Showing papers in "Reproductive Health in 2016"

Prevalence and risk factors related to preterm birth in Brazil

Abstract: The rate of preterm birth has been increasing worldwide, including in Brazil. This constitutes a significant public health challenge because of the higher levels of morbidity and mortality and long-term health effects associated with preterm birth. This study describes and quantifies factors affecting spontaneous and provider-initiated preterm birth in Brazil. Data are from the 2011–2012 “Birth in Brazil” study, which used a national population-based sample of 23,940 women. We analyzed the variables following a three-level hierarchical methodology. For each level, we performed non-conditional multiple logistic regression for both spontaneous and provider-initiated preterm birth. The rate of preterm birth was 11.5 % , (95 % confidence 10.3 % to 12.9 %) 60.7 % spontaneous - with spontaneous onset of labor or premature preterm rupture of membranes - and 39.3 % provider-initiated, with more than 90 % of the last group being pre-labor cesarean deliveries. Socio-demographic factors associated with spontaneous preterm birth were adolescent pregnancy, low total years of schooling, and inadequate prenatal care. Other risk factors were previous preterm birth (OR 3.74; 95 % CI 2.92–4.79), multiple pregnancy (OR 16.42; 95 % CI 10.56–25.53), abruptio placentae (OR 2.38; 95 % CI 1.27–4.47) and infections (OR 4.89; 95 % CI 1.72–13.88). In contrast, provider-initiated preterm birth was associated with private childbirth healthcare (OR 1.47; 95 % CI 1.09–1.97), advanced-age pregnancy (OR 1.27; 95 % CI 1.01–1.59), two or more prior cesarean deliveries (OR 1.64; 95 % CI 1.19–2.26), multiple pregnancy (OR 20.29; 95 % CI 12.58–32.72) and any maternal or fetal pathology (OR 6.84; 95 % CI 5.56–8.42). The high proportion of provider-initiated preterm birth and its association with prior cesarean deliveries and all of the studied maternal/fetal pathologies suggest that a reduction of this type of prematurity may be possible. The association of spontaneous preterm birth with socially-disadvantaged groups reaffirms that the reduction of social and health inequalities should continue to be a national priority.

Use of Robson classification to assess cesarean section rate in Brazil: the role of source of payment for childbirth

Abstract: Cesarean section (CS) rates are increasing worldwide but there is some concern with this trend because of potential maternal and perinatal risks. The Robson classification is the standard method to monitor and compare CS rates. Our objective was to analyze CS rates in Brazil according to source of payment for childbirth (public or private) using the Robson classification. Data are from the 2011–2012 “Birth in Brazil” study, which used a national hospital-based sample of 23,940 women. We categorized all women into Robson groups and reported the relative size of each Robson group, the CS rate in each group and the absolute and relative contributions made by each to the overall CS rate. Differences were analyzed through chi-square and Z-test with a significance level of < 0.05. The overall CS rate in Brazil was 51.9 % (42.9 % in the public and 87.9 % in the private health sector). The Robson groups with the highest impact on Brazil’s CS rate in both public and private sectors were group 2 (nulliparous, term, cephalic with induced or cesarean delivery before labor), group 5 (multiparous, term, cephalic presentation and previous cesarean section) and group 10 (cephalic preterm pregnancies), which accounted for more than 70 % of CS carried out in the country. High-risk women had significantly greater CS rates compared with low-risk women in almost all Robson groups in the public sector only. Public policies should be directed at reducing CS in nulliparous women, particularly by reducing the number of elective CS in these women, and encouraging vaginal birth after cesarean to reduce repeat CS in multiparous women.

Incidence and risk factors for postpartum hemorrhage in Uganda

Abstract: Globally, postpartum haemorrhage (PPH) remains a leading cause of maternal deaths. However in many low and middle income countries, there is scarcity of information on magnitude of and risk factors for PPH (blood loss of 500 ml or more). It is important to understand the relative contributions of different risk factors for PPH. We assessed the incidence of, and risk factors for postpartum hemorrhage among rural women in Uganda. Between March 2013 and March 2014, a prospective cohort study was conducted at six health facilities in Uganda. Women were administered a questionnaire to ascertain risk factors for postpartum hemorrhage, defined as a blood loss of 500 mls or more, and assessed using a calibrated under-buttocks drape at childbirth. We constructed two separate multivariable logistic regression models for the variables associated with PPH. Model 1 included all deliveries (vaginal and cesarean sections). Model 2 analysis was restricted to vaginal deliveries. In both models, we adjusted for clustering at facility level. Among the 1188 women, the overall incidence of postpartum hemorrhage was 9.0 %, (95 % confidence interval [CI]: 7.5–10.6 %) and of severe postpartum hemorrhage (1000 mls or more) was 1.2 %, (95 % CI 0.6–2.0 %). Most (1157 [97.4 %]) women received a uterotonic after childbirth for postpartum hemorrhage prophylaxis. Risk factors for postpartum hemorrhage among all deliveries (model 1) were: cesarean section delivery (adjusted odds ratio [aOR] 7.54; 95 % CI 4.11–13.81); multiple pregnancy (aOR 2.26; 95 % CI 0.58–8.79); foetal macrosomia ≥4000 g (aOR 2.18; 95 % CI 1.11–4.29); and HIV positive sero-status (aOR 1.93; 95 % CI 1.06–3.50). Risk factors among vaginal deliveries only, were similar in direction and magnitude as in model 1, namely: multiple pregnancy, (aOR 7.66; 95 % CI 1.81–32.34); macrosomia, (aOR 2.14; 95 % CI1.02–4.47); and HIV positive sero-status (aOR 2.26; 95 % CI 1.20–4.25). The incidence of postpartum hemorrhage was high in our setting despite use of uterotonics. The risk factors identified could be addressed by extra vigilance during labour and preparedness for PPH management in all women giving birth.

Mitigating disrespect and abuse during childbirth in Tanzania: an exploratory study of the effects of two facility-based interventions in a large public hospital

Abstract: Background There is emerging evidence that disrespect and abuse (DA increase and improve patient-provider and provider-administrator communication; and improve women’s experience and provider attitudes. The effects of the interventions were assessed using a pre-post design and a range of tools: pre-post questionnaires for OBD participants and pre-post questionnaires for workshop participants; structured interviews with healthcare providers and administrators; structured interviews with women who gave birth at the study facility; and direct observations of patient-provider interactions during labor and delivery. Results Comparisons before and after the interventions showed an increase in patient and provider knowledge of user rights across multiple dimensions, as well as women’s knowledge of the labor and delivery process. Women reported feeling better prepared for delivery and provider attitudes towards them improved, with providers reporting higher levels of empathy for the women they serve and better interpersonal relationships. Patients and providers reported improved communication, which direct observations confirmed. Additionally, women reported feeling more empowered and confident during delivery. Provider job satisfaction increased substantially from baseline levels, as did user reports of satisfaction and perceptions of care quality. Conclusions Collectively, the outcomes of this study indicate that the tested interventions have the potential to be successful in promoting outcomes that are prerequisite to reducing disrespect and abuse. However, a more rigorous evaluation is needed to determine the full impact of these interventions.

Teenage pregnancy rates and associations with other health risk behaviours: a three-wave cross-sectional study among South African school-going adolescents

Abstract: Teenage pregnancy still remains high in low and middle-income countries (LMIC), as well as in high-income countries (HIC). It is a major contributor to maternal and child morbidity and mortality rates. Furthermore, it has social consequences, such as perpetuating the cycle of poverty including early school dropout by the pregnant adolescent, especially in sub-Saharan Africa (SSA). Few studies in SSA have investigated the trends in teenage pregnancy and the associated factors, while this is critical in fully understanding teenage pregnancy and for promotion of reproductive health among adolescents at large in SSA. To examine the trends in teenage pregnancy and to identify associations with other health risk behaviours in South Africa (SA), a total of 31 816 South African school-going adolescents between 11 to 19 years of age were interviewed in three cross-sectional surveys. Data from the first (2002, n = 10 549), second (2008, n = 10 270) and the third (2011, n = 10 997) nationally representative South African youth risk behaviour surveys (YRBS) were used for this study. The overall prevalence of having ever been pregnant among the combined 3-survey sample was self-reported to be 11.0 % and stable across the three surveys. Sexual intercourse among adolescents in SA has decreased from 41.9 % in 2002 to 36.9 % in 2011. However, pregnancy among girls who ever had sex increased from 17.3 % (95 % CI: 0.16–0.19) in 2002, to 23.6 % (95 % CI: 0.21–0.26) in 2008 and decreased to 21.3 % (95 % CI: 0.19–0.23) in 2011. The odds for ever been pregnant were higher for girls who had 2 or more sexual partners (OR: 1.250, 95 % CI: 1.039–1.503), girls who ever used alcohol before sex (OR: 1.373, 95 % CI: 1.004–1.878), practised binge-drinking during the last month (OR: 0.624, 95 % CI: 0.503–0.774), and girls who used mandrax (OR: 1.968, 95 % CI: 1,243–3.117). The odds for never been pregnant were lower for those who used condoms (OR: 0.462, 95 % CI: 0.309–0.691). Girls continue to become pregnant at unacceptably high rates in SA. Sexual intercourse among adolescents in SA has decreased slightly. However, among those who are sexually active pregnancy prevalence rates have increased. More over, this is in the context of high prevalence of HIV and other STI. There is a need to address adolescents’ sexual and reproductive health, and several health risk behaviours, including substance use, that are associated with teenage pregnancy in SA.

Barriers and facilitators to health care seeking behaviours in pregnancy in rural communities of southern Mozambique

Abstract: In countries, such as Mozambique, where maternal mortality remains high, the greatest contribution of mortality comes from the poor and vulnerable communities, who frequently reside in remote and rural areas with limited access to health care services. This study aimed to understand women’s health care seeking practices during pregnancy, taking into account the underlying social, cultural and structural barriers to accessing timely appropriate care in Maputo and Gaza Provinces, southern Mozambique. This ethnographic study collected data through in-depth interviews and focus group discussions with women of reproductive age, including pregnant women, as well as household-level decision makers (partners, mothers and mothers-in-law), traditional healers, matrons, and primary health care providers. Data was analysed thematically using NVivo 10. Antenatal care was sought at the heath facility for the purpose of opening the antenatal record. Women without antenatal cards feared mistreatment during labour. Antenatal care was also sought to resolve discomforts, such as headaches, flu-like symptoms, body pain and backache. However, partners and husbands considered lower abdominal pain as the only symptom requiring care and discouraged women from revealing their pregnancy early in gestation. Health care providers for pregnant women often included those at the health facility, matrons, elders, traditional birth attendants, and community health workers. Although seeking care from traditional healers was discouraged during the antenatal period, they did provide services during pregnancy and after delivery. Besides household-level decision-makers, matrons, community health workers, and neighbours were key actors in the referral of pregnant women. The decision-making process may be delayed and particularly complex if an emergency occurs in their absence. Limited access to transport and money makes the decision-making process to seek care at the health facility even more complex. Women do seek antenatal care at health facilities, despite the presence of other health care providers in the community. There are important factors that prevent timely care-seeking for obstetric emergencies and delivery. Unfamiliarity with warning signs, especially among partners, discouragement from revealing pregnancy early in gestation, complex and untimely decision-making processes, fear of mistreatment by health-care providers, lack of transport and financial constraints were the most commonly cited barriers. Women of reproductive age would benefit from community saving schemes for transport and medication, which in turn would improve their birth preparedness and emergency readiness; in addition, pregnancy follow-up should include key family members, and community-based health care providers should encourage prompt referrals to health facilities, when appropriate. NCT01911494

Factors associated with unintended pregnancy in Brazil: cross-sectional results from the Birth in Brazil National Survey, 2011/2012.

Abstract: Unintended pregnancy, a pregnancy that have been either unwanted or mistimed, is a serious public health issue in Brazil. It is reported for more than half of women who gave birth in the country, but the characteristics of women who conceive unintentionally are rarely documented. The aim of this study is to analyse the prevalence and the association between unintended pregnancy and a set of sociodemographic characteristics, individual-level variables and history of obstetric outcomes. Birth in Brazil is a cross-sectional study with countrywide representation that interviewed 23,894 women after birth. The information about intendedness of pregnancy was obtained after birth at the hospital and classified into three categories: intended, mistimed or unwanted. Multinomial regression analysis was used to estimate the associations between intendedness of a pregnancy, and sociodemographic and obstetric variables, calculating odds ratios and 95 % confidence intervals. All significant variables in the bivariate analysis were included in the multinomial multivariate model and the final model retaining variables that remained significant at the 5 % level. Unintended pregnancy was reported by 55.4 % of postpartum women. The following variables maintained positive and significant statistical associations with mistimed pregnancy: maternal age < 20 years (OR = 1.89, 95 % CI: 1.68–2.14); brown (OR = 1.15, 95 % CI: 1.04–1.27) or yellow skin color (OR = 1.56, 95 % CI: 1.05–2.32); having no partner (OR = 2.32, 95 % CI: 1.99–2.71); having no paid job (OR = 1.15, 95 % CI: 1.04–1.27); alcohol abuse with risk of alcoholism (OR = 1.25, 95 % CI: 1.04–1.50) and having had three or more births (OR = 2.01, 95 % CI: 1.63–2.47). The same factors were associated with unwanted pregnancy, though the strength of the associations was generally stronger. Women with three or more births were 14 times more likely to have an unwanted pregnancy, and complication in the previous pregnancies and preterm birth were 40 % and 19 % higher, respectively. Previous neonatal death was a protective factor for both mistimed (OR = 0.61, 95 % CI: 0.44–0.85) and unwanted pregnancy (OR = 0.44, 95 % CI: 0.34–0.57). This study confirms findings from previous research about the influence of socioeconomic and individual risk factors on unintended pregnancy. It takes a new approach to the problem by showing the importance of previous neonatal death, preterm birth and complication during pregnancy as risk factors for unintended pregnancy.

Male involvement in reproductive, maternal and child health: a qualitative study of policymaker and practitioner perspectives in the Pacific.

Abstract: Background The importance of involving men in reproductive, maternal and child health programs is increasingly recognised globally. In the Pacific region, most maternal and child health services do not actively engage expectant fathers and fathers of young children and few studies have been conducted on the challenges, benefits and opportunities for involving fathers. This study explores the attitudes and beliefs of maternal and child health policymakers and practitioners regarding the benefits, challenges, risks and approaches to increasing men’s involvement in maternal and child health education and clinical services in the Pacific.

The neonatal mortality and its determinants in rural communities of Eastern Uganda

Abstract: In Uganda, neonatal mortality rate (NMR) remains high at 27 deaths per 1000 live births. There is paucity of data on factors associated with NMR in rural communities in Uganda. The objective of this study was to determine NMR as well as factors associated with neonatal mortality in the rural communities of three districts from eastern Uganda. Data from a baseline survey of a maternal and newborn intervention in the districts of Pallisa, Kibuku and Kamuli, Eastern Uganda was analyzed. A total of 2237 women who had delivered in the last 12 months irrespective of birth outcome were interviewed in the survey. The primary outcome for this paper was neonatal mortality. The risk ratio (RR) was used to determine the factors associated with neonatal mortality using log - binomial model. The neonatal mortality was found to be 34 per 1000 live births (95 % CI = 27.1–42.8); Kamuli 31.9, Pallisa 36.5 and Kibuku 30.8. Factors associated with increased neonatal deaths were parity of 5+ (adj. RR =2.53, 95 % CI =1.14–5.65) relative to parity of 4 and below, newborn low birth weight (adj. RR = 3.10, 95 % CI = 1.47–6.56) and presence of newborn danger signs (adj. RR = 2.42, 95 % CI = 1.04–5.62). Factors associated with lower risk of neonatal death were, home visits by community health workers’ (CHW) (adj. RR =0.13, 95 % CI = 0.02–0.91), and attendance of at least 4 antenatal visits (adj. RR = 0.65, 95 % CI = 0.43–0.98). Neonatal mortality in rural communities is higher than the national average. The use of CHW’s to mobilize and sensitize households on appropriate maternal and newborn care practices could play a key role in reducing neonatal mortality.

Utilization of maternal health care services and their determinants in Karnataka State, India

Abstract: Karnataka State continues to have the highest rates of maternal mortality in south India at 144/100,000 live births, but lower than the national estimates of 190–220/100,000 live births. Various barriers exist to timely and appropriate utilization of services during pregnancy, childbirth and postpartum. This study aimed to describe the patterns and determinants of routine and emergency maternal health care utilization in rural Karnataka State, India. This study was conducted in Karnataka in 2012–2013. Purposive sampling was used to convene twenty three focus groups and twelve individual interviews with community and health system representatives: Auxiliary Nurse Midwives and Staff Nurses, Accredited Social Health Activists, community leaders, male decision-makers, female decision-makers, women of reproductive age, medical officers, private health care providers, senior health administrators, District health officers, and obstetricians. Local researchers familiar with the setting and language conducted all focus groups and interviews, these researchers were not known to community participants. All discussions were audio recorded, transcribed, and translated to English for analysis. A thematic analysis approach was taken utilizing an a priori thematic framework as well as inductive identification of themes. Most women in the focus groups reported regular antenatal care attendance, for an average of four visits, and more often for high-risk pregnancies. Antenatal care was typically delivered at the periphery by non-specialised providers. Participants reported that sought was care women experienced danger signs of complications. Postpartum care was reportedly rare, and mainly sought for the purpose of neonatal care. Factors that influenced women’s care-seeking included their limited autonomy, poor access to and funding for transport for non-emergent conditions, perceived poor quality of health care facilities, and the costs of care. Rural south Indian communities reported regular use of health care services during pregnancy and for delivery. Uptake of maternity care services was attributed to new government programmes and increased availability of maternity services; nevertheless, some women delayed disclosure of pregnancy and first antenatal visit. Community-based initiatives should be enhanced to encourage early disclosure of pregnancies and to provide the community information regarding the importance of facility-based care. Health facility infrastructure in rural Karnataka should also be enhanced to ensure a consistent power supply and improved cleanliness on the wards. NCT01911494

Age at menarche in Korean adolescents: trends and influencing factors

Abstract: An increased incidence of central precocious puberty has been recently reported in South Korea, which suggests an ongoing downward trend in pubertal development in the Korean population. We aimed to verify the trend in age at menarche in young Korean women during the last decade and associated factors. We analyzed a population-based sample of 3409 Korean girls, aged 10–18 years, using data from the Korean National Health and Nutrition Examination Surveys (KNHANES) II (2001), III (2005), IV (2007–2009), and V (2010 and 2011). Average age at menarche was studied using the Kaplan-Meier survival method and predictors were analyzed using Cox proportional hazards model. The percentage of subjects who had experienced menarche at each age level was compared by using the Cochran-Armitage test. Overall mean age at menarche was 12.7 years. The percentage of subjects who experienced menarche before the age of 12 years was 21.4 % in 2001 but increased to 34.6 % in 2010/2011 (p < 0.01). In addition, the percentage of girls who experienced menarche before the age of 14 years increased from 76 % in 2001 to 92 % in 2010/2011 (p < 0.005). Adolescents whose mothers who had experienced early menarche (HR 1.48, 95 % CI [1.22–1.80]), and adolescents who were overweight (HR 1.24, 95 % CI [1.04–1.49]) were more likely to have experienced menarche. Additionally, underweight adolescents (HR 0.27, 95 % CI [0.12–0.60]) and adolescents who had a mother having late menarche (HR 0.68, 95 % CI [0.59–0.79]) were expected to have late menarche. None of the socioeconomic factors assessed in our study showed an association with age at menarche. A downward trend in age at menarche was defined in Korean adolescents during the last decade. Furthermore, influences of genetic and nutritional parameters on individual variance in age at menarche were defined.

Fertility awareness and attitudes towards parenthood among Danish university college students

Abstract: Postponing parenthood has steadily increased during the past decades in Western countries. This trend has affected the size of families in the direction of fewer children born per couple. In addition, higher maternal age is associated with an increased risk of pregnancy-related complications such as prematurity and foetal death, while higher paternal age increases the risk of miscarriage and affects time-to-pregnancy. Hence, understanding the circumstances and reflections that influence the decision is greatly needed and little is known about potential gender difference influencing the choice. The aim was to investigate attitudes towards parenthood, intentions for childbirth and knowledge about fertility issues among men and women. We conducted a cross-sectional study based on a validated 49-item questionnaire among students, who attended selected mandatory lectures at a Danish university college in February to April 2016. The participation rate was 99%, and 517 completed the questionnaire. Though the majority of all participants wished to have children in the future (>86%), there was significant difference between the genders (p = 0.002). Women rated having children to be more important than men did (p < 0.001), while men rated higher the likelihood of abstaining from having children if faced with infertility (p = 0.003). Knowledge about fertility issues was similar between genders including poor knowledge about the age-related decline in female fertility. While women found it more important to have children before being ‘too old’ (p = 0.04), still more than 40% of all respondents intended to have their last child after the age of 35 years. For both genders the most important prerequisite for parenthood was having a partner to share responsibility with. Perceived or experienced life changes related to parenthood were generally positive such as personal development. The majority of respondents wished to have children, but many desired to have these after the biological decline in female fertility. The moderate knowledge level among both genders uncovered in this study is of concern. Future research should address the potential link between fertility knowledge and planning of parenthood. We may benefit from intervention studies examining the effect of routine preconception care.

Inequalities in the coverage of place of delivery and skilled birth attendance: analyses of cross-sectional surveys in 80 low and middle-income countries.

Abstract: Having a health worker with midwifery skills present at delivery is one of the key interventions to reduce maternal and newborn mortality. We sought to estimate the frequencies of (a) skilled birth attendant coverage, (b) institutional delivery, and (c) the combination of place of delivery and type of attendant, in LMICs. National surveys (DHS and MICS) performed in 80 LMICs since 2005 were analyzed to estimate these four categories of delivery care. Results were stratified by wealth quintile based on asset indices, and by urban/rural residence. The combination of place of delivery and type of attendant were also calculated for seven world regions. The proportion of institutional SBA deliveries was above 90 % in 25 of the 80 countries, and below 40 % in 11 countries. A strong positive correlation between SBA and institutional delivery coverage (rho: 0.97, p <0,001) was observed. Eight countries had over 10 % of home SBA deliveries, and two countries had over 10 % of institutional non-SBA deliveries. Except for South Asia, all regions had over 80 % of urban deliveries in the institutional SBA category, but in rural areas, only two regions (CEE & CIS, Middle East & North Africa) presented average coverage above 80 %. In all regions, institutional SBA deliveries were over 80 % in the richest quintile. Home SBA deliveries were more common in rural than in urban areas, and in the poorest quintiles in all regions. Facility non-SBA deliveries also tended to be more common in rural areas and among the poorest. Four different categories of delivery assistance were identified worldwide. Pro-urban and pro-rich inequalities were observed for coverage of institutional SBA deliveries.

Maternal death and obstetric care audits in Nigeria : a systematic review of barriers and enabling factors in the provision of emergency care

Abstract: Maternal death reviews and obstetric audits identify causes and circumstances related to occurrence of a maternal death or serious complication and inform improvements in quality of care. Given Nigeria’s high maternal mortality, the lessons learned from past experiences can provide a good evidence base for informed decision making. We aimed to synthesise findings from maternal death reviews and other obstetric audits conducted in Nigeria through a systematic review, seeking to identify common barriers and enabling factors related to the provision of emergency obstetric care. We searched for maternal death reviews and obstetric care audits reported in the published literature from 2000–2014. A ‘best-fit’ framework approach was used to extract data using a structured data extraction form. The articles that met the inclusion criteria were assessed using a nine point quality score. Of the 1,841 abstracts and titles at initial screening, 329 full text articles were reviewed and 43 papers fulfilled the inclusion criteria. Four types of barriers were reported related to: transport and referral; health workers; availability of services; and organisational factors. Three elements stand out in Nigeria as contributing to maternal mortality: delays in Caesarean section, unavailability of magnesium sulphate and lack of safe blood transfusion services. Obstetric care reviews and audits are useful activities to undertake and should be promoted by improving the processes used to conduct them, as well as extending their implementation to rural and basic level health facilities and to the community. Urgent areas for quality improvement in obstetric care, even in tertiary and teaching hospitals should focus on organisational factors to reduce delays in conducting Caesarean section and making blood and magnesium sulphate available for all who need these interventions.

Labor and birth care by nurse with midwifery skills in Brazil.

Abstract: The participation of nurses and midwives in vaginal birth care is limited in Brazil, and there are no national data regarding their involvement. The goal was to describe the participation of nurses and nurse-midwives in childbirth care in Brazil in the years 2011 and 2012, and to analyze the association between hospitals with nurses and nurse-midwives in labor and birth care and the use of good practices, and their influence in the reduction of unnecessary interventions, including cesarean sections. Birth in Brazil is a national, population-based study consisting of 23,894 postpartum women, carried out in the period between February 2011 and October 2012, in 266 healthcare settings. The study included all vaginal births involving physicians or nurses/nurse-midwives. A logistic regression model was used to examine the association between the implementation of good practices and suitable interventions during labor and birth, and whether care was a physician or a nurse/nurse-midwife led care. We developed another model to assess the association between the use of obstetric interventions during labor and birth to the personnel responsible for the care of the patient, comparing hospitals with decisions revolving exclusively around a physician to those that also included nurses/nurse-midwives as responsible for vaginal births. 16.2 % of vaginal births were assisted by a nurse/nurse-midwife. Good practices were significantly more frequent in those births assisted by nurses/nurse-midwives (ad lib. diet, mobility during labor, non-pharmacological means of pain relief, and use of a partograph), while some interventions were less frequently used (anesthesia, lithotomy position, uterine fundal pressure and episiotomy). In maternity wards that included a nurse/nurse-midwife in labour and birth care, the incidence of cesarean section was lower. The results of this study illustrate the potential benefit of collaborative work between physicians and nurses/nurse-midwives in labor and birth care. The adoption of good practices in managing labor and birth could be the first step toward more effective obstetric and midwifery care in Brazil. It may be easier to introduce new approaches rather than to eliminate old ones, which may explain why the reduction of unnecessary interventions during labor and birth was less pronounced than the adoption of new practices.

Global regional and national levels and trends of preterm birth rates for 1990 to 2014: protocol for development of World Health Organization estimates.

Abstract: The official WHO estimates of preterm birth are an essential global resource for assessing the burden of preterm birth and developing public health programmes and policies. This protocol describes the methods that will be used to identify, critically appraise and analyse all eligible preterm birth data, in order to develop global, regional and national level estimates of levels and trends in preterm birth rates for the period 1990 – 2014. We will conduct a systematic review of civil registration and vital statistics (CRVS) data on preterm birth for all WHO Member States, via national Ministries of Health and Statistics Offices. For Member States with absent, limited or lower-quality CRVS data, a systematic review of surveys and/or research studies will be conducted. Modelling will be used to develop country, regional and global rates for 2014, with time trends for Member States where sufficient data are available. Member States will be invited to review the methodology and provide additional eligible data via a country consultation before final estimates are developed and disseminated. This research will be used to generate estimates on the burden of preterm birth globally for 1990 to 2014. We invite feedback on the methodology described, and call on the public health community to submit pertinent data for consideration. Registered at PROSPERO CRD42015027439 Contact: pretermbirth@who.int

Health care seeking behaviours in pregnancy in rural Sindh, Pakistan: a qualitative study

Abstract: Pakistan has alarmingly high numbers of maternal mortality along with suboptimal care-seeking behaviour. It is essential to identify the barriers and facilitators that women and families encounter, when deciding to seek maternal care services. This study aimed to understand health-seeking patterns of pregnant women in rural Sindh, Pakistan. A qualitative study was undertaken in rural Sindh, Pakistan as part of a large multi-country study in 2012. Thirty three focus group discussions and 26 in-depth interviews were conducted with mothers [n = 173], male decision-makers [n = 64], Lady Health Workers [n = 64], Lady Health Supervisors [n = 10], Women Medical Officers [n = 9] and Traditional Birth Attendants [n = 7] in the study communities. A set of a priori themes regarding care-seeking during pregnancy and its complications as well as additional themes as they emerged from the data were used for analysis. Qualitative analysis was done using NVivo version 10. Women stated they usually visited health facilities if they experienced pregnancy complications or danger signs, such as heavy bleeding or headache. Findings revealed the importance of husbands and mothers-in-law as decision makers regarding health care utilization. Participants expressed that poor availability of transport, financial constraints and the unavailability of chaperones were important barriers to seeking care. In addition, private facilities were often preferred due to the perceived superior quality of services. Maternal care utilization was influenced by social, economic and cultural factors in rural Pakistani communities. The perceived poor quality care at public hospitals was a significant barrier for many women in accessing health services. If maternal lives are to be saved, policy makers need to develop processes to overcome these barriers and ensure easily accessible high-quality care for women in rural communities. NCT01911494

Determinants of health care seeking behaviour during pregnancy in Ogun State, Nigeria.

Abstract: In Nigeria, women too often suffer the consequences of serious obstetric complications that may lead to death. Delay in seeking care (phase I delay) is a recognized contributor to adverse pregnancy outcomes. This qualitative study aimed to describe the health care seeking practices in pregnancy, as well as the socio-cultural factors that influence these actions. The study was conducted in Ogun State, in south-western Nigeria. Data were collected through focus group discussions with pregnant women, recently pregnant mothers, male decision-makers, opinion leaders, traditional birth attendants, health workers, and health administrators. A thematic analysis approach was used with QSR NVivo version 10. Findings show that women utilized multiple care givers during pregnancy, with a preference for traditional providers. There was a strong sense of trust in traditional medicine, particularly that provided by traditional birth attendants who are long-term residents in the community. The patriarchal c influenced health-seeking behaviour in pregnancy. Economic factors contributed to the delay in access to appropriate services. There was a consistent concern regarding the cost barrier in accessing health services. The challenges of accessing services were well recognised and these were greater when referral was to a higher level of care which in most cases attracted unaffordable costs. While the high cost of care is a deterrent to health seeking behaviour, the cost of death of a woman or a child to the family and community is immeasurable. The use of innovative mechanisms for health care financing may be beneficial for women in these communities to reduce the barrier of high cost services. To reduce maternal deaths all stakeholders must be engaged in the process including policy makers, opinion leaders, health care consumers and providers. Underlying socio-cultural factors, such as structure of patriarchy, must also be addressed to sustainably improve maternal health. NCT01911494

Rate of gestational weight gain and preterm birth in relation to prepregnancy body mass indices and trimester: a follow-up study in China.

Abstract: To evaluate the association between rate of gestational weight gain and preterm birth varying prepregnancy body mass indices and trimester. Data from Maternal and Newborn’s Health Monitoring System on 17475 pregnant women who delivered live singletons at ≥ 28 weeks of gestation between October 2013 and September 2014 from 12 districts/counties of 6 provinces in China and started prenatal care at ≤ 12 weeks of gestation was analyzed. Gestational weight gain was categorized by rate of weight gain during the 2nd and 3rd trimester, based on the 2009 Institute of Medicine guidelines. Multivariable binary logistic regression models were conducted to investigate the association between rate of gestational weight gain and preterm birth stratified by prepregnancy body mass indices and trimester. Excessive weight gain occurred in 57.9 % pregnant women, and insufficient weight gain 12.5 %. Average rate of gestational weight gain in 2nd and 3rd trimester was independently associated with preterm birth (U-shaped), and the association varied by prepregnancy body mass indices and trimesters. In underweight women, excessive gestational weight gain was positively associated with preterm birth (OR 1.93, 95 % confidence interval (CI): 1.29- 2.88) when compared with women who gained adequately. While in overweight/obese women, insufficient gestational weight gain was positively associated with preterm birth (OR 3.92, 95 % CI: 1.13–13.67). When stratifying by trimester, we found that excessive weight gain in 3rd trimester had a significantly positive effect on preterm birth (OR 1.27, 95 % CI: 1.02–1.58). Excessive gestational weight gain among underweight pregnant women, insufficient gestational weight gain among overweight/obese women and excessive gestational weight gain in 3rd trimester were important predictors of preterm birth.

Challenges and strategies for sustaining youth-friendly health services — a qualitative study from the perspective of professionals at youth clinics in northern Sweden

Abstract: Youth-friendly health-care services — those that are accessible, acceptable, equitable, appropriate and effective for different youth subpopulations – are beneficial for youth health, but not easy to implement and sustain. Sweden is among the few countries where youth-friendly health-care services have been integrated within the public health system and sustained for a long time. This study explores the challenges and strategies in providing sustainable youth-friendly health-care services, from the perspective of professionals working in youth clinics in northern Sweden. Eleven semi-structured interviews with various health-care professionals working in youth clinics in northern Sweden were conducted. The interviews were transcribed verbatim, and analysed using thematic analysis in relation to the World Health Organization domains of youth friendliness. Four themes emerged from the analysis of the data: 1) ‘Meeting youths on their own terms – the key to ensuring a holistic and youth-centred care’ was related to the acceptability and appropriateness of the services; 2) ‘Organizational challenges and strategies in keeping professionals’ expertise on youth updated’ referred to the domain of effectiveness; 3) ‘Youth clinics are accessible for those who know and can reach them’ was related to the domains of accessibility and equity, and 4) ‘The challenge of combining strong directions and flexibility in diverse local realities’ focused on the struggle to sustain the youth clinics organization and their goals within the broader health system. Professionals working in youth clinics are perceived as motivated, interested and knowledgeable about youth, and the clinics ensure confidentiality and a youth-centred and holistic approach. Challenges remain, especially in terms of ensuring equitable access to different youth subpopulations, improving monitoring routines and ensuring training and competence for all professionals, independently of the location and characteristics of the clinic. Youth clinics are perceived as an indisputable part of the Swedish health system, but organizational challenges are also pointed out in terms of weak clear directives and leadership, heavy workload, local/regional diversity and unequitable distribution of resources.

Pregnancy wantedness, frequency and timing of antenatal care visit among women of childbearing age in Kenya

Abstract: A woman’s health seeking behaviour during pregnancy has been found to have significant repercussions on her wellbeing and that of her unborn child. For example, the risk of poor pregnancy outcomes and maternal death is higher among women who do not receive antenatal care. The study described the characteristics of women who reported wanted, unwanted and mistimed pregnancies from their last birth at the time of the survey; the linkage between frequency of antenatal care visits and pregnancy wantedness and the relationship between timing of the first antenatal care visit and pregnancy wantedness since maternal morbidity and mortality are higher among women who do not receive antenatal care. The 2008-09 Kenya Demographic and Health Survey data is used and multinomial logistic regression and logistic regression informed the study analysis. Results showed that women, who reported wanted pregnancy were more likely to receive antenatal care while those who reported unwanted pregnancy were less likely to receive antenatal care, but more likely to attend late the first time and have fewer than four antenatal care visits. Also, mistimed pregnancies were associated with low frequency of antenatal care visit and late timing of the first visit. Our findings confirm an association between pregnancy wantedness, frequency of antenatal care visits and timing of the first antenatal care visit. Women whose pregnancy was reported as mistimed and unwanted were more likely not to receive any antenatal care and when they did; they went for fewer than the recommended four visits with late timing. Health policy and strategies should ensure that all pregnant women regardless of their pregnancy status at the time of conception first receive antenatal care, and receive it in a timely manner and make at least four antenatal care visits before delivery. This will help to identify health complications that may arise during and after delivery and reduce maternal, new-born and infant mortality. Information, education and communication campaigns on family planning especially for spacing and matters related to antenatal care visits, timing and frequency should be intensified nationally.

Attitudes towards Human Papillomavirus vaccination among African parents in a city in the north of England: A qualitative study.

Abstract: Human papillomavirus (HPV) is sexually transmitted and has been conclusively linked to cervical cancer and genital warts. Cervical cancer is attributed to approximately 1100 deaths annually in UK, and is the second most common female cancer globally. It has been suggested that black African women are more predisposed to HPV infection and cervical cancer. A vaccine has been developed to reduce HPV infection, and in the UK, has been offered to 12–13 year old adolescent girls through schools as part of their childhood immunization programme since 2008. Upon programme initiation, it was noted that vaccine uptake was lower in schools where girls from ethnic minority groups were proportionately higher. The study’s objectives were to explore factors influencing UK based African parents’ acceptance or decline of the HPV vaccine, whether fathers and mothers share similar views pertaining to vaccination and any interfamily tensions resulting from differing views. A qualitative study was conducted with five African couples residing in north England. Face to face semi-structured interviews were carried out. Participants were parents to at least one daughter aged between 8 and 14 years. Recruitment was done through purposive sampling using snowballing. HPV and cervical cancer awareness was generally low, with awareness lower in fathers. HPV vaccination was generally unacceptable among the participants, with fear of promiscuity, infertility and concerns that it’s still a new vaccine with yet unknown side effects cited as reasons for vaccine decline. There was HPV risk denial as religion and good cultural upbringing seemed to result in low risk perceptions, with HPV and cervical cancer generally perceived as a white person’s disease. Religious values and cultural norms influenced vaccine decision-making, with fathers acting as the ultimate decision makers. Current information about why the vaccine is necessary was generally misunderstood. Tailored information addressing religious and cultural concerns may improve vaccine acceptability in African parents.

Factors associated with maternal near miss in childbirth and the postpartum period: findings from the birth in Brazil National Survey, 2011-2012.

Abstract: Maternal near-miss (MNM) audits are considered a useful approach to improving maternal healthcare. The aim of this study was to evaluate the factors associated with maternal near-miss cases in childbirth and the postpartum period in Brazil. The study is based on data from a nationwide hospital-based survey of 23,894 women conducted in 2011–2012. The data are from interviews with mothers during the postpartum period and from hospital medical files. Univariate and multivariable logistic regressions were performed to analyze factors associated with MNM, including estimation of crude and adjusted odds ratios and their respective 95 % confidence intervals (95 % CI). The estimated incidence of MNM was 10.2/1,000 live births (95 % CI: 7.5–13.7). In the adjusted analyses, MNM was associated with the absence of antenatal care (OR: 4.65; 95 % CI: 1.51–14.31), search for two or more services before admission to delivery care (OR: 4.49; 95 % CI: 2.12–9.52), obstetric complications (OR: 9.29; 95 % CI: 6.69–12.90), and type of birth: elective C-section (OR: 2.54; 95 % CI: 1.67–3.88) and forceps (OR: 9.37; 95 % CI: 4.01–21.91). Social and demographic maternal characteristics were not associated with MNM, although women who self-reported as white and women with higher schooling had better access to antenatal and maternity care services. The high proportion of elective C-sections performed among women in better social and economic situations in Brazil is likely attenuating the benefits that could be realized from improved prenatal care and greater access to maternity services. Strategies for reducing the rate of MNM in Brazil should focus on: 1) increasing access to prenatal care and delivery care, particularly among women who are at greater social and economic risk and 2) reducing the rate of elective cesarean section, particularly among women who receive services at private maternity facilities, where C-section rates reach 90 % of births.

Who's that girl? A qualitative analysis of adolescent girls' views on factors associated with teenage pregnancies in Bolgatanga, Ghana

Abstract: Adolescent pregnancy remains a public health concern, with diverse serious consequences, including increased health risk for mother and child, lost opportunities for personal development, social exclusion, and low socioeconomic attainments. Especially in Africa, teenage pregnancy rates are high. It is important to find out how girls without pregnancy experience differ in their contraceptive decision-making processes as compared with their previously studied peers with pregnancy experience to address the high rate of teenage pregnancies. We conducted semi-structured in-depth interviews with never been pregnant girls (N = 20) in Bolgatanga, Ghana, to explore the psychosocial and environmental factors influencing the sexual decision making of adolescents. Themes such as relationships, sex, pregnancy, family planning and psychosocial determinants (knowledge, attitudes, self-efficacy, norms, risk perceptions) derived from empirical studies and theories related to sexuality behavior guided the development of the interview protocol. Results showed that the girls did talk about sexuality with their mothers at home and did receive some form of sexual and reproductive health education, including the use of condoms discussions in school. Participants reported high awareness of pregnancy risk related to unprotected sex, were positive about using condoms and indicated strong self-efficacy beliefs towards negotiating condom use. The girls also formulated clear future goals, including coping plans such as ways to prevent unwanted pregnancies to reach these targets. On the other hand, their attitudes towards family planning (i.e., contraceptives other than condoms) were negative, and they hold boys responsible for buying condoms. An open parental communication on sexuality issues at home, comprehensive sex education in school and attitude, self-efficacy, risk perception towards contraception, alongside with goal-setting, seem to be protective factors in adolescent girls’ pregnancy prevention efforts. These factors should be targets in future intervention programs at the individual, interpersonal, and school and community levels.

Tobacco smoking is associated with decreased semen quality

Abstract: Tobacco smoking is a public health issue and has been implicated in adverse reproductive outcomes including semen quality. Available data however provides conflicting findings. The objective of this study was to evaluate the effect of tobacco smoking on semen quality among men in Ghana. In this study, a total of 140 subjects were recruited, comprising 95 smokers and 45 non-smokers. Smokers were further categorized into mild, moderate and heavy smokers. Semen parameters such as sperm concentration, motility, viability and normal morphology were measured according to the World Health Organisation criteria. The study showed that smokers had significantly lower semen volume, sperm concentration, sperm motility, total sperm count, sperm morphology, free testosterone and follicle stimulating hormone (p <0.05 respectively), compared with non-smokers. Smokers were at a higher risk of developing oligospermia, asthenozoospermia and teratozoospermia (OR = 3.1, 4.2 and, 4.7; p <0.05) than non-smokers. Results demonstrated a decline in semen quality in a dose dependent tobacco smoking manner.

Clinical and perceived quality of care for maternal, neonatal and antenatal care in Kenya and Namibia: the service provision assessment.

Abstract: The majority of women in sub-Saharan Africa now deliver in a facility, however, little is known about the quality of services for maternal and newborn basic and emergency care, nor how this is associated with patient’s perception of their experiences. Using data from the Service Provision Assessment (SPA) survey from Kenya 2010 and Namibia 2009, we explore whether facilities have the necessary signal functions for providing emergency and basic maternal (EmOC) and newborn care (EmNC), and antenatal care (ANC) using descriptives and multivariate regression. We explore differences by type of facility (hospital, center or other) and by private and public facilities. Finally, we see if patient satisfaction (taken from exit surveys at antenatal care) is associated with the quality of services (specific services provided). We find that most facilities do not have all of the signal functions, with 46 and 27 % in Kenya and 18 and 5 % in Namibia of facilities have high/basic scores in routine and emergency obstetric care, respectively. We found that hospitals preform better than centers in general and few differences emerged between public and private facilities. Patient perceptions were not consistently associated with services provided; however, patients had fewer complaints in private compared to public facilities in Kenya (−0.46 fewer complaints in private) and smaller facilities compared to larger in Namibia (−0.26 fewer complaints in smaller facilities). Service quality itself (measured in scores), however, was only significantly better in Kenya for EmOC and EmNC. This analysis sheds light on the inadequate levels of care for saving maternal and newborn lives in most facilities in two countries of Africa. It also highlights the disconnect between patients’ perceptions and clinical quality of services. More effort is needed to ensure that high quality supply of services is present to meet growing demand as an increasing number of women deliver in facilities.

Family planning knowledge attitudes and practices in refugee and migrant pregnant and post-partum women on the Thailand-Myanmar border - a mixed methods study.

Abstract: Lack of data in marginalized populations on knowledge, attitudes and practices (KAP) hampers efforts to improve modern contraceptive practice. A mixed methods study to better understand family planning KAP amongst refugee and migrant women on the Thailand-Myanmar border was conducted as part of an ongoing effort to improve reproductive health, particularly maternal mortality, through Shoklo Malaria Research Unit (SMRU) antenatal and birthing services. Cross-sectional surveys and focus group discussions (FGDs) in currently pregnant women; and in-depth interviews (IDIs) in selected post-partum women with three children or more; were conducted. Quantitative data were described with medians and proportions and compared using standard statistical tests. Risk factors associated with high parity (>3) were identified using logistic regression analysis. Qualitative data were coded and grouped and discussed using identified themes. In January-March 2015, 978 women participated in cross-sectional studies, 120 in FGD and 21 in IDI. Major positive findings were: > 90 % of women knew about contraceptives for birth spacing, >60 % of women in the FGD and IDI reported use of family planning (FP) in the past and nearly all women knew where they could obtain FP supplies. Major gaps identified included: low uptake of long acting contraception (LAC), lack of awareness of emergency contraception (>90 % of women), unreliable estimates of when child bearing years end, and misconceptions surrounding female sterilization. Three was identified as the ideal number of children in the cross-sectional survey but less than half of the women with this parity or higher in the IDI actually adopted LAC leaving them at risk for unintended pregnancy. Discussing basic female anatomy using a simple diagram was well received in FGD and IDIs. LAC uptake has increased particularly the IUD from 2013–2015. Definitive contextual issues were identified during this study and a significant range of action points have been implemented in FP services at SMRU as a result, particularly in regard to the IUD. The importance of the role and attitudes of husbands were acknowledged by women and studies to investigate male perspectives in future may enhance FP practice in this area.

The ongoing violence against women: Female Genital Mutilation/Cutting

Abstract: Female Genital Mutilation/Cutting (FGM/C) comprises different practices involving cutting, pricking, removing and sometimes sewing up external female genitalia for non-medical reasons. The practice of FGM/C is highly concentrated in a band of African countries from the Atlantic coast to the Horn of Africa, in areas of the Middle East such as Iraq and Yemen, and in some countries in Asia like Indonesia. Girls exposed to FGM/C are at risk of immediate physical consequences such as severe pain, bleeding, and shock, difficulty in passing urine and faeces, and sepsis. Long-term consequences can include chronic pain and infections. FGM/C is a deeply entrenched social norm, perpetrated by families for a variety of reasons, but the results are harmful. FGM/C is a human rights issue that affects girls and women worldwide. The practice is decreasing, due to intensive advocacy activities of international, national, and grassroots agencies. An adolescent girl today is about a third less likely to be cut than 30 years ago. However, the rates of abandonment are not high enough, and change is not happening as rapidly as necessary. Multiple interventions have been implemented, but the evidence base on what works is lacking. We in reproductive health must work harder to find strategies to help communities and families abandon these harmful practices.

Young people's parental discussion about sexual and reproductive health issues and its associated factors in Awabel woreda, Northwest Ethiopia.

Abstract: In Ethiopia besides the very low health seeking behavior of young people, they do not have access to sexual and reproductive health information and even the existing health services are adult-centered. Furthermore, health providers are not well equipped in addressing young people sexual and reproductive health needs. Therefore, parent-young people discussion about sexual and reproductive health issues are crucial in increasing their awareness and reduces their risky sexual behaviors. This study was aimed to assess young people’s parental discussion about sexual and reproductive health issues and its associated factors in Awabel woreda, Northwest Ethiopia. A community based cross-sectional study was conducted among 781 young people aged 10–24 years in Awabel Woreda, Northwest Ethiopia. A pre-tested structured interview administered questionnaire was used for the data collection. The collected data were entered using Epi Data 3.1 and analyzed using SPSS for windows version 21. In the past 6 months, about one quarter, 25.3 % of young people had a parental discussion about sexual and reproductive health issues. Young people who reside in urban areas were more likely to discuss on sexual and reproductive health issues with their parents [AOR = 2.44, 95 % CI: 1.54–3.89]. Similarly, being male was more likely to have a parental discussion about sexual and reproductive health issues than females [AOR = 1.63, 95 % CI: 1.11–2.38]. Furthermore, the odds of parent-young people discussion about SRH matters was more likely among young people aged 20–24 years [AOR = 4.57, 95 % CI: 2.13–9.82], living with fathers [AOR = 2.46, 95 % CI: 1.20–5.04] and had attained a primary level of education [AOR = 2.89, 95 % CI: 1.22–6.87]. Parents lack of interest to discuss, feeling ashamed and culturally not acceptable to talk about sexual matters were found to deter young people’s in discussing sexual and reproductive health matters. Parent-young people discussion about sexual and reproductive health is very low and there are different hindering factors. And therefore, young people’s sexual and reproductive health programs or policies should be designed in addressing the cultural and societal factors besides the individual or behavioral factors.

Inter-pregnancy interval and risk of recurrent pre-eclampsia: systematic review and meta-analysis.

Abstract: Women with a history of pre-eclampsia have a higher risk of developing pre-eclampsia in subsequent pregnancies. However, the role of the inter-pregnancy interval on this association is unclear. To explore the effect of inter-pregnancy interval on the risk of recurrent pre-eclampsia or eclampia. MEDLINE, EMBASE and LILACS were searched (inception to July 2015). Cohort studies assessing the risk of recurrent pre-eclampsia in the immediate subsequent pregnancy according to different birth intervals. Two reviewers independently performed screening, data extraction, methodological and quality assessment. Meta-analysis of adjusted odds ratios (aOR) with 95 % confidence intervals (CI) was used to measure the association between various interval lengths and recurrent pre-eclampsia or eclampsia. We identified 1769 articles and finally included four studies with a total of 77,561 women. The meta-analysis of two studies showed that compared to inter-pregnancy intervals of 2–4 years, the aOR for recurrent pre-eclampsia was 1.01 [95 % CI 0.95 to 1.07, I2 0 %] with intervals of less than 2 years and 1.10 [95 % CI 1.02 to 1.19, I2 0 %] with intervals longer than 4 years. Compared to inter-pregnancy intervals of 2 to 4 years, shorter intervals are not associated with an increased risk of recurrent pre-eclampsia but longer intervals appear to increase the risk. The results of this review should be interpreted with caution as included studies are observational and thus subject to possible confounding factors.