Showing papers in "BMC Pregnancy and Childbirth in 2011"
TL;DR: The study results show that place of residence, household wealth, education, ethnicity, parity, marital status and age at birth of the last child had strong influences on timing of first ANC visit and the type of delivery assistance received.
Abstract: Background: Use of maternal health services is an effective means for reducing the risk of maternal morbidity and mortality, especially in places where the general health status of women is poor. This study was guided by the following objectives: 1) To determine the relationship between timing of first antenatal care (ANC) visit and type of delivery assistance 2) To establish the determinants of timing of first ANC visit and type delivery assistance. Methods: Data used were drawn from the 2003 Kenya Demographic and Health Survey, with a focus on young women aged 15-24. The dependent variables were: Timing of first ANC visit coded as “None"; “Late” and “Early”, and type of delivery assistance coded as “None”; “Traditional Birth Attendant (TBA)” and “Skilled professional”. Control variables included: education, household wealth, urban-rural residence, ethnicity, parity, age at birth of the last child and marital status. Multivariate ordered logistic regression model was used. Results: The study results show that place of residence, household wealth, education, ethnicity, parity, marital status and age at birth of the last child had strong influences on timing of first ANC visit and the type of delivery assistance received. The major finding is an association between early timing of the first ANC visit and use of skilled professionals at delivery. Conclusion: This study confirms that timing of first antenatal care is indeed an important entry point for delivery care as young women who initiated antenatal care early were more likely to use skilled professional assistance at delivery than their counterparts who initiated ANC late. The results indicate that a large percentage of young pregnant women do not seek ANC during their first trimester as is recommended by the WHO, which may affect the type of assistance they receive during delivery. It is important that programs aimed at improving maternal health include targeting young women, especially those from rural areas, with low levels of education, higher parity and from poor households, given their high risk during pregnancy. The finding that a considerably high proportion of young women use TBAs as opposed to use of skilled professionals is baffling and calls for further research.
336 citations
TL;DR: Dietary advice during pregnancy appears effective in decreasing total GWG and long-term postpartum weight retention, but so far there is limited evidence for further benefits on infant and maternal health.
Abstract: Excessive weight gain during pregnancy and subsequent postpartum weight retention may contribute to the epidemic of obesity among women of childbearing age. Preventing excessive gestational weight gain (GWG) to optimize maternal, fetal and infant wellbeing is therefore of great importance. A number of dietary interventions in this area has been conducted with inconsistent results, which has made it difficult to identify effective strategies to prevent excessive weight gain during pregnancy among normal weight, overweight and obese women. The primary objective of this review was to evaluate the effect of dietary interventions for reducing GWG. The secondary objective was to examine the impact of these interventions on different child and maternal health outcomes. The PUBMED, the Cochrane Central Register of Controlled Trials (CENTRAL) and the LILACS databases were searched for relevant articles. All published randomized controlled trials (RCT) and quasi-randomized controlled trials (QCT), with concurrent controls, on dietary interventions during pregnancy were considered. Results were presented using relative risk (RR) for categorical data and weighted mean difference (WMD) for continuous data. Data were primarily analyzed with a fixed-effect model and a random-effects model was used in the presence of heterogeneity. No date and language restrictions were applied. In total, 13 studies were included in this review and 10 trials contributed data on total GWG. Dietary intervention significantly reduced total GWG (n = 1434; WMD = -1.92 kg; 95% CI = -3.65/-0.19; p = 0.03), weight retention at six months postpartum (n = 443; WMD = -1.90 kg; 95% CI = -2.69/-1.12; p < 0.0001) and incidence of cesarean section (n = 609; RR = 0.75; 95% CI = 0.60/0.94; p = 0.013). However, dietary intervention had no significant effect on weight retention at six weeks postpartum, birth weight, preeclampsia, gestational diabetes and preterm birth. Dietary advice during pregnancy appears effective in decreasing total GWG and long-term postpartum weight retention, but so far there is limited evidence for further benefits on infant and maternal health.
247 citations
TL;DR: The EBF rate in Nigeria is low and falls well short of the expected levels needed to achieve a substantial reduction in child mortality, and appropriate infant feeding practises are needed if Nigeria is to reach the child survival Millennium Development Goal.
Abstract: Exclusive breast feeding (EBF) has important protective effects on the survival of infants and decreases risk for many early-life diseases. The purpose of this study was to assess the factors associated with EBF in Nigeria. Data on 658 children less than 6 months of age were obtained from the Nigeria Demographic and Health Survey (NDHS) 2003. The 2003 NDHS was a multi-stage cluster sample survey of 7864 households. EBF rates were examined against a set of individual, household and community level variables using a backward stepwise multilevel logistic regression method. The average EBF rate among infants younger than 6 months of age was 16.4% (95%CI: 12.6%-21.1%) but was only 7.1% in infants in their fifth month of age. After adjusting for potential confounders, multivariate analyses revealed that the odds of EBF were higher in rich (Adjusted Odds Ratios (AOR) = 1.15, CI = 0.28-6.69) and middle level (AOR = 2.45, CI = 1.06-5.68) households than poor households. Increasing infant age was associated with significantly less EBF (AOR = 0.65, 95%CI: 0.51-0.82). Mothers who had four or more antenatal visits were significantly more likely to engage in EBF (AOR = 2.70, 95%CI = 1.04-7.01). Female infants were more likely to be exclusively breastfed than male infants (AOR = 2.13, 95%CI = 1.03-4.39). Mothers who lived in the North Central geopolitical region were significantly more likely to exclusively breastfeed their babies than those mothers who lived in other geopolitical regions. The EBF rate in Nigeria is low and falls well short of the expected levels needed to achieve a substantial reduction in child mortality. Antenatal care was strongly associated with an increased rate of EBF. Appropriate infant feeding practises are needed if Nigeria is to reach the child survival Millennium Development Goal of reducing infant mortality from about 100 deaths per 1000 live births to a target of 35 deaths per 1000 live births by the year 2015.
221 citations
TL;DR: It is indicated that no single magic bullet intervention exists for reduction of maternal mortality and that all interventional programs should be integrated in order to bring significant changes in resource limited countries.
Abstract: The burden of maternal mortality in resource limited countries is still huge despite being at the top of the global public health agenda for over the last 20 years. We systematically reviewed the impacts of interventions on maternal health and factors for change in these countries. A systematic review was carried out using the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles published in the English language reporting on implementation of interventions, their impacts and underlying factors for maternal health in resource limited countries in the past 23 years were searched from PubMed, Popline, African Index Medicus, internet sources including reproductive health gateway and Google, hand-searching, reference lists and grey literature. Out of a total of 5084 articles resulting from the search only 58 qualified for systematic review. Programs integrating multiple interventions were more likely to have significant positive impacts on maternal outcomes. Training in emergency obstetric care (EmOC), placement of care providers, refurbishment of existing health facility infrastructure and improved supply of drugs, consumables and equipment for obstetric care were the most frequent interventions integrated in 52% - 65% of all 54 reviewed programs. Statistically significant reduction of maternal mortality ratio and case fatality rate were reported in 55% and 40% of the programs respectively. Births in EmOC facilities and caesarean section rates increased significantly in 71% - 75% of programs using these indicators. Insufficient implementation of evidence-based interventions in resources limited countries was closely linked to a lack of national resources, leadership skills and end-users factors. This article presents a list of evidenced-based packages of interventions for maternal health, their impacts and factors for change in resource limited countries. It indicates that no single magic bullet intervention exists for reduction of maternal mortality and that all interventional programs should be integrated in order to bring significant changes. State leaders and key actors in the health sectors in these countries and the international community are proposed to translate the lessons learnt into actions and intensify efforts in order to achieve the goals set for maternal health.
183 citations
TL;DR: Pre-pregnancy obesity or excessive GWG are associated with greater risk of pregnancy complications, caesarean delivery and greater birth and placenta weight and it is vital that clinical practice considers excess GWG as another indicator of adverse pregnancy outcomes.
Abstract: It is relatively less known whether pre-pregnancy obesity and excess gestational weight gain (GWG) are associated with caesarean delivery, pregnancy complications, preterm birth, birth and placenta weights and increased length of postnatal hospital stay. We used a population-based cohort of 6632 women who gave birth in Brisbane, Australia, between 1981 and 1983. The independent associations of pre-pregnancy obesity, GWG and institute of medicine (IOM) categories of combined pre-pregnancy BMI and GWG with outcomes were examined using multivariable regression (for continuous outcomes) and multivariable multinomial regression (for categorical outcomes) models. We found women who were obese prior to pregnancy and women who gained excess weight during pregnancy were at greater risk for a pregnancy complications (OR: 2.10; 1.74, 2.54; age adjusted model), caesarean section (OR 1.29; 1.09, 1.54), higher birth weight difference (206.45 gm; 178.82, 234.08) and greater placental weight difference (41.16 gm; 33.83, 48.49) and longer length of hospital stay. We also found that mothers who gained inadequate weight or were underweight before pregnancy were at greater risk of preterm birth (2.27; 1.71, 3.00), lower risk of pregnancy complications (0.58; 0.44, 0.77) and had lower birth (-190.63;-221.05,-160.20) and placental (-37.16; -45.23,-29.09) weights. Results indicate that all associations remain consistent after adjustment for a range of potential confounding factors with the exception of the association between pre-pregnancy obesity and hospital stay. Pre-pregnancy obesity or excessive GWG are associated with greater risk of pregnancy complications, caesarean delivery and greater birth and placenta weight. Excess GWG is associated with a longer stay in hospital after delivery, independent of pre-pregnancy BMI, pregnancy complications and caesarean delivery. In addition to pre-pregnancy obesity, it is vital that clinical practice considers excess GWG as another indicator of adverse pregnancy outcomes.
182 citations
TL;DR: Prostaglandin E2 and vaginal misoprostol were more effective than oxytocin in bringing about vaginal delivery within 24 hours but were associated with more uterine hyperstimulation and membrane sweeping reduced post-term gestations.
Abstract: Background
Rates of labour induction are increasing. We conducted this systematic review to assess the evidence supporting use of each method of labour induction.
168 citations
TL;DR: There was insufficient evidence of adequate quality to recommend routine implementation of any of the programmes as a means of reducing infant mortality in disadvantaged/vulnerable women.
Abstract: Background: Infant mortality has shown a steady decline in recent years but a marked socioeconomic gradient persists. Antenatal care is generally thought to be an effective method of improving pregnancy outcomes, but the effectiveness of specific antenatal care programmes as a means of reducing infant mortality in socioeconomically disadvantaged and vulnerable groups of women has not been rigorously evaluated. Methods: We conducted a systematic review, focusing on evidence from high income countries, to evaluate the effectiveness of alternative models of organising or delivering antenatal care to disadvantaged and vulnerable groups of women vs. standard antenatal care. We searched Medline, Embase, Cinahl, PsychINFO, HMIC, CENTRAL, DARE, MIDIRS and a number of online resources to identify relevant randomised and observational studies. We assessed effects on infant mortality and its major medical causes (preterm birth, congenital anomalies and sudden infant death syndrome (SIDS)). Results: We identified 36 distinct eligible studies covering a wide range of interventions, including group antenatal care, clinic-based augmented care, teenage clinics, prenatal substance abuse programmes, home visiting programmes, maternal care coordination and nutritional programmes. Fifteen studies had adequate internal validity: of these, only one was considered to demonstrate a beneficial effect on an outcome of interest. Six interventions were considered ‘promising’. Conclusions: There was insufficient evidence of adequate quality to recommend routine implementation of any of the programmes as a means of reducing infant mortality in disadvantaged/vulnerable women. Several interventions merit further more rigorous evaluation.
162 citations
TL;DR: It is suggested that an internet-based lifestyle intervention program should be tested as a novel approach to prevent type 2 diabetes in postpartum women with a history of GDM.
Abstract: Women who develop gestational diabetes mellitus (GDM) have an increased risk for the development of type 2 diabetes. Despite this "window of opportunity," few intervention studies have targeted postpartum women with a history of GDM. We sought perspectives of women with a history of GDM to identify a) barriers and facilitators to healthy lifestyle changes postpartum, and b) specific intervention approaches that would facilitate participation in a postpartum lifestyle intervention program. We used mixed methods to gather data from women with a prior history of GDM, including focus groups and informant interviews. Analysis of focus groups relied on grounded theory and used open-coding to categorize data by themes, while frequency distributions were used for the informant interviews. Of 38 women eligible to participate in focus groups, only ten women were able to accommodate their schedules to attend a focus group and 15 completed informant interviews by phone. We analyzed data from 25 women (mean age 35, mean pre-pregnancy BMI 28, 52% Caucasian, 20% African American, 12% Asian, 8% American Indian, 8% refused to specify). Themes from the focus groups included concern about developing type 2 diabetes, barriers to changing diet, and barriers to increasing physical activity. In one focus group, women expressed frustration about feeling judged by their physicians during their GDM pregnancy. Cited barriers to lifestyle change were identified from both methods, and included time and financial constraints, childcare duties, lack of motivation, fatigue, and obstacles at work. Informants suggested facilitators for lifestyle change, including nutrition education, accountability, exercise partners/groups, access to gyms with childcare, and home exercise equipment. All focus group and informant interview participants reported access to the internet, and the majority expressed interest in an intervention program delivered primarily via the internet that would include the opportunity to work with a lifestyle coach. Time constraints were a major barrier. Our findings suggest that an internet-based lifestyle intervention program should be tested as a novel approach to prevent type 2 diabetes in postpartum women with a history of GDM. ClinicalTrials.gov: NCT01102530
155 citations
TL;DR: Healthcare professionals using the Edinburgh Postnatal Depression Scale should be aware of the significant suicidality that is likely to be present in women endorsing 'yes, quite often' to question 10 of the EPDS, however, suicidal ideation does not appear to predict poor outcomes in women being treated for postnatal depression.
Abstract: 1 Abstract 1.1 Background: Suicide is a leading cause of perinatal maternal deaths in industrialised countries but there has been little research to investigate prevalence or correlates of postpartum suicidality. The Edinburgh Postnatal Depression Scale is widely used in primary and maternity services to screen for perinatal depressive disorders, and includes a question on suicidal ideation (question 10). We aimed to investigate the prevalence, persistence and correlates of suicidal thoughts in postpartum women in the context of a randomised controlled trial of treatments for postnatal depression. 1.2 Methods: Women in primary care were sent postal questionnaires at 6 weeks postpartum to screen for postnatal depression before recruitment into an RCT. The Edinburgh Postnatal Depression Scale (EPDS) was used to screen for postnatal depression and in those with high levels of symptoms, a home visit with a standardised psychiatric interview was carried out using the Clinical Interview Schedule-Revised version (CIS-R). Other sociodemographic and clinical variables were measured, including functioning (SF12) and quality of the marital relationship (GRIMS). Women who entered the trial were followed up for 18 weeks. 1.3 Results: 9% of 4,150 women who completed the EPDS question relating to suicidal ideation reported some suicidal ideation (including hardly ever); 4% reported that the thought of harming themselves had occurred to them sometimes or quite often. In women who entered the randomised trial and completed the EPDS question relating to suicidal ideation (n = 253), suicidal ideation was associated with younger age, higher parity and higher levels of depressive symptoms in the multivariate analysis. Endorsement of ‘yes, quite often’ to question 10 on the EPDS was associated with affirming at least two CIS-R items on suicidality. We found no association between suicidal ideation and SF-12 physical or mental health or the EPDS total score at 18 weeks. 1.4 Conclusions: Healthcare professionals using the EPDS should be aware of the significant suicidality that is likely to be present in women endorsing ‘yes, quite often’ to question 10 of the EPDS. However, suicidal ideation does not appear to predict poor outcomes in women being treated for postnatal depression.
155 citations
TL;DR: Women need unambiguous advice regarding healthy lifestyles, diet and exercise in pregnancy to address a lack of knowledge and a tendency towards unhelpful self-talk messages.
Abstract: Twenty percent of pregnant women in the UK are obese (BMI ≥ 30 kg/m2), reflecting the growing public health challenge of obesity in the 21st century. Obesity increases the risk of adverse outcomes during pregnancy and birth and has significant cost implications for maternity services. Gestational weight management strategies are a high priority; however the evidence for effective, feasible and acceptable weight control interventions is limited and inconclusive. This qualitative study explored the experiences and perceptions of pregnant women and midwives regarding existing support for weight management in pregnancy and their ideas for service development. A purposive sample of 6 women and 7 midwives from Doncaster, UK, participated in two separate focus groups. Transcripts were analysed thematically. Two overarching themes were identified, 'Explanations for obesity and weight management' and 'Best care for pregnant women'. 'Explanations' included a lack of knowledge about weight, diet and exercise during pregnancy; self-talk messages which excused overeating; difficulties maintaining motivation for a healthy lifestyle; the importance of social support; stigmatisation; and sensitivity surrounding communication about obesity between midwives and their clients. 'Best care' suggested that weight management required care which was consistent and continuous, supportive and non-judgemental, and which created opportunities for interaction and mutual support between obese pregnant women. Women need unambiguous advice regarding healthy lifestyles, diet and exercise in pregnancy to address a lack of knowledge and a tendency towards unhelpful self-talk messages. Midwives expressed difficulties in communicating with their clients about their weight, given awareness that obesity is a sensitive and potentially stigmatising issue. This indicates more could be done to educate and support them in their work with obese pregnant women. Motivation and social support were strong explanatory themes for obesity and weight management, suggesting that interventions should focus on motivational strategies and social support facilitation.
133 citations
TL;DR: Given that the increased CS rate in NSW cannot be explained by known and collected maternal or pregnancy characteristics, the increase may be related to differences in clinical decision making or maternal request.
Abstract: Caesarean section (CS) rates around the world have been increasing and in Australia have reached 30% of all births. Robson's Ten-Group Classification System (10-group classification) provides a clinically relevant classification of CS rates that provides a useful basis for international comparisons and trend analyses. This study aimed to investigate trends in CS rates in New South Wales (NSW), including trends in the components of the 10-group classification. We undertook a cross-sectional study using data from the Midwives Data Collection, a state-wide surveillance system that monitors patterns of pregnancy care, services and pregnancy outcomes in New South Wales, Australia. The study population included all women giving birth between 1st January 1998 and 31st December 2008. Descriptive statistics are presented including age-standardised CS rates, annual percentage change as well as regression analyses. From 1998 to 2008 the CS rate in NSW increased from 19.1 to 29.5 per 100 births. There was a significant average annual increase in primary 4.3% (95%CI 3.0-5.7%) and repeat 4.8% (95% CI 3.9-5.7%) CS rates from 1998 to 2008. After adjusting for maternal and pregnancy factors, the increase in CS delivery over time was maintained. When examining CS rates classified according to the 10-group classification, the greatest contributors to the overall CS rate and the largest annual increases occurred among nulliparae at term having elective CS and multipara having elective repeat CS. Given that the increased CS rate cannot be explained by known and collected maternal or pregnancy characteristics, the increase may be related to differences in clinical decision making or maternal request. Future efforts to reduce the overall CS rate should be focussed on reducing the primary CS rate.
TL;DR: Aerobic-dance exercise was not associated with reduction in birth weight, preterm birth rate or neonatal well-being, and per protocol analyses showed higher Apgar score in the EG compared with the CG.
Abstract: Birth weight plays an important role in infant mortality and morbidity, childhood development, and adult health. To date there are contradictory results regarding the role of physical activity on birth weight. In addition, it is questioned whether exercise during second and third trimesters of pregnancy might affect gestational age and increase the risk of preterm delivery. Hence, the purpose of this study was to examine the effect of a supervised exercise-program on birth weight, gestational age at delivery and Apgar-score. Sedentary, nulliparous pregnant women (N = 105), mean age 30.7 ± 4.0 years, pre-pregnancy BMI 23.8 ± 4.3 were randomized to either an exercise group (EG, n = 52) or a control group (CG, n = 53). The exercise program consisted of supervised aerobic dance and strength training for 60 minutes, twice per week for a minimum of 12 weeks, with an additional 30 minutes of self-imposed physical activity on the non-supervised week-days. There was no statistically significant difference between groups in mean birth weight, low birth weight (< 2500 g) or macrosomia (≥ 4000 g). Per protocol analyses showed higher Apgar score (1 min) in the EG compared with the CG (p = 0.02). No difference was seen in length of gestation. Aerobic-dance exercise was not associated with reduction in birth weight, preterm birth rate or neonatal well-being. ClinicalTrials.gov: NCT00617149
TL;DR: There is an increased risk of placenta previa in the subsequent pregnancy after CS delivery at first birth, but the risk is lower than previously estimated.
Abstract: Background: Objective: To compare the risk of placenta previa at second birth among women who had a cesarean section (CS) at first birth with women who delivered vaginally. Methods: Retrospective cohort study of 399,674 women who gave birth to a singleton first and second baby between April 2000 and February 2009 in England. Multiple logistic regression was used to adjust the estimates for maternal age, ethnicity, deprivation, placenta previa at first birth, inter-birth interval and pregnancy complications. In addition, we conducted a meta-analysis of the reported results in peer-reviewed articles since 1980. Results: The rate of placenta previa at second birth for women with vaginal first births was 4.4 per 1000 births, compared to 8.7 per 1000 births for women with CS at first birth. After adjustment, CS at first birth remained associated with an increased risk of placenta previa (odds ratio = 1.60; 95% CI 1.44 to 1.76). In the meta-analysis of 37 previously published studies from 21 countries, the overall pooled random effects odds ratio was 2.20 (95% CI 1.96-2.46). Our results from the current study is consistent with those of the meta-analysis as the pooled odds ratio for the six population-based cohort studies that analyzed second births only was 1.51 (95% CI 1.39-1.65). Conclusions: There is an increased risk of placenta previa in the subsequent pregnancy after CS delivery at first birth, but the risk is lower than previously estimated. Given the placenta previa rate in England and the adjusted effect of previous CS, 359 deliveries by CS at first birth would result in one additional case of placenta previa in the next pregnancy. Background Placenta previa can have serious adverse consequences for both mother and baby, including an increased risk of maternal and neonatal mortality[1-3], fetal growth restriction and preterm delivery[4], antenatal and intrapartum hemorrhage[5-7], and women may require a blood transfusion[8] or even an emergency hysterectomy. It is a relatively uncommon condition, with an overall incidence in England of 6.3 per 1000 births[9], but incidence rates are higher among women with advanced maternal age, multiple gestation, high parity, or who smoke or use illegal drugs[10]. The risk of placenta previa is also reported to be higher among women with previous uterine surgery, including cesarean section[11].
TL;DR: Low proportion of optimal birth spacing practices with short actual birth interval length and longer preferred birth interval lengths were evident among the study subjects, Hence interventions to enhance contraceptive utilization behaviors among women in Lemo district would be helpful to narrow the gap between optimal and actual birth spacing.
Abstract: Longer intervals between consecutive births decrease the number of children a woman can have. This results in beneficial effects on population size and on the health status of mothers and children. Therefore, understanding the practice of birth interval and its determinants is helpful to design evidence based strategies for interventions. The objective of this study was to determine duration and determinants of birth interval among women of child bearing age in Lemo district, southern Ethiopia in March 2010. A community based cross sectional study design with stratified multistage sampling technique was employed. A sample of 844 women of child bearing age were selected by using simple random sampling technique after complete census was conducted in selected kebeles prior to data collection. Structured interviewer administered questionnaire was used for data collection. Actual birth interval was measured with the respondents' memory since majority of the women or their children in the area had no birth certificate. Majority (57%) of women were practicing short birth interval length with the median birth interval length of 33 months. Actual birth interval length is significantly shorter than preferred birth interval length. Birth interval showed significant variation by contraceptive use, residence, wealth index, breast feeding and occupation of husbands. low proportion of optimal birth spacing practices with short actual birth interval length and longer preferred birth interval lengths were evident among the study subjects. Hence interventions to enhance contraceptive utilization behaviors among women in Lemo district would be helpful to narrow the gap between optimal and actual birth spacing.
TL;DR: Inequalities in wealth and education of the mother are seen to be the main drivers of inequities in the percentage of births attended by skilled health personnel in Namibia and that a concerted multi-sectoral action is needed in line with the principles of the Primary health Care.
Abstract: The fifth Millennium Development Goal (MDG5) aims at improving maternal health. Globally, the maternal mortality ratio (MMR) declined from 400 to 260 per 100000 live births between 1990 and 2008. During the same period, MMR in sub-Saharan Africa decreased from 870 to 640. The decreased in MMR has been attributed to increase in the proportion of deliveries attended by skilled health personnel. Global improvements maternal health and health service provision indicators mask inequalities both between and within countries. In Namibia, there are significant inequities in births attended by skilled providers that favour those that are economically better off. The objective of this study was to identify the drivers of wealth-related inequalities in child delivery by skilled health providers. Namibia Demographic and Health Survey data of 2006-07 are analysed for the causes of inequities in skilled birth attendance using a decomposable health concentration index and the framework of the Commission on Social Determinants of Health. About 80.3% of the deliveries were attended by skilled health providers. Skilled birth attendance in the richest quintile is about 70% more than that of the poorest quintile. The rate of skilled attendance among educated women is almost twice that of women with no education. Furthermore, women in urban areas access the services of trained birth attendant 30% more than those in rural areas. Use of skilled birth attendants is over 90% in Erongo, Hardap, Karas and Khomas Regions, while the lowest (about 60-70%) is seen in Kavango, Kunene and Ohangwena. The concentration curve and concentration index show statistically significant wealth-related inequalities in delivery by skilled providers that are to the advantage of women from economically better off households (C = 0.0979; P < 0.001). Delivery by skilled health provider by various maternal and household characteristics was 21 percentage points higher in urban than rural areas; 39 percentage points higher among those in richest wealth quintile than the poorest; 47 percentage points higher among mothers with higher level of education than those with no education; 5 percentage points higher among female headed households than those headed by men; 20 percentage points higher among people with health insurance cover than those without; and 31 percentage points higher in Karas region than Kavango region. Inequalities in wealth and education of the mother are seen to be the main drivers of inequities in the percentage of births attended by skilled health personnel. This clearly implies that addressing inequalities in access to child delivery services should not be confined to the health system and that a concerted multi-sectoral action is needed in line with the principles of the Primary health Care.
TL;DR: The overall satisfaction of hospital delivery services in this study is found to be suboptimal and the study strongly suggests that more could be done to assure that services provided are more patient centered.
Abstract: A woman's satisfaction with the delivery service may have immediate and long-term effects on her health and subsequent utilization of the services. Providing satisfying delivery care increases service utilization. The objective of this study is to assess the satisfaction of mothers with referral hospitals' delivery service and identify some possible factors affecting satisfaction in Amhara region of Ethiopia. A hospital-based cross-sectional survey that involved an exit interview was conducted from September to November 2009 in three referral hospitals in Ethiopia. A total of 417 delivering mothers were enrolled in the study. Client satisfaction was measured using a survey instrument adopted from the Donabedian quality assessment framework. We collect data systematically from every other postnatal woman who delivered in the referral hospitals. Multivariate and binary logistic regression was applied to identify the relative effect of each explanatory variable on the outcome (satisfaction). The proportion of mothers who were satisfied with delivery care in this study was 61.9%. Women's satisfaction with delivery care was associated with wanted status of the pregnancy, immediate maternal condition after delivery, waiting time to see the health worker, availability of waiting area, care providers' measure taken to assure privacy during examinations, and amount of cost paid for service. The overall satisfaction of hospital delivery services in this study is found to be suboptimal. The study strongly suggests that more could be done to assure that services provided are more patient centered.
TL;DR: This study shows that cultural beliefs and norms have a strong influence on maternal care practices among the ultra poor households, and override the beneficial economic effects from livelihood support intervention.
Abstract: Although many studies have been carried out to learn about maternal care practices in rural areas and urban-slums of Bangladesh, none have focused on ultra poor women. Understanding the context in which women would be willing to accept new practices is essential for developing realistic and relevant behaviour change messages. This study sought to fill in this knowledge gap by exploring maternal care practices among women who participated in a grant-based livelihood programme for the ultra poor. This is expected to assist the designing of the health education messages programme in an effort to improve maternal morbidity and survival towards achieving the UN millennium Development Goal 5. Qualitative method was used to collect data on maternal care practices during pregnancy, delivery, and post-partum period from women in ultra poor households. The sample included both currently pregnant women who have had a previous childbirth, and lactating women, participating in a grant-based livelihood development programme. Rangpur and Kurigram districts in northern Bangladesh were selected for data collection. Women usually considered pregnancy as a normal event unless complications arose, and most of them refrained from seeking antenatal care (ANC) except for confirmation of pregnancy, and no prior preparation for childbirth was taken. Financial constraints, coupled with traditional beliefs and rituals, delayed care-seeking in cases where complications arose. Delivery usually took place on the floor in the squatting posture and the attendants did not always follow antiseptic measures such as washing hands before conducting delivery. Following the birth of the baby, attention was mainly focused on the expulsion of the placenta and various maneuvres were adapted to hasten the process, which were sometimes harmful. There were multiple food-related taboos and restrictions, which decreased the consumption of protein during pregnancy and post-partum period. Women usually failed to go to the healthcare providers for illnesses in the post-partum period. This study shows that cultural beliefs and norms have a strong influence on maternal care practices among the ultra poor households, and override the beneficial economic effects from livelihood support intervention. Some of these practices, often compromised by various taboos and beliefs, may become harmful at times. Health behavior education in this livelihood support program can be carefully tailored to local cultural beliefs to achieve better maternal outcomes.
TL;DR: Midwife-led care, as practised in this study, is as safe as consultant-led Care and is associated with less intervention during labour and delivery.
Abstract: No midwifery-led units existed in Ireland before 2004. The aim of this study was to compare midwife-led (MLU) versus consultant-led (CLU) care for healthy, pregnant women without risk factors for labour and delivery. An unblinded, pragmatic randomised trial was designed, funded by the Health Service Executive (Dublin North-East). Following ethical approval, all women booking prior to 24 weeks of pregnancy at two maternity hospitals with 1,300-3,200 births annually in Ireland were assessed for trial eligibility.1,653 consenting women were centrally randomised on a 2:1 ratio to MLU or CLU care, (1101:552). 'Intention-to-treat' analysis was used to compare 9 key neonatal and maternal outcomes. No statistically significant difference was found between MLU and CLU in the seven key outcomes: caesarean birth (163 [14.8%] vs 84 [15.2%]; relative risk (RR) 0.97 [95% CI 0.76 to 1.24]), induction (248 [22.5%] vs 138 [25.0%]; RR 0.90 [0.75 to 1.08]), episiotomy (126 [11.4%] vs 68 [12.3%]; RR 0.93 [0.70 to 1.23]), instrumental birth (139 [12.6%] vs 79 [14.3%]; RR 0.88 [0.68 to 1.14]), Apgar scores < 8 (10 [0.9%] vs 9 [1.6%]; RR 0.56 [0.23 to 1.36]), postpartum haemorrhage (144 [13.1%] vs 75 [13.6%]; RR 0.96 [0.74 to 1.25]); breastfeeding initiation (616 [55.9%] vs 317 [57.4%]; RR 0.97 [0.89 to 1.06]). MLU women were significantly less likely to have continuous electronic fetal monitoring (397 [36.1%] vs 313 [56.7%]; RR 0.64 [0.57 to 0.71]), or augmentation of labour (436 [39.6%] vs 314 [56.9%]; RR 0.50 [0.40 to 0.61]). Midwife-led care, as practised in this study, is as safe as consultant-led care and is associated with less intervention during labour and delivery. ISRCTN: ISRCTN14973283
TL;DR: Participating services had both strengths and weaknesses in the delivery of maternal health care, and increasing access to evidence-based screening and health information were consistently identified as opportunities for improvement across services.
Abstract: Background
Australia's Aboriginal and Torres Strait Islander (Indigenous) populations have disproportionately high rates of adverse perinatal outcomes relative to other Australians. Poorer access to good quality maternal health care is a key driver of this disparity. The aim of this study was to describe patterns of delivery of maternity care and service gaps in primary care services in Australian Indigenous communities.
TL;DR: Data suggest that maternal exposure to air pollution before and during pregnancy may alter the immune competence in offspring thus increasing the child's risk of developing health conditions later in life, including asthma and allergies.
Abstract: Toxicants can cross the placenta and expose the developing fetus to chemical contamination leading to possible adverse health effects, by potentially inducing alterations in immune competence. Our aim was to investigate the impacts of maternal exposure to air pollution before and during pregnancy on newborn's immune system. Exposure to background particulate matter less than 10 μm in diameter (PM10) and nitrogen dioxide (NO2) was assessed in 370 women three months before and during pregnancy using monitoring stations. Personal exposure to four volatile organic compounds (VOCs) was measured in a subsample of 56 non-smoking women with a diffusive air sampler during the second trimester of pregnancy. Cord blood was analyzed at birth by multi-parameter flow cytometry to determine lymphocyte subsets. Among other immunophenotypic changes in cord blood, decreases in the CD4+CD25+ T-cell percentage of 0.82% (p = 0.01), 0.71% (p = 0.04), 0.88% (p = 0.02), and 0.59% (p = 0.04) for a 10 μg/m3 increase in PM10 levels three months before and during the first, second and third trimester of pregnancy, respectively, were observed after adjusting for confounders. A similar decrease in CD4+CD25+ T-cell percentage was observed in association with personal exposure to benzene. A similar trend was observed between NO2 exposure and CD4+CD25+ T-cell percentage; however the association was stronger between NO2 exposure and an increased percentage of CD8+ T-cells. These data suggest that maternal exposure to air pollution before and during pregnancy may alter the immune competence in offspring thus increasing the child's risk of developing health conditions later in life, including asthma and allergies.
TL;DR: Efforts to improve antenatal care should address shortages of trained staff through expanding training opportunities, including health worker cadres with little pre-service training, and attention should be paid to the identification of informal practices resulting from individual coping strategies and "street-level bureaucracy" in order to tackle problems before they become part of the organizational culture.
Abstract: Background: The potential of antenatal care for reducing maternal morbidity and improving newborn survival and health is widely acknowledged. Yet there are worrying gaps in knowledge of the quality of antenatal care provided in Tanzania. In particular, determinants of health workers’ performance have not yet been fully understood. This paper uses ethnographic methods to document health workers’ antenatal care practices with reference to the national Focused Antenatal Care guidelines and identifies factors influencing health workers’ performance. Potential implications for improving antenatal care provision in Tanzania are discussed. Methods: Combining different qualitative techniques, we studied health workers’ antenatal care practices in four public antenatal care clinics in the Kilombero Valley, south-eastern Tanzania. A total of 36 antenatal care consultations were observed and compared with the Focused Antenatal Care guidelines. Participant observation, informal discussions and in-depth interviews with the staff helped to identify and explain health workers’ practices and contextual factors influencing antenatal care provision. Results: The delivery of antenatal care services to pregnant women at the selected antenatal care clinics varied widely. Some services that are recommended by the Focused Antenatal Care guidelines were given to all women while other services were not delivered at all. Factors influencing health workers’ practices were poor implementation of the Focused Antenatal Care guidelines, lack of trained staff and absenteeism, supply shortages and use of working tools that are not consistent with the Focused Antenatal Care guidelines. Health workers react to difficult working conditions by developing informal practices as coping strategies or “street-level bureaucracy”. Conclusions: Efforts to improve antenatal care should address shortages of trained staff through expanding training opportunities, including health worker cadres with little pre-service training. Attention should be paid to the identification of informal practices resulting from individual coping strategies and “street-level bureaucracy” in order to tackle problems before they become part of the organizational culture.
TL;DR: This randomised controlled trial is to assess whether the implementation of a package of dietary and lifestyle advice to overweight and obese women during pregnancy to limit gestational weight gain is effective in improving maternal, fetal and infant health outcomes.
Abstract: Obesity is a significant global health problem, with the proportion of women entering pregnancy with a body mass index greater than or equal to 25 kg/m2 approaching 50%. Obesity during pregnancy is associated with a well-recognised increased risk of adverse health outcomes both for the woman and her infant, however there is more limited information available regarding effective interventions to improve health outcomes. The aims of this randomised controlled trial are to assess whether the implementation of a package of dietary and lifestyle advice to overweight and obese women during pregnancy to limit gestational weight gain is effective in improving maternal, fetal and infant health outcomes. Design: Multicentred randomised, controlled trial. Inclusion Criteria: Women with a singleton, live gestation between 10+0-20+0 weeks who are obese or overweight (defined as body mass index greater than or equal to 25 kg/m2), at the first antenatal visit. Trial Entry & Randomisation: Eligible, consenting women will be randomised between 10+0 and 20+0 weeks gestation using a central telephone randomisation service, and randomisation schedule prepared by non-clinical research staff with balanced variable blocks. Stratification will be according to maternal BMI at trial entry, parity, and centre where planned to give birth. Treatment Schedules: Women randomised to the Dietary and Lifestyle Advice Group will receive a series of inputs from research assistants and research dietician to limit gestational weight gain, and will include a combination of dietary, exercise and behavioural strategies. Women randomised to the Standard Care Group will continue to receive their pregnancy care according to local hospital guidelines, which does not currently include routine provision of dietary, lifestyle and behavioural advice. Outcome assessors will be blinded to the allocated treatment group. Primary Study Outcome: infant large for gestational age (defined as infant birth weight ≥ 90th centile for gestational age). Sample Size: 2,180 women to detect a 30% reduction in large for gestational age infants from 14.40% (p = 0.05, 80% power, two-tailed). This is a protocol for a randomised trial. The findings will contribute to the development of evidence based clinical practice guidelines. Australian and New Zealand Clinical Trials Registry ACTRN12607000161426
TL;DR: This study shows the importance of specifying which cases of AIP are incident and provides supportive evidence for a causal relation between parity and occurrence of incidental AIP.
Abstract: Studies that explore the controversial association between parity and anaemia-in-pregnancy (AIP) were often hampered by not distinguishing incident cases caused by pregnancy from prevalent cases complicated by pregnancy. The authors' aim in conducting this study was to overcome this methodological concern. A retrospective cohort study was conducted in Oman on 1939 pregnancies among 479 parous female participants with available pregnancy records in a community trial. We collected information from participants, the community trial, and health records of each pregnancy. Throughout the follow-up period, we enumerated 684 AIP cases of which 289 (42.2%) were incident cases. High parity (HP, ≥ 5 pregnancies) accounted for 48.7% of total pregnancies. Two sets of regression analyses were conducted: the first restricted to incident cases only, and the second inclusive of all cases. The relation with parity as a dichotomy and as multiple categories was examined for each set; multi-level logistic regression (MLLR) was employed to produce adjusted models. In the fully adjusted MLLR models that were restricted to incident cases, women with HP pregnancies had a higher risk of AIP compared to those who had had fewer pregnancies (Risk Ratio, RR = 2.92; 95% CI 2.02, 4.59); the AIP risk increased in a dose-response fashion over multiple categories of parity. In the fully adjusted MLLR models that included all cases, the association disappeared (RR = 1.11; 95% CI 0.91, 1.18) and the dose-response pattern flattened. This study shows the importance of specifying which cases of AIP are incident and provides supportive evidence for a causal relation between parity and occurrence of incidental AIP.
TL;DR: The findings provide weak evidence of an association between experiences of abuse before and during pregnancy and preterm birth and small for gestational age but they indicate that several dimensions of abuse and violence are consistently associated with postpartum depression.
Abstract: Abuse and violence against women constitute a global public health problem and are particularly important among women of reproductive age. The literature is not conclusive regarding the impact of violence against pregnant women on adverse pregnancy outcomes, such as preterm birth, small for gestational age and postpartum depression. Most studies have been conducted on relatively small samples of high-risk women. Our objective was to investigate what dimensions of violence against pregnant women were associated with preterm birth, small for gestational age and postpartum depression in a nationally representative sample of Canadian women. We analysed data of the Maternity Experiences Survey, a nationally representative survey of Canadian women giving birth in 2006. The comprehensive questionnaire included a 19-item section to collect information on different dimensions of abuse and violence, such as type, frequency, timing and perpetrator of violence. The survey design is a stratified simple random sample from the 2006 Canadian Census sampling frame. Participants were 6,421 biological mothers (78% response rate) 15 years and older who gave birth to a singleton live birth and lived with their infant at the time of the survey. Logistic regression was used to compute Odds Ratios. Survey weights were used to obtain point estimates and 95% confidence intervals were obtained with the jacknife method of variance estimation. Covariate control was informed by use of directed acyclic graphs. No statistically significant associations were found for preterm birth or small for gestational age, after adjustment. Most dimensions of violence were associated with postpartum depression, particularly the combination of threats and physical violence starting before and continuing during pregnancy (Adjusted Odds Ratio = 4.1, 95% confidence interval: 1.9, 8.9) and perpetrated by the partner (4.3: 2.1, 8.7). Our findings provide weak evidence of an association between experiences of abuse before and during pregnancy and preterm birth and small for gestational age but they indicate that several dimensions of abuse and violence are consistently associated with postpartum depression.
TL;DR: How poor quality of care at health facilities contributes to delays that lead to severe birth injuries is illustrated, highlighting the need to ensure women's rights to accessible, acceptable and adequate quality services during labour and delivery.
Abstract: Obstetric fistula is a physically and socially disabling obstetric complication that affects about 3,000 women in Tanzania every year. The fistula, an opening that forms between the vagina and the bladder and/or the rectum, is most frequently caused by unattended prolonged labour, often associated with delays in seeking and receiving appropriate and adequate birth care. Using the availability, accessibility, acceptability and quality of care (AAAQ) concept and the three delays model, this article provides empirical knowledge on birth care experiences of women who developed fistula after prolonged labour. We used a mixed methods approach to explore the birthing experiences of women affected by fistula and the barriers to access adequate care during labour and delivery. Sixteen women were interviewed for the qualitative study and 151 women were included in the quantitative survey. All women were interviewed at the Comprehensive Community Based Rehabilitation Tanzania in Dar es Salaam and Bugando Medical Centre in Mwanza. Women experienced delays both before and after arriving at a health facility. Decisions on where to seek care were most often taken by husbands and mothers-in-law (60%). Access to health facilities providing emergency obstetric care was inadequate and transport was a major obstacle. About 20% reported that they had walked or were carried to the health facility. More than 50% had reported to a health facility after two or more days of labour at home. After arrival at a health facility women experienced lack of supportive care, neglect, poor assessment of labour and lack of supervision. Their birth accounts suggest unskilled birth care and poor referral routines. This study reveals major gaps in access to and provision of emergency obstetric care. It illustrates how poor quality of care at health facilities contributes to delays that lead to severe birth injuries, highlighting the need to ensure women's rights to accessible, acceptable and adequate quality services during labour and delivery.
TL;DR: A large, adequately powered, randomized trial of clotrimazole to prevent preterm birth in women with asymptomatic vaginal candidiasis is both feasible and warranted.
Abstract: Although the connection between ascending infection and preterm birth is undisputed, research focused on finding effective treatments has been disappointing. However evidence that eradication of Candida in pregnancy may reduce the risk of preterm birth is emerging. We conducted a pilot study to assess the feasibility of conducting a large randomized controlled trial to determine whether treatment of asymptomatic candidiasis in early pregnancy reduces the incidence of preterm birth. We used a prospective, randomized, open-label, blinded-endpoint (PROBE) study design. Pregnant women presenting at <20 weeks gestation with singleton pregnancies self-collected a vaginal swab. Those who were asymptomatic and culture positive for Candida were randomized to 6-days of clotrimazole vaginal pessaries (100mg) or usual care (screening result is not revealed, no treatment). The primary outcomes were the rate of asymptomatic vaginal candidiasis, participation and follow-up. The proposed primary trial outcome of spontaneous preterm birth <37 weeks gestation was also assessed. Of 779 women approached, 500 (64%) participated in candidiasis screening, and 98 (19.6%) had asymptomatic vaginal candidiasis and were randomized to clotrimazole or usual care. Women were not inconvenienced by participation in the study, laboratory testing and medication dispensing were problem-free, and the follow-up rate was 99%. There was a tendency towards a reduction in spontaneous preterm birth among women with asymptomatic candidiasis who were treated with clotrimazole RR = 0.33, 95%CI 0.04-3.03. A large, adequately powered, randomized trial of clotrimazole to prevent preterm birth in women with asymptomatic candidiasis is both feasible and warranted. Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609001052224
TL;DR: The TPDS constitutes a valid and user friendly instrument to assess pregnancy distress because of its proven ability to pick up pregnancy specific negative affect and also includes an important sub-scale measuring perceived partner involvement.
Abstract: Background: Pregnant women with high levels of stress, depression and/or anxiety are at increased risk for adverse perinatal outcomes and impaired neurologic and emotional development of the offspring. Pregnancy specific instruments to measure psychological functioning during gestation are scarce and do not define items based on in-depth interviews of pregnant and recently delivered women. The current study developed a pregnancy specific scale that measures psychological functioning using in-depth interviews. Methods: Three focus groups were formed to discuss issues most relevant to pregnancy distress; 22 candidate items were derived for pilot testing (study I, n = 419) its psychometric properties by means of explorative factor analyses (EFA). This resulted in a 17-item TPDS which was further explored by confirmatory factor analyses (CFA) and concurrent and construct validity assessment (study II, n = 454). Results: EFA in study I suggested a two component solution (negative affect (NA) and partner involvement (PI)). CFA in study II resulted in a higher order model of the NA subscale into three more subscales: NA regarding confinement, delivery and general health. TPDS, EPDS and GAD-7 were all significantly correlated. Conclusions: The TPDS constitutes a valid and user friendly instrument to assess pregnancy distress. In addition to its proven ability to pick up pregnancy specific negative affect it also includes an important sub-scale measuring perceived partner involvement.
TL;DR: The concentration of C-reactive protein at admission for premature rupture of membranes is the most accurate infectious marker for prediction of early-onset neonatal infection in routine use with a sensitivity > 90%.
Abstract: Background
Accurate prediction of infection, including maternal chorioamnionitis and early-onset neonatal infection, remains a critical challenge in cases of preterm rupture of membranes and may influence obstetrical management. The aim of our study was to investigate the predictive value for early-onset neonatal infection and maternal histological and clinical chorioamnionitis of maternal biological markers in routine use at or after 34 weeks of gestation in women with premature rupture of membranes.
TL;DR: Public Health campaigns need to emphasise the importance of peri-conceptional health and pre-pregnancy planning, and Fetal Alcohol Syndrome is likely to be under-reported despite the high prevalence of alcohol consumption in this population.
Abstract: Evidence-based advice on alcohol consumption is required for pregnant women and women planning a pregnancy. Our aim was to investigate the prevalence, predictors and perinatal outcomes associated with peri-conceptional alcohol consumption. A cohort study of 61,241 women who booked for antenatal care and delivered in a large urban maternity hospital between 2000 and 2007. Self-reported alcohol consumption at the booking visit was categorised as low (0-5 units per week), moderate (6-20 units per week) and high (>20 units per week). Of the 81% of women who reported alcohol consumption during the peri-conceptional period, 71% reported low intake, 9.9% moderate intake and 0.2% high intake. Factors associated with moderate alcohol consumption included being in employment OR 4.47 (95% CI 4.17 to 4.80), Irish nationality OR 16.5 (95% CI 14.9 to 18.3), private health care OR 5.83 (95% CI 5.38 to 6.31) and smoking OR 1.86 (95% CI 1.73 to 2.01). Factors associated with high consumption included maternal age less than 25 years OR 2.70 (95% CI 1.86 to 3.91) and illicit drug use OR 6.46 (95% CI 3.32 to 12.60). High consumption was associated with very preterm birth (<32 weeks gestation) even after controlling for socio-demographic factors, adjusted OR 3.15 (95% CI 1.26-7.88). Only three cases of Fetal Alcohol Syndrome were recorded (0.05 per 1000 total births), one each in the low, moderate and high consumption groups. Public Health campaigns need to emphasise the importance of peri-conceptional health and pre-pregnancy planning. Fetal Alcohol Syndrome is likely to be under-reported despite the high prevalence of alcohol consumption in this population.
TL;DR: Auditing near miss cases expanded the understanding of the spectrum from maternal morbidity to mortality and the importance of promoting adhesion to clinical protocols among maternal mortality committee members.
Abstract: Auditing of sentinel health events based on best-practice protocols has been recommended. This study describes a population-based investigation on adverse perinatal events including severe acute maternal morbidity (near-miss), maternal and perinatal mortality, as a health intervention to help improve the surveillance system. From October to December 2005, all cases of maternal death (MD), near-miss (NM), fetal deaths (FD), and early neonatal deaths (END), occurring in Campinas, Brazil, were audited by maternal mortality committees. A total of 4,491 liveborn infants (LB) and 159 adverse perinatal events (35.4/1000 LB) were revised, consisting of 4 MD (89/100.000 LB) and 95 NM (21.1/1000 LB), 23.7 NM for each MD. In addition, 32 FD (7.1/1000 LB) and 28 END (6.2/1000 LB) occurred. The maternal death/near miss rate was 23.7:1. Some delay in care was recognized for 34%, and hypertensive complications comprised 57.8% of the NM events, followed by postpartum hemorrhage. Auditing near miss cases expanded the understanding of the spectrum from maternal morbidity to mortality and the importance of promoting adhesion to clinical protocols among maternal mortality committee members. Hypertensive disorders and postpartum hemorrhage were identified as priority topics for health providers training, and organization of care.