipment and
materials, referral system deficiency, difficulties to access health services and gender
issues. This study assesses the barriers to health care access, regular attendance at ante
natal consultations, institutional delivery and postnatal and neonatal follow-up. This is
part of the baseline study for an implementation research project to reduce maternal and
neonatal mortality in Natikiri, Nampula, Mozambique.
Methods: descriptive mixed study with two components: 1) data analysis from primary
sources (interviews and focus group discussions with community members, health
professionals) in the catchment area of Marrere health center and hospital, in Natikiri; 2)
data analysis of secondary sources (national and international literature).
Results: 300 people were surveyed and 11 focal group discussions were held.
Respondents were asked why they thought pregnant women and newborns were dying in
their community. Local community members and health professionals some reasons:
1. Long walking distances required to reach health services.
2. Unsafe travel conditions for women.
1
Project leader, conception, data collection and interpretation, final approval of the version to be published;
MD Master in Occupational Health, Health Sciences Faculty Dean, Lúrio University, Nampula,
Mozambique.
2
Study protocol conception and design, data collection, analysis and interpretation, article draft, final
approval of the version to be published; Family and Community Medicine Specialist, Lecturer, Health
Sciences Faculty, Lúrio University, Nampula, Mozambique.
3
Study protocol conception and design, data collection, treatment, analysis and interpretation, article draft,
final approval of the version to be published; Nurse, Health Services Management Specialist, Master in
Epidemiology, Lecturer, Health Sciences Faculty, Lúrio University, Nampula, Mozambique.
4
Study protocol conception, data collection and interpretation, translation to English, final approval of the
version to be published; MD Paediatrician, Lecturer, University Saskatchewan, Saskatoon, Canada.
5
Study protocol conception, data collection and interpretation, final approval of the version to be
published; MD Family Medicine Specialist, Lecturer, University Saskatchewan, Saskatoon, Canada.
6
Study protocol conception, data treatment, analysis and interpretation, final approval of the version to be
published; MD Family Medicine Specialist, Lecturer, University Saskatchewan, Saskatoon, Canada.
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3. Poor treatment in health facilities
including illicit payments and bribes.
4. Long waits to be attended to.
5. Poor training and lack of knowledge
of health professionals.
6. Health professionals neglecting
patients and not giving family
centered care.
7. Teenage pregnancies and short
spacing of pregnancies.
8. Inability of women to make
informed decisions about family
planning.
9. Home births without trained support
and traditional methods of treatment.
10. Myths and cultural taboos about
pregnancy and newborn care.
11. Women and community limited
knowledge about women and
adolescent girls’ health.
12. Need of "mother's house waiting"
near the hospital for pregnant
women.
13. Weak government policies and little
funding to support maternal and
child health care.
Discussion: literature review identified
several factors causing delay in pregnant
women and newborns appropriate care.
These poor quality determinants on
primary and secondary health care, for
pregnant and newborn, can be grouped
into three delays: (1) the decision to seek
care by pregnant woman and woman
who have delivered; 2) accessing and
arriving at the health center; 3) receiving
quality health care.
Conclusion: local community members
and health professionals were asked to
state what they thought would be the
best way to intervene. These ideas were
then discussed further at a conference
with health professionals and
government representatives. Six
intervention strategies to address
identified problems were decided on and
will be the basis for the ongoing
implementation research project. They
were:
1. Expanding family planning
especially with adolescents.
2. Community based transport system
for pregnant women.
3. Strengthening maternal and child
health services by training maternity
personnel in obstetrical emergency
care and neonatal resuscitation.
4. Providing four quality prenatal visits.
5. Providing quality cesarean
deliveries.
6. Supporting the Mozambican
Government's campaign against
bribery.
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Keywords: access, prenatal,
consultation, pregnancy, puerperium,
newborn, Mozambique.
1. Introduction
This study carried out by Lúrio
University (UniLúrio) Health Sciences
Faculty (HSF) in partnership with
Nampula Provincial Health Directorate
(NPHD), Marrere Hospital (MH) and the
University of Saskatchewan, Saskatoon,
Canada constitutes part of the baseline
evaluation for an implementation
research on maternal and newborn
health.
Every day, about 800 women die from
preventable causes related to pregnancy
and childbirth. Almost three million
newborn babies die each year and 2.6
million babies are stillborn.
1
The World Health Organization (WHO)
defines maternal mortality as the death
of a woman during pregnancy or up to
42 days after giving birth, irrespective of
the duration and place of the pregnancy,
due to any cause related or aggravated
by pregnancy or its management.
Currently maternal and neonatal
mortality rates in Mozambique are
unacceptably high: 4,800 maternal
deaths during the year 2013.
2
The complications responsible for
almost 75 % of maternal deaths in the
world are: severe bleeding and infections
(usually after childbirth), high blood
pressure during pregnancy (preeclampsia
and eclampsia), other childbirth and
unsafe abortion complications.
3
In Mozambique, about 43 % of maternal
deaths occur during childbirth and up to
24 hours later, 76 % of these deaths were
due to direct causes and 24 % to indirect
causes. Among main causes of death are
uterine rupture (17 %), postpartum
haemorrhage (14 %), preeclampsia and
eclampsia (13 %), Acquired Human
Immunodeficiency Syndrome (AIDS)
(12 %) and puerperal sepsis (11 %).
AIDS appears as the first indirect cause
of maternal death and the fourth leading
cause. In primary health care (PHC)
units death occurs more frequently
before the woman reaches the first two
hours of hospitalization, showing the
precarious conditions and women’s late
arrival to the health center (HC).
4
The main causes of neonatal morbidity
and mortality are prematurity and low
birth weight, asphyxia, sepsis,
pneumonia, human immunodeficiency
virus (HIV), malaria, diarrhea, syphilis
and other congenital infections. In
addition to these factors, the low
frequency of institutional delivery, (54
% in 2011), the reduced quality and
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quantity of antenatal consultations
(ANC) also contribute to morbidity and
mortality.
5
,
6
In Mozambique, among other
determinants of maternal and neonatal
deaths, are the shortage of qualified
personnel in the HC, poor quality and
quantity of materials and equipment, low
quality care, deficiency in referral
system, long travel distances to the HC,
lack of transportation, poor
communication between health
professionals (HP) and the community,
and gender issues such as the low
decision-making power of women and
low literacy levels.
7
,
8
These factors can be grouped using the
three-delay model: 1) delay in the
decision to seek appropriate maternal or
neonatal health care; 2) delay in arrival
to the HC; 3) delay in receiving timely
and appropriate obstetric or neonatal
emergency care.
9
The national health system (NHS)
covers 40 % of the population with
hospital care and 60 % in PHC. The
remaining population is covered by a
community network composed of
traditional midwives (TMW) and
traditional health practitioners (THP).
A study in Mali showed that organized
participation of TMW improved the
access of women to ANC, institutional
delivery, neonatal follow-up and
children vaccination.
10
Well equipped maternities with trained
personnel are key to provide skilled birth
attendants and deal with obstetric
complications. However there is a
persistence of inequities in HC
distribution in the country: about half of
pediatricians and obstetricians are
concentrated in Maputo, the
Mozambican capital.
The proportion of births in Mozambique
in HC with trained birth attendants
increased from 48 % in 2003 to 55 % in
2011 but neonatal mortality has declined
more slowly than infant and child
mortality. This puts the country still far
from achieving the annual decline
needed to achieve the Sustainable
Millennium Goals (SMG).
11
Considering the importance of delivery
and birth care for maternal and neonatal
health, it is necessary to invest in actions
with a positive impact on this reality.
The best potential to modify the situation
is in the puerperium and immediate
postpartum (the first 24 hours after
childbirth) where 24 to 45% of neonatal
and 45% of maternal deaths occur.
12
,
13
Several programs have been developed
in Mozambique to reduce maternal and
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neonatal mortality. One is the
distribution to pregnant women of the
Women's Health Handbook.
14
The
Community Health Program,
implemented through Local Health
Councils, aimed to reduce family and
community barriers to access ANC and
increase social mobilization. Another
program focused on sexual and
reproductive health (SRH) barriers, by
building "Mother's Waiting Homes" to
house mothers near the HC while
awaiting delivery, reviewing the
abortion law, using information from
both men and women and extending the
coverage of SRH services.
15
The creation of Hospital Co-
management Committees, participated
by HP and managers and community
members who work together in the
planning, implementation, follow-up and
evaluation of activities, including
analysis and decision-making in the HC
and the community, aims to improve
health services’ performance.
16
The Model Maternity Program aims to
improve the quality of delivery and the
humanization of health services to
women and children, but to date with a
reduced implementation.
17
The objective of this study is to evaluate
the barriers to access and adherence to
ANC, institutional birth and follow-up
during puerperal and neonatal periods in
the HC and MH. The secondary
objectives were: (a) analyze local
community’ perception about pregnancy,
childbirth, care during puerperal and
neonatal periods; b) assess HP providing
Maternal and Child Health (MCH)
assistance’ knowledge in HC and MH,
regarding barriers to access and
attendance; c) evaluate TMW and THP
knowledge regarding pregnancy,
childbirth and care during the puerperal
and neonatal periods.
2. Methods
Descriptive mixed-methods research,
using quantitative and qualitative data
collection from two sources:
1) data analysis from secondary sources
(scientific communications, HC and MH
reports and programs, scientific articles,
national policy and strategy reports,
population and health surveys,
population census, national and
international data).
2) data analysis from primary sources
(interviews with provincial department
members responsible for MCH, district
medical director, MH and HC workers in
the area of MCH, TMW, THP, Natikiri
community members including women
of childbearing age, pregnant women,
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postpartum women, adolescents, fathers,
elderly women and community leaders).
Interviews used semi structured
questionnaires, pre-tested and approved,
addressing questions about pregnancy,
childbirth and care during puerperium
and neonatal period.
Focal group discussions (FGD) were
conducted with MCH workers, TMW,
THP, community members including
women of childbearing age, pregnant
women, post-partum women,
adolescents, parents, grandparents and
community leaders residing in the same
area with two questions: why are women
and children dying during pregnancy and
the newborn period in your community?
Secondly, what are possible solutions to
the problems identified?
Statistics and reports regarding numbers
of deliveries and complications
occurring at the HC and MH (hospital
for Natikiri district) were collected.
The study was approved by the
Institutional Committee on Health
Bioethics of Lúrio University and the
Behavioral Ethics Board at the
University of Saskatchewan.
A representative sample of women of
childbearing age was calculated using
the Epi Info 7.2 program considering
the size of the target population, the
expected frequency, with a margin of
error of 10% and a 95% confidence
interval. The sample size for heads of
households was the same as for women
of childbearing age: heads of households
were considered as partners of women of
childbearing age. The same sample size
was considered for older women (above
45 years): considered as mothers /
mothers-in-law of women of
childbearing age. A total of 125 THP
operate in the intervention area and the
choice of a representative sample used
Epi Info 7.2 program with the
expected frequency of 50%, with a 10%
margin of error and a 95% confidence
interval. TMW, HP and community
leaders willing to participate in the
interviews were included.
The estimated sample size for the
interviews was 328 people (72 women of
childbearing age, 72 male heads of
households, 72 elderly women, 54 THP,
32 TMW, 14 HP and 12 community
leaders.
11 focus groups were formed with at
least 5 participants and a maximum of
12 participants in each group: two
groups of women of childbearing age
over the age of 18, one for mothers
under the age of 18 (adolescents), one
for heads of households, one for elderly
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women over 45, one for community
leaders, one for THP, two of TMW and
two of HP.
Participants included had the following
criteria:
1. Women of reproductive age, pregnant
women, puerperal women over 17 years
of age.
2. Adolescents of reproductive age,
pregnant, puerperal women aged 17
years or less.
3. Head of household (parents, mothers-
in-law and grandparents).
4. Community leaders.
5. HP.
6. THP, TMW.
7. Those who are able and willing to
give informed consent.
Different variables and information
supports were used for each target group
in interview sheets with multiple choice
questions and answers (adapted Likert
scale):
1) Woman of childbearing age: age,
residence, household number, level of
schooling, number of pregnancies,
number of institutional births, number of
abortions; trimester of pregnancy in
which the first ANC was performed;
number of ANC visits during the last
pregnancy; number of follow-up visits
for the child during the first year; reason
for delay in prenatal and non-
institutional delivery (42 questions).
2) Elderly woman (mother in law or
grandmother): age, residence, number in
household, level of education; cause
invoked for delay in prenatal and non-
institutional delivery (41 questions).
3) Head of household: age, residence,
number of people in household, level of
education, occupation, number of
children (41 questions).
4) HP: age, gender, profession, position,
reasons for delayed ANC visits and non-
institutional delivery (40 questions).
5) THP / TMW: age, gender, residence,
reasons for delayed ANC visits and non-
institutional delivery (41 questions).
6) Community leader: age, gender, area
of residence, level of schooling, reason
for delayed ANC visits and non-
institutional delivery (41 questions).
7) Hospital indicators and statistics:
maternal and newborn statistical data
collection sheets.
Marrere, in the Administrative Post of
Natikiri, City and District of Nampula, is
located to the west of the city in plateau
zone, mainly of sedimentary soil with
granite outcrops and is crossed by six
Rivers (Namialo, Marrere, Muepelume,
Mussarne, Monapo, Mutivazi). Climate
is tropical humid (rainfall > 1,000 mm /
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year). Urbanization is deficient (minimal
roadways, water supply, domestic
sanitation and solid waste collection
system) and the population is mostly
dispersed, residing in precarious housing
of traditional model.
It is estimated that childbearing age
women population reaches 10,088
inhabitants (18 % of the total
population).
Traditional authorities play an important
role in social organization and culture
imposes rules and taboos related to
pregnancy, childbirth and newborns,
often with a negative impact on their
health.
MH is located in Marrere subdivision of
Natikiri, 12 km from the central part of
the city. It is associated with an HC, near
a secondary school and refers more
difficult health issues to Nampula
Central Hospital (NCH) in Nampula
city. The radius of the catchment area of
MH is about 15 km, with an estimated
population of 56,025. It provides
pediatric, maternity, emergency, general
medicine, basic surgery, radiology,
pharmacy, blood bank, vaccination
program, and administrative and support
services. It has a total of 140 in patient
beds. It serves as a site for nursing and
medical students training periods and,
participates in the training of allied HP
(students of the Health Sciences Institute
of Nampula). It is the referral hospital
for patients with tuberculosis in the
northern part of the country. In 2015,
1,560 births were attended. There are 12
beds for obstetrics and gynecology
services. The HP for the care of women
and newborns consist of four general
practitioners, eight nurses with maternity
training, six with basic maternity
training and four elementary midwives.
There are no Obstetrician /
Gynecologists at the hospital.
The interviews and focus groups were
done using a Macua (local language)
translator.
Data collection focused on the following
areas:
A) Challenges faced by pregnant women
in the community, preventing them from
accessing and joining ANC visits and
monitoring during the puerperium and
neonatal period.
B) Challenges faced by pregnant women
on the way to the HC / MH, preventing
them from accessing and joining ANC’s
and follow-up during the puerperium
and neonatal period.
C) Challenges faced by pregnant women
in the HC / MH, preventing them from
accessing and joining ANC visits and
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follow-up during the puerperium and
neonatal period.
D) What is there in communities, HC
and MH that is working well and what
should be improved in relation to
pregnancy, childbirth and neonatal
period?
E) Existing traditional knowledge in the
community related to pregnancy,
childbirth and birth.
F) Perception of mothers, pregnant
women, postpartum women on ANC and
follow-up during the puerperium and
neonatal period.
G) Perception of parents and community
leaders about ANC visits and follow-up
during the puerperium and neonatal
period.
H) Perception of TMW and THP on
ANC visits and follow-up during the
puerperium and neonatal period.
I) HP perception about ANC visits and
follow-up during the puerperium and
neonatal period.
Data were collected by a team of
research assistants composed of students
of the UniLúrio medical and nursing
courses who speak the local language
(Macua) after theoretical and practical
training, including pre-testing of data
collection instruments.
Participants were interviewed in their
most comfortable language (Portuguese
or Macua) to improve understanding of
the questions and the elaboration of the
answers. To maximize the freedom to
speak and eliminate problems of gender
bias, repression and domination,
participants were interviewed separately
by gender.
Data qualitative analysis was thematic.
The transcripts of the research assistants
were typed in Microsoft Excel format
and processed. Afterwards the
summaries of the main ideas and
observations were organized according
to the opinion of the majority.
The study was authorized by HSF Board
and Scientific Committee, NPHD, the
Secretariat of the Administrative Post of
Natikiri, the Lúrio University
Institutional Health Bioethics Committee
and the Bioethics Committee of the
University of Saskatchewan, following
all Helsinki Declaration (2013)
recommendations.
No changes were made in the study
procedures to the initial protocol.
3. Results
300 people were surveyed (see Table I) and 11 FGD were held (see Table II).
Table I: sample of subjects interviewed.
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Women of Childbearing Age
77
Male Heads of Households
78
Older Women
75
TMW and THP
46
Community Leaders
15
Maternal Child Health nurses
9
Total
300
Table II: focus groups discussions.
Women of Childbearing age
1
Male Heads of households
1
Adolescent mothers
1
Older Women
1
Community Leaders
1
TMW
2
THP
2
Maternal Newborn care nurses
2
Total
11
The answers on the questionnaire were
classified using the Likert scoring
system
(Always = 1, Sometimes = 2, Never =
3). The mean and standard deviation for
each response was calculated and
compared between groups. Consistent
themes emerged across all groups and
were supported by data from shared
testimonies in the FGD. The consistent
themes found were:
1. Limited knowledge about maternal
health and family planning (FP) needs.
2. Lack of transportation to access
maternal newborn health care.
3. Poor quality of maternal health care.
4. Continued need for government
support and funding for maternal
newborn care.
Due to the limited knowledge and access
to FP women become pregnant again a
very short time after delivery. Nurses (to
a greater extent) and men (to a lesser
extent) recognize this concern (see Table
III). A maternal newborn nurse in the
focus group justifies this situation:
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"There are mothers who forbid
daughters to continue the FP because
they want grandchildren and say that
contraceptives spoil the girls'
reproductive system."
Table III: spacing between pregnancies.
N
x
s.d.
78
2.08
0.79
77
1.82
0.66
75
1.85
0.73
15
1.67
0.62
9
1.33
0.50
46
1.85
0.69
Another recognized problem is the high
frequency of early pregnancy; a
community leader in a FGD said:
"The issue of early pregnancy is
worrying and those in the community do
not know how to overcome this problem,
but people in the community care a lot."
Women find it difficult to access health
care because transport options are
limited. All groups reported that women
go on foot to consultations and rarely
went by public transport or by car.
Unsafe travel conditions were also cited
as one of the main concerns (see Table
IV). A community leader participating in
a FCD summarized the situation:
"They require lights on public roads and
paths. This could make it easier for
people to go to the hospital at night, and
it would also help if a woman gives birth
on the way to the hospital ".
Table IV: access to care for pregnant women.
Question: Do women go to antenatal visits on foot? 1= always,
2 = sometimes 3 = never
Group
N
x
s.d.
Men
78
1.67
0.62
Women of Childbearing Age
77
1.41
0.61
Older Women
75
1.52
0.81
Community Leaders
15
1.40
0.57
Maternal Newborn nurses
9
1.78
0.44
TMW and THP
46
1.41
0.69
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The quantitative results did not provide a
clear picture of the HC experience of
maternal and newborn health care.
However, qualitative evidence
demonstrates knowledge of specific
difficulties for quality health care. A
FGD participant parent said:
"When I arrived with my wife, the
maternal health nurse did not greet us
sympathetically and I could say she
despised us, perhaps because we seemed
very poor."
A THP said:
"Once there was a woman in labor and
the maternal newborn nurse simply
abandoned her and went to bed. When
the TMW tried to help her, the maternal
newborn nurse threatened to leave the
woman in labor and also insulted the
TMW ".
One parent reinforces:
"When I arrived with my pregnant wife
crying in pain, the maternal newborn
nurse said to my wife laughingly: you
are crying now, but what were you
thinking when you were doing these
things (sex)?”
A community leader adds,
"One of the mothers said that when she
was pregnant, at the time of delivery,
after being admitted, the maternity nurse
asked if she had any money. She asked
how much, but the maternity nurse did
not answer but left her alone during
labor and she gave birth alone. She just
called the maternity nurse to finish the
rest. "
Maternal, neonatal and child health, in
the opinion of the participants, is
considered a priority for the Government
of Mozambique. This result is evident
both in the quantitative data (see Table
V) and in the FGD.
Table V: how does the Government value maternal and newborn health?
Question: Maternal health is an important priority for the
government 1= always 2 = sometimes 3 = never
Group
N
x
s.d.
Men
78
1.83
1.21
Women of Childbearing Age
77
1.62
1.00
Older Women
75
1.23
0.56
Community Leaders
15
1.27
0.46
Maternal newborn nurses
9
2.11
0.78
TMW and THP
46
1.61
1.02
But the continuing need for Government
support and funding of policies for
maternal and newborn care is also
recognized. A maternal newborn nurse
participant in a FGD said:
"The Ministry of Health should continue
to require husbands to accompany their
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wives to ANC visits because FP is
explained in detail in these visits."
One community leader said:
"One of the biggest problems is that
TMW do not feel valued or recognized in
the HC and do not receive any payment.
They work but receive nothing in return
and are requesting, at least, some
payment."
A parent head of household said:
"Sometimes the Government provides
some support to the community, like
mosquito nets and meals for children or
pregnant women, to combat
malnutrition, however, there is a need
for transparency in distribution so that
community leaders and HP do not
prevent supplies from reaching the
community and keep them for personal
gain."
The main results can be summarized in
the themes that were consistently present
in all FGD:
1. Long walking distances required to
get to the HC or MH.
2. Unsafe travel conditions for women
who walk alone.
3. Bad treatment in HC including illicit
payments and bribes.
4. Long waits to be attended in the HC
or MH.
5. HP poor training and knowledge.
6. Neglect and lack of family centered
care.
7. Women who become pregnant very
soon after their last birth or at very
young age.
8. Inability of women to make informed
decisions about FP.
9. Continued practices of home births
and traditional methods of treatment.
10. Myths and cultural taboos about
pregnancy and newborn care.
11. Limited knowledge and
understanding among women and the
community regarding the health needs of
women and young people.
12. Need for "Maternity Waiting homes"
near the hospital for pregnant women.
13. Weak Government policies and little
funding to support MCH care.
FGD participants identified priorities for
maternal and newborn health:
1) Transportation options to meet the
long distances needed to reach the HC.
2) Lack of attendance at ANC visits and
neglect of maternal care needs.
3) Poor and insufficient service in MH.
4) Lack of qualified HP in childbirth
care.
5) The need for Government policies to
support adherence to maternal care and
respectful treatment for mothers.
4.Discussion
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International literature review
identifying factors causing delay in the
search for care and treatment by
pregnant and newborn confirm this study
results:
18
,
19
,
20
,
21
,
22
,
23
,
24
,
25
,
26
,
27
,
28
,
29
,
30
,
31
,
32
,
33
,
34
,
35
,
36
,
37
,
38
,
39
,
40
,,
41
,
42
,
43
,
44
,
45
,
46
,
47
,
48
,
49
, ,
50
,
51
,
52
,
53
,
54
,
55
1) Delay in the decision to seek care:
a) Decision to seek health care is
dependent on husband.
b) Decision to use FP is
dependent on husband.
c) Lack of knowledge of
pregnancy warning signs.
d) Lack of basic knowledge
about SRH.
e) Lack of support for household
chores.
f) Lack of confidence in the
health system.
g) Cultural taboos and witchcraft.
56
h) Poor participation of men in
maternal and neonatal care.
i) High cost of health services.
2. Delay on arrival at HC:
a) Long distance to HC.
b) Lack of money for
transportation payment.
c) Lack of means of transport.
d) Conditional authorization to
seek health care.
e) Do not have a trusted or
supportive person.
3. Delay in providing quality care
a) Hospital lacking HP.
b) Hospital lack of resources.
c) Maternal newborn nurse
professional negligence.
d) Maternal newborn nurse
professionals with poor training.
e) Maternal newborn nurse
services not being a Government
priority.
5. Conclusion
The baseline study and consultations
with local community and institutional
partners, indicate six intervention lines,
evidence based, that might reverse the
problems identified. These are:
1. Expanding FP especially with
adolescents.
2. Community based transport system
for pregnant women.
3. Strengthening maternal and child
health services by training maternity
personnel in Obstetrical Emergency
care (EmOC) and neonatal
resuscitation (Helping Babies
Breath).
4. Providing four quality prenatal
visits.
5. Providing quality cesarean
deliveries.
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6. Supporting the Mozambican
government's campaign against
bribery.
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... These target groups have high morbidity and mortality rates, far from the Sustainable Development Goals, and might be now in higher risk with the response to The Alert Community for a Prepared Hospital implementation research (ACPH), a partnership between the Faculty of Health Science (FHS) of Lúrio University (UniLúrio) with the University of Saskatchewan in Canada, and Nampula Provincial Health Board, is promoting in Natikiri, Nampula, for the last four years, access to maternal, child and adolescent health care, at Marrere General Hospital (MGH) and Marrere Health Centre (MHC). 8 The base line study' designed strategies, were to empower local communities and leaders, including traditional birth attendants (TBAs), on sexual and reproductive health (SRH), SRH rights and participation in health services, contraceptives and FP, implement a motorcycle ambulance transport system for delivering women, and training HPs on obstetric risk, new-born resuscitation, humanized care, patient centred consultation, family friendly visit and obstetric ultrasonography. 9 ...
Preprint
Full-text available
Background The Covid-19 pandemic limited access to health services in most countries, impacting negatively global health. Last March 2020 in Mozambique, a public state of emergency restrained people’s movements, reduced public services, and launched a national information campaign. The Alert Community for a Prepared Hospital implementation research, has been promoting access to maternal and child health care, at Marrere General Hospital and Marrere Health Centre, in Natikiri, Nampula, the city with the third highest incidence of Covid-19 in Mozambique. Our research aimed to assess the impact of Covid-19 on access to maternal and children health services in Nampula and estimate Alert Community for a Prepared Hospital project sustainability. Methods Mixed-methods research, descriptive, cross-sectional, and retrospective, using review of patient visits documentation, comparing March to May 2019 to same months in 2020, and interviews with health professionals, traditional birth attendants and patients. We involved two health centres and two hospitals. The two Marrere centres were Alert Community for a Prepared Hospital intervention centres, and the other two were control centres, compared using KrushKall Wallis, One-way Anova, mean and standard deviation tests. Results Comparing 2019 maternal health services indicators with those from 2020, the intervention area had decreases of 28% in family planning visits, 26% in women in first ante-natal visits in the first trimester, and a 74% increase in home deliveries, all without statistical significance. The decrease in hospital maternity deliveries (4%) was statistically significant (p=0.046). The non-intervention area showed a decrease in women in first ante-natal visits in the first trimester (12%). Concerning child health, the intervention area had a 20% reduction in children presenting for vaccination and an 18% in children completely vaccinated, comparable to a reduction of 16% in the non-intervention area. Interviews revealed that most health professionals, traditional birth attendants and patients, have adequate knowledge about Covid-19. Conclusion Our results demonstrate negative collateral effects of Covid-19 on maternal and child health access and a deficient health information system in Mozambique. The Government’s media campaign promoting access to preventive health services, is not achieving its aim. The Alert Community project will need further research, to assess lasting effect on reducing the negative effects of Covid-19 on sexual and reproductive health. Trial registration This study was not registered in any data base.
... A baseline study showed a low level of knowledge about SRH and rights in the Natikiri population and poor family planning (FP) practice. 11 Project activities stimulated community participation and SRH and FP education, and also provided trainings for HPs in obstetric emergencies, new born resuscitation, SRH rights, ante-natal consultation and humanization of care in Marrere General Hospital (MGH). One echograph and some other equipment and consumables were also provided to the maternity. ...
Preprint
Full-text available
Background Maternity service quality is essential to reduce maternal and new-born morbidity and mortality (extremely high in Africa, including Mozambique). In Mozambique, maternal mortality rate is 451.6 maternal deaths per 100000 live births (2017). The reasons for this are complex, but one important factor to reduce this burden is ensuring the quality of maternity services, with the availability of efficient care, to improve institutional deliveries. To contribute to reduce maternal and new-born mortality rates in Natikiri, Nampula, the Lúrio University and the University of Saskatchewan, carried out an implementation research, including training activities for health professionals in maternal and child health care. We planned a mid-project evaluation, to assess the impact of the trainings, on the quality of services at Marrere Hospital Maternity.Methods Quantitative pre-post study, applying two cross-sectional surveys about maternity service quality, one of the surveys being conducted after five health professionals’ trainings and the other after six more trainings. The two surveys included samples of post-partum women in the maternity, calculated with a 10% margin error and 90% confidence interval for the first survey, and with a 7% margin error and 95% confidence interval for the second. The surveys were entered into REDCap and analysed to assess frequency, percentage, mean and standard deviation. This research was approved by the Institutional Committees of Bioethics at Lúrio University and at the University of Saskatchewan.Results116 post-partum women were surveyed at the maternity, assessing standards of patient centred care during delivery labour. Most areas showed no improvement. Some positive improvements were: delivering women were given the option to have a person of their choice to accompany them during labour (75%), notably a traditional birth attendant (34%), and they had continuous support from an health professional (68%). But many shortcomings persisted in areas of privacy (33%), and confidentiality (57%). Conclusion The quality of patient centred care at Marrere General Hospital Maternity, did not improve with health professionals training. Decreasing the large turnover rate, and reviewing health professionals learning styles, promoting continuous professional capacity building, would be the next steps to improve quality of patient centred care.Trial registrationThis study was not registered in any data base.
... A baseline study showed a low level of knowledge about sexual and reproductive health (SRH) and rights in the Natikiri population and poor family planning (FP) practice. 15 Project activities stimulated community participation and SRH and FP education, empowering population health knowledge, attitudes and practice. Another strategy was to improve training of HPs in obstetric emergencies, new born resuscitation, SRH rights, ante-natal consultation and humanization of care in Marrere Health Centre (MHC); some equipment and supplies were also provided, knowing that most newborn deaths can be prevented by effective interventions. ...
Preprint
Full-text available
Background New-born morbidity and mortality are high in Africa, including Mozambique. One important factor to reduce this public health burden is ensuring the frequency and quality of new-born visits, with the availability of efficient, timely, patient centred care. To contribute to the reduction of new-born mortality rate in Nampula, the Lúrio University and the University of Saskatchewan, carried out an implementation research project which included training activities for health professionals in maternal and child health care. We planned a mid-project evaluation, to assess the impact of health professionals training on the quality of services at Marrere Health Centre. Methods Quantitative study, applying two cross-sectional surveys about new-born visits service quality. The first surveys were conducted after two health professionals’ training sessions and the other after five more sessions. The samples of carers of infants up to 28 days of age in Marrere Health Centre, were calculated considering the average number of post-partum visits per month (47 in 2018, with a margin of error of 10% and a confidence interval of 90 %, 134 in 2019, with a margin of error of 5% and a confidence interval of 95%). The individual surveys used a five-point Likert scale and were entered into REDCap, and analysed to assess frequency, percentage, mean and standard deviation. This research was approved by the bioethics committees at Lúrio University and at the University of Saskatchewan. Results 188 child carers were surveyed at Marrere Health Centre, about new-born services quality. Most areas showed no improvement. Positive improvements were a 48% increase in health professionals encouraging mothers to share any difficulties during the patient encounter, a 31% increase in encouraging mothers to have a person of their choice to accompany them during labour, suggesting a traditional birth attendant (97%). Many shortcomings persisted in practices of introducing themselves, communication with patients, privacy, and confidentiality. Conclusion The quality of care at Marrere Health Centre did not improve and health professionals are not practising according to the protocol. Reviewing health professionals learning approach, developing continuous capacity building, would be the next best steps to improve quality of new-born centred care. Trial registration This study was not registered in any data base.
... This approach allowed the design of 7 strategies and 20 objectives, to be achieved with 80 different targets. 2 The implementation research method involves scheduled and repeated intermediate evaluations, with data collection through surveys, interviews and focus groups discussions, taking place in health units, at the university campus, at secondary schools, at family houses and other public facilities. By complying with the ethical guidelines of the Helsinki Declaration, participants receive detailed information about the project (vocal explanation, written information sheet to the participant, answers to personal questions), understand the objectives and methods (informed consent form), presenting doubts and comments to respondents and interviewers at the end of data collection. ...
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Mozambique has high maternal and new-born mortality rates. The Alert Community for a Prepared Hospital care continuum project is an implementation research, aiming to reduce maternal and new-born mortality rates in Natikiri, Nampula, Northern Mozambique. Target groups (women, adolescents, heads of families, religious leaders, community leaders, traditional midwives, counsellors of initiation rites, traditional healers, secondary school pupils and teachers) were submitted to repeated intermediate evaluations (surveys, interviews and focus groups discussions), improving knowledge, attitude and practice on sexual and reproductive health and rights and family planning. Implementation research methods were an efficient extension tool in population health education and health and educational professionals vocational training.
... Project activities target community participation and education, HP training and antenatal and maternity technological improvements. The baseline study showed a low knowledge level of SRH in the Natikiri community and low use and practice of FP. 10 Therefore, one strategy of this project is to share key maternal and child health (MCH) messages (FP is beneficial and important and attend at least four prenatal consultations; institutional delivery is beneficial and important and attend two postnatal visits), using a media campaign and trained community volunteers. ...
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Objective To increase knowledge, attitudes and practice of sexual and reproductive health and family planning and to reduce maternal and neonatal mortality rates in Mozambique. Design An implementation research project’s intermediate evaluation, applying two cross-sectional surveys. The surveys were planned for 316 subjects before and after interventions. Setting Research performed in Natikiri district of Nampula province in northern Mozambique, targeting a suburban and rural populations in their homes. Participants 452 people were surveyed (91 before, 361 after), all belonging to the Macua ethnic group. Interventions A media campaign (2 weekly radio spots, bimonthly theatre performances) was performed for 8 months (2017 to 2018) and family health champions’ teachings (monthly home visits) performed for 3 months, on sexual and reproductive health and family planning. Outcome measures planned and measured were adolescent’s and adult’s knowledge, attitudes and practice about those. Data were analysed by gender, age group and frequencies, using a CI of 95% (p<0.5 statistically significant). Results Radio spots, community theatre and volunteer champions increased population’s knowledge about sexual and reproductive health and led to a more positive attitude toward family planning. Concerning attitude, results show differences between adults’ proportions before and after: (1) did you hear about sexual and reproductive health (p=0.0425); (2) knows project key messages (p<0.001); (3) knows prenatal visits importance (p=0.0301); (4) access to contraceptives was easy (p<0.001). Adolescents showed statistically significant differences before and after: (1) knows project key messages (p<0.001); (2) access to contraceptives was easy (p=0.0361). Family planning practice did not increase in both groups. Conclusion A health education intervention, using a media campaign and local volunteers, is useful to promote mother and child health. There is an unmet need for family planning and the use of modern contraception is below desired practice, needing further research about cultural barriers. Communication for behaviour change activities will pursue and impact will be assessed to document family planning practice improvement.
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Background The Covid-19 pandemic has so far infected more than 30 million people in the world, having major impact on global health with collateral damage. In Mozambique, a public state of emergency was declared at the end of March 2020. This has limited people’s movements and reduced public services, leading to a decrease in the number of people accessing health care facilities. An implementation research project, The Alert Community for a Prepared Hospital, has been promoting access to maternal and child health care, in Natikiri, Nampula, for the last four years. Nampula has the second highest incidence of Covid-19. The purpose of this study is to assess the impact of Covid-19 pandemic Government restrictions on access to maternal and child healthcare services. We compared health centres in Nampula city with healthcare centres in our research catchment area. We wanted to see if our previous research interventions have led to a more resilient response from the community. Methods Mixed-methods research, descriptive, cross-sectional, retrospective, using a review of patient visit documentation. We compared maternal and child health care unit statistical indicators from March–May 2019 to the same time-period in 2020. We tested for significant changes in access to maternal and child health services, using KrushKall Wallis, One-way Anova and mean and standard deviation tests. We compared interviews with health professionals, traditional birth attendants and patients in the two areas. We gathered data from a comparable city health centre and the main city referral hospital. The Marrere health centre and Marrere General Hospital were the two Alert Community for a Prepared Hospital intervention sites. Results Comparing 2019 quantitative maternal health services access indicators with those from 2020, showed decreases in most important indicators: family planning visits and elective C-sections dropped 28%; first antenatal visit occurring in the first trimester dropped 26%; hospital deliveries dropped a statistically significant 4% (p = 0.046), while home deliveries rose 74%; children vaccinated down 20%. Conclusion Our results demonstrated the negative collateral effects of Covid-19 pandemic Government restrictions, on access to maternal and child healthcare services, and highlighted the need to improve the health information system in Mozambique.
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Background: High maternal and neonatal mortality rates in Mozambique, are due to adolescent pregnancies, difficulties in accessing health services, traditional constraints, and gender inequalities. An implementation research project, Alert Community to Prepared Hospital in Natikiri, Nampula, Mozambique was developed to reduce maternal and new-born mortality. From 2016 to 2020, it implemented activities to improve population knowledge and function in sexual and reproductive health, and to enable community participation in maternal health services. In this paper we will assess and discuss the impact of community participation on improving sexual and reproductive health. Methods: Implementation research with community intervention and programmed mid-term evaluations, using mixed methods research, with descriptive quantitative surveys and qualitative focus groups discussions and interviews, applied from 2017 to 2020. Local health committees, traditional birth attendants, traditional healers and local leadership all participated: trained in sexual and reproductive health and participated in radio discussion groups; community and hospital members of the co-management committee enabled local programming. Maternal and child health indicators were evaluated with health unit’s operational data. Quantitative data were captured in Microsoft Office Excel, analysed with SPSS21 to find frequency, percentage, mean and standard deviation; qualitative data registered in Word was analysed with NVIVO. This research received bioethical approvals from both the Mozambique and Canadian universities and followed Helsinki Declaration recommendations. Results: Comparing changes from 2016 to 2019, the number of health committees operating in Natikiri rose from 7 to 20. Each committee integrated four Family Health Champions, who attained 24738 residents with health education interventions on reproductive health. A theatre group developed dramas about the same key messages, presented in communities. Population access to contraceptives was facilitated, from 42% to 91% in women and from 65% to 90% in men. At Marrere Health Centre, women with four ante-natal visits rose by 185%, and children less than one year of age’ visits 89%; at Marrere General Hospital deliveries rose 60%. Conclusion: Community participation, at all levels of maternal and child health service care continuum, from community to hospital, enhanced with complementary interventions well contextualised, is effective in improving adolescent and adult sexual and reproductive health. Trial registration This study was not registered in any data base.
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Background: Rates of caesarean section have steadily increased in most middle- and high-income countries over the last few decades without medical justification. Maternal request is one of the frequently cited non-medical factors contributing to this trend. The objectives of this study were to assess pregnant women's preferences regarding mode of delivery and to compare actual caesarean section rates in the public and private sectors. Methods: A prospective cohort study was conducted in two public and three private hospitals in Buenos Aires, Argentina. 382 nulliparous pregnant women (183 from the private sector and 199 from the public sector) aged 18 to 35 years, with single pregnancies over 32 weeks of gestational age were enrolled during antenatal care visits between October 2010 and September 2011. We excluded women with pregnancies resulting from assisted fertility, women with known pre-existing major diseases or, with pregnancy complications, or with a medical indication of elective cesarean section. We used two different approaches to assess women's preferences: a survey using a tailored questionnaire, and a discrete choice experiment. Results: Only 8 and 6% of the healthy nulliparous women in the public and private sectors, respectively, expressed a preference for caesarean section. Fear of pain and safety were the most frequently expressed reasons for preferring caesarean section. When reasons for delivery mode were assessed by a discrete choice experiment, women placed the most emphasis on sex after childbirth. Of women who expressed their preference for vaginal delivery, 34 and 40% ended their pregnancies by caesarean section in public and private hospitals, respectively. Conclusions: The preference for caesarean section is low among healthy nulliparous women in Buenos Aires. The reasons why these women had a rate of more than 35% caesarean sections are unlikely related to their preferences for mode of delivery.
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Key lessons can be drawn from innovative approaches that have been implemented to ensure access to better antenatal care (ANC) and postnatal care (PNC). This paper examines the successes and challenges of ANC and PNC delivery models in several settings around the world; discusses the lessons to be learned from them; and makes recommendations for future programmes. Based on this review, we conclude that close monitoring of ANC and PNC quality and delivery models, health workforce support, appropriate use of electronic technologies, integrated care, a woman-friendly perspective, and adequate infrastructure are key elements of successful programmes that benefit the health and wellbeing of women, their newborns and families. However, a full evaluation of care delivery models is needed to establish their acceptability, accessibility, availability and quality. Tweetable abstract: New paper examines global innovations in antenatal/postnatal care @MHTF @ICS_Integrare #MNCH #healthsystems.
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Maternal mortality remains a daunting problem in Mozambique and many other low-resource countries. High quality antenatal care (ANC) services can improve maternal and newborn health outcomes and increase the likelihood that women will seek skilled delivery care. This study explores the factors influencing provider uptake of the recommended package of ANC interventions in Mozambique. This study used qualitative research methods including key informant interviews with stakeholders from the health sector and a total of five focus group discussions with women with experience with ANC or women from the community. Study participants were selected from three health centers located in Maputo city, Tete, and Cabo Delgado provinces in Mozambique. Staff responsible for the medicines/supply chain at national, provincial and district level were interviewed. A check list was implemented to confirm the availability of the supplies required for ANC. Deductive content analysis was conducted. Three main groups of factors were identified that hinder the implementation of the ANC package in the study setting: a) system or organizational: include chronic supply chain deficiencies, failures in the continuing education system, lack of regular audits and supervision, absence of an efficient patient record system and poor environmental conditions at the health center; b) health care provider factors: such as limited awareness of current clinical guidelines and a resistant attitude to adopting new recommendations; and c) Users: challenges with accessing ANC, poor recognition amongst women about the purpose and importance of the specific interventions provided through ANC, and widespread perception of an unfriendly environment at the health center. The ANC package in Mozambique is not being fully implemented in the three study facilities, and a major barrier is poor functioning of the supply chain system. Recommendations for improving the implementation of antenatal interventions include ensuring clinical protocols based on the ANC model. Increasing the community understanding of the importance of ANC would improve demand for high quality ANC services. The supply chain functioning could be strengthened through the introduction of a kit system with all the necessary supplies for ANC and a simple monitoring system to track the stock levels is recommended.
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Family planning contributes significantly to the prevention of maternal and child mortality. However, many women still do not use modern contraception and the numbers of unintended pregnancies, abortions and subsequent deaths are high. In this paper, we estimate the service delivery costs of scaling up modern contraception, and the potential impact on maternal, newborn and child survival in South Africa. The Family Planning model in Spectrum was used to project the impact of modern contraception on pregnancies, abortions and births in South Africa (2015-2030). The contraceptive prevalence rate (CPR) was increased annually by 0.68 percentage points. The Lives Saved Tool was used to estimate maternal and child deaths, with coverage of essential maternal and child health interventions increasing by 5% annually. A scenario analysis was done to test impacts when: the change in CPR was 0.1% annually; and intervention coverage increased linearly to 99% in 2030. If CPR increased by 0.68% annually, the number of pregnancies would reduce from 1.3 million in 2014 to one million in 2030. Unintended pregnancies, abortions and births decrease by approximately 20%. Family planning can avert approximately 7,000 newborn and child and 600 maternal deaths. The total annual costs of providing modern contraception in 2030 are estimated to be US$33 million and the cost per user of modern contraception is US$7 per year. The incremental cost per life year gained is US$40 for children and US$1,000 for mothers. Maternal and child mortality remain high in South Africa, and scaling up family planning together with optimal maternal, newborn and child care is crucial. A huge impact can be made on maternal and child mortality, with a minimal investment per user of modern contraception.
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Background: Postpartum maternal and infant mortality is high in sub-Saharan Africa and improving postpartum care as a strategy to enhance maternal and infant health has been neglected. We describe the design and selection of suitable, context-specific interventions that have the potential to improve postpartum care. Methods: The study is implemented in rural districts in Burkina Faso, Kenya, Malawi and Mozambique. We used the four steps 'systems thinking' approach to design and select interventions: 1) we conducted a stakeholder analysis to identify and convene stakeholders; 2) we organised stakeholders causal analysis workshops in which the local postpartum situation and challenges and possible interventions were discussed; 3) based on comprehensive needs assessment findings, inputs from the stakeholders and existing knowledge regarding good postpartum care, a list of potential interventions was designed, and; 4) the stakeholders selected and agreed upon final context-specific intervention packages to be implemented to improve postpartum care. Results: Needs assessment findings showed that in all study countries maternal, newborn and child health is a national priority but specific policies for postpartum care are weak and there is very little evidence of effective postpartum care implementation. In the study districts few women received postpartum care during the first week after childbirth (25 % in Burkina Faso, 33 % in Kenya, 41 % in Malawi, 40 % in Mozambique). Based on these findings the interventions selected by stakeholders mainly focused on increasing the availability and provision of postpartum services and improving the quality of postpartum care through strengthening postpartum services and care at facility and community level. This includes the introduction of postpartum home visits, strengthening postpartum outreach services, integration of postpartum services for the mother in child immunisation clinics, distribution of postpartum care guidelines among health workers and upgrading postpartum care knowledge and skills through training. Conclusion: There are extensive gaps in availability and provision of postpartum care for mothers and infants. Acknowledging these gaps and involving relevant stakeholders are important to design and select sustainable, context-specific packages of interventions to improve postpartum care.
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This study explores the consequences of a maternal death to households in rural Western Kenya focusing particularly on the immediate financial and economic impacts. Between September 2011 and March 2013 all households in the study area with a maternal death were surveyed. Data were collected on the demographic characteristics of the deceased woman; household socio-economic status; a history of the pregnancy and health care access and utilization; and disruption to household functioning due to the maternal death. These data were supplemented by in-depth and focus group discussions. The health service utilization costs associated with maternal deaths were significantly higher, due to more frequent service utilization as well as due to the higher cost of each visit suggesting more involved treatments and interventions were sought with these women. The already high costs incurred by cases during pregnancy were further increased during delivery and postpartum mainly a result of higher facility-based fees and expenses. Households who experienced a maternal death spent about one-third of their annual per capita consumption expenditure on healthcare access and use as opposed to at most 12% among households who had a health pregnancy and delivery. Funeral costs were often higher than the healthcare costs and altogether forced households to dis-save, liquidate assets and borrow money. What is more, the surviving members of the households had significant redistribution of labor and responsibilities to make up for the lost contributions of the deceased women. Kenya is in the process of instituting free maternity services in all public facilities. Effectively implemented, this policy can lift a major economic burden experienced by a very large number of household who seek maternal health services which can be catastrophic in complicated cases that result in maternal death. There needs to be further emphasis on insurance schemes that can support households through catastrophic health spending.
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Developing countries account for 99 percent of maternal deaths annually. While increasing service availability and maintaining acceptable quality standards, it is important to assess maternal satisfaction with care in order to make it more responsive and culturally acceptable, ultimately leading to enhanced utilization and improved outcomes. At a time when global efforts to reduce maternal mortality have been stepped up, maternal satisfaction and its determinants also need to be addressed by developing country governments. This review seeks to identify determinants of women’s satisfaction with maternity care in developing countries. The review followed the methodology of systematic reviews. Public health and social science databases were searched. English articles covering antenatal, intrapartum or postpartum care, for either home or institutional deliveries, reporting maternal satisfaction from developing countries (World Bank list) were included, with no year limit. Out of 154 shortlisted abstracts, 54 were included and 100 excluded. Studies were extracted onto structured formats and analyzed using the narrative synthesis approach. Determinants of maternal satisfaction covered all dimensions of care across structure, process and outcome. Structural elements included good physical environment, cleanliness, and availability of adequate human resources, medicines and supplies. Process determinants included interpersonal behavior, privacy, promptness, cognitive care, perceived provider competency and emotional support. Outcome related determinants were health status of the mother and newborn. Access, cost, socio-economic status and reproductive history also influenced perceived maternal satisfaction. Process of care dominated the determinants of maternal satisfaction in developing countries. Interpersonal behavior was the most widely reported determinant, with the largest body of evidence generated around provider behavior in terms of courtesy and non-abuse. Other aspects of interpersonal behavior included therapeutic communication, staff confidence and competence and encouragement to laboring women. Quality improvement efforts in developing countries could focus on strengthening the process of care. Special attention is needed to improve interpersonal behavior, as evidence from the review points to the importance women attach to being treated respectfully, irrespective of socio-cultural or economic context. Further research on maternal satisfaction is required on home deliveries and relative strength of various determinants in influencing maternal satisfaction.
Article
Background: The World Health Organization (WHO) is in the process of updating antenatal care (ANC) guidelines. Objectives: To map the existing clinical practice guidelines related to routine ANC for healthy women and to summarise all practices considered during routine ANC. Search strategy: A systematic search in four databases for all clinical practice guidelines published after January 2000. Selection criteria: Two researchers independently assessed the list of potentially eligible publications. Data collection and analysis: Information on scope of the guideline, type of practice, associated gestational age, recommendation type and the source of evidence were mapped. Main results: Of 1866 references, we identified 85 guidelines focusing on the ANC period: 15 pertaining to routine ANC and 70 pertaining to specific situations. A total of 135 interventions from routine ANC guidelines were extracted, and categorised as clinical interventions (n = 80), screening/diagnostic procedures (n = 47) and health systems related (n = 8). Screening interventions, (syphilis, anaemia) were the most common practices. Within the 70 specific situation guidelines, 102 recommendations were identified. Overall, for 33 (out of 171) interventions there were conflicting recommendations provided by the different guidelines. Conclusion: Mapping the current guidelines including practices related to routine ANC informed the scoping phase for the WHO guideline for ANC. Our analysis indicates that guideline development processes may lead to different recommendations, due to context, evidence base or assessment of evidence. It would be useful for guideline developers to map and refer to other similar guidelines and, where relevant, explore the discrepancies in recommendations and others. Tweetable abstract: We identified existing ANC guidelines and mapped scope, practices, recommendations and source of evidence.
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In Tanzania, maternal mortality is high and coverage with health facility delivery low, despite efforts to reduce barriers to utilization. Disrespect and abuse during childbirth has not been explored as a contributor to delivery satisfaction or as a deterrent to institutional delivery. We assessed the association between reported disrespectful treatment during childbirth and delivery satisfaction, perceived quality of care, and intention to deliver at the same facility in the future. Interviews using a structured questionnaire were conducted in Tanga Region, Tanzania with women on discharge from delivery at two hospitals. Disrespect and abuse was measured by asking women about specific disrespectful events during childbirth. Multivariable logistic regression models were used to assess the association between disrespect/abuse and (1) satisfaction with delivery, (2) perceived quality of care for delivery, and (3) intent to use the same facility for a future delivery, controlling for confounders. 1388 women participated in the survey (67 % response rate). Disrespect/abuse during childbirth was associated with lower satisfaction with delivery (OR 0.26, 95 % CI 0.19-0.36) and reduced likelihood of rating perceived quality of care as excellent/very good (OR 0.55, 95 % CI 0.35-0.85). Of women who planned to have more children (N = 766), those who experienced disrespect/abuse were half as likely to plan to deliver again at the same facility (OR 0.51, 95 % CI 0.32-0.82). Our study highlights disrespectful and abusive treatment during childbirth as an important factor in reducing women's confidence in health facilities. Improving interpersonal care must be an integral part of quality improvement in maternal health.