(Abstracted from
Lancet Glob Health
2021;9:e1119–e1128)
Hypertension in pregnancy (HIP) has served as a marker for increased risk of adverse pregnancy outcomes, including fetal growth restriction, ...stillbirth, severe maternal morbidity, and maternal mortality. Traditionally, HIP has been defined as systolic blood pressure (sBP) of ≥140 mm Hg, diastolic BP (dBP) of ≥90 mm Hg, or both.
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.
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.
INTRODUCTION:
Understanding cost drivers and estimating societal costs are important challenges for economic evaluation of health technologies in low-and-middle-income countries (LMICs) (1). This ...study assessed community experiences of health resource utilization and perceived cost drivers from a societal perspective to inform the design of an economic model for the Community Level Interventions for Pre-eclampsia (CLIP) trials (2).
METHODS:
Qualitative research was undertaken alongside the CLIP trial in two districts of Sindh province, Pakistan. Nine focus groups were conducted with a wide range of stakeholders, including pregnant women, mothers-in-law, husbands, fathers-in-law, healthcare providers at community and health facility-levels, and health decision-/policy-makers at the district-level. The societal perspective included out-of-pocket (OOP), health system, and program implementation costs related to CLIP. Thematic analysis was performed using NVivo software.
RESULTS:
Most pregnant women and male decision makers reported a large burden of OOP costs for in- and out-patient care, informal care from traditional healers, self-medication, childbirth, newborn care, transport to health facility, and missed wages by caretakers. Many healthcare providers identified health system costs associated with human resources for hypertension risk assessment, transport, and communication about patient referrals. Health decision-/policy-makers recognized program implementation costs (such as the mobile health infrastructure, staff training, and monitoring/supervision) as major investments for the health system.
CONCLUSIONS:
Our investigation of care-seeking practices revealed financial implications for families of pregnant women, and program implementation costs for the health system. The societal perspective provided comprehensive knowledge of cost drivers to guide an economic appraisal of the CLIP trial in Sindh, Pakistan.
Abstract
Background
The Three Delays Framework was instrumental in the reduction of maternal mortality leading up to, and during the Millennium Development Goals. However, this paper suggests the ...original framework might be reconsidered, now that most mothers give birth in facilities, the quality and continuity of the clinical care is of growing importance.
Methods
The paper explores the factors that contributed to maternal deaths in rural Pakistan and Mozambique, using 76 verbal autopsy narratives from the Community Level Interventions for Pre-eclampsia (CLIP) Trial.
Results
Qualitative analysis of these maternal death narratives in both countries reveals an interplay of various influences, such as, underlying risks and comorbidities, temporary improvements after seeking care, gaps in quality care in emergencies, convoluted referral systems, and arrival at the final facility in critical condition. Evaluation of these narratives helps to reframe the pathways of maternal mortality beyond a single journey of care-seeking, to update the categories of seeking, reaching and receiving care.
Conclusions
There is a need to supplement the pioneering “Three Delays Framework” to include focusing on continuity of care and the “Four Critical Connection Points”: (1) between the stages of pregnancy, (2) between families and health care workers, (3) between health care facilities and (4) between multiple care-seeking journeys.
Trial registration
NCT01911494, Date Registered 30/07/2013.
Objective: To gain insight into learning-environment of Maternal Neonatal and Child Health community clerkship, using Dundee Ready Educational Environment Measure questionnaire and focus group ...discussion to improve students' quality of learning.Study Design: Sequential Mixed Method Study.Place and Duration of Study: Primary Centers (Aga Khan Health Services, Pakistan) and Secondary Center (Aga Khan University), from Nov 2014 to Oct 2015.Material and Methods: All consenting third-year MBBS students after completing maternal neonatal and childhealth (MNCH) rotation anonymously filled the Dundee Ready Educational Environment Measure (DREEM) questionnaire. Data was entered in MS Excel 2013 and SPSS version 21. Descriptive statistics were calculated such as frequencies, mean and standard deviation of the total/subscale scores. Independent samples t test was used to identify gender-related differences among DREEM scores with p-value of < 0.05 as statistically significant.Focus Group Discussion (FGD) was conducted with all consenting facilitators (Faculty/Lady Health Visitors). Thematic analysis of qualitative data was done using constant iterative approach.Results: From a total of 99 students, 78 (78.8%) consented, of which 36 (46.2%) were males and 42 (53.8%) females. Mean total DREEM score was 126.26/200 (63.13%) indicating a more positive learning environment. Total means with percentages and interpretation of subscale scores showed 'Students Perception of Learning (SPOL)', 28.92/ 48 (60.25%) indicating more positive approach; 'Students Perception of Teachers (SPOT)', 28.58/ 44 (64.95%) indicating teachers are moving in right direction; 'Students Academic Self-Perception (SASP)', 20.64/32 (64.5%) indicating students felt positive academically; 'Students' Perception of Atmosphere (SPOA)' 31.17/48 (64.93%) indicating positive learning-atmosphere and Students' Social Self-Perception (SSSP), 16.93/28 (60.46%) showing not-too-bad social-environment. Thus, DREEM results showed, students perceived their learning environment to be overall positive.As a composite score in the five domains of educational environment no statistically significant difference was found between males and females. (SPOL: p value 0.655; SPOT: p value 0.760; SASP: p value 0.685; SPOA: p value 0.245; SSSP: p value 0.280).Common issues identified through DREEM and student-facilitators through FGD were grouped into three themes; 'Challenges faced', 'Student-learning facilitation' and 'Way-forward'. Triangulation of data from DREEM questionnaire and FGD indicated validation of outcomes.Conclusion: MNCH clerkship is a rotation, in a low/middle income country, in early years of inception. Students are satisfied but there is scope for improvement. This evaluation helped identify problem areas to enable improvement of program and inspire other institutions to arrange community clerkships.
Maternal mortality is of global public health concern and >99 % of maternal deaths occur in less developed countries. The common causes of direct maternal death are hemorrhage, sepsis and ...pre-eclampsia/eclampsia. In Pakistan, pre-eclampsia/eclampsia deaths represents one-third of maternal deaths reported at the tertiary care hospital settings. This study explored community perceptions, and traditional management practices about pre-eclampsia/eclampsia.
A qualitative study was conducted in Sindh Province of Pakistan from February to July 2012. Twenty-six focus groups were conducted, 19 with women of reproductive age/mothers-in-law (N = 173); and 7 with husbands/fathers-in-law (N = 65). The data were transcribed verbatim in Sindhi and Urdu, then analyzed for emerging themes and sub-themes using NVivo version 10 software.
Pre-eclampsia in pregnancy was not recognized as a disease and there was no name in the local languages to describe this. Women however, knew about high blood pressure and were aware they can develop it during pregnancy. It was widely believed that stress and weakness caused high blood pressure in pregnancy and it caused symptoms of headache. The perception of high blood pressure was not based on measurement but on symptoms. Self-medication was often used for headaches associated with high blood pressure. They were also awareness that severely high blood pressure could result in death.
Community-based participatory health education strategies are recommended to dispel myths and misperceptions regarding pre-eclampsia and eclampsia. The educational initiatives should include information on the presentation, progression of illness, danger signs associated with pregnancy, and appropriate treatment.
To analyse referral pattern of high-risk obstetric cases from secondary to tertiary care hospitals and to assess their maternal and neonatal outcomes.
This retrospective study was conducted at the ...Aga Khan University Hospital, Karachi, and comprised all referred obstetric cases from secondary-level hospitals to tertiary-level care within and outside the Hospital between January 2011 and December 2014. Day and time of referral, reason for referral as well as maternal and neonatal outcomes were collected. SPSS 19 was used for data analysis.
Of the 634 obstetric referrals, 279(44%) patients were referred to the study site, while 355(56%) sought care in other hospitals. Of those patients who were referred to the AKUH, medical records of 195(69.9%) were available for review. The mean age of the participants was 28±4.7 years. Obstetric complications led to 122(61%) referrals. The top three reasons among these were pregnancy-induced hypertension, preterm labour and foetal causes. Medical causes such as viral infections were the cause of 50(27%) referrals. Moreover, 177(91%) patients were pregnant at the time of referral and the remaining 18(9%) were referred after delivery. Of the pregnant women, 133(75%) delivered at the study site. Caesarean section was the mode in 92(69%) deliveries. There was 1(0.75%) maternal death due to puerperal sepsis while 9(7%) neonatal deaths were recorded.
The most common reason for referrals was obstetric indications. Moreover, a quarter of referrals were initiated due to medical conditions, most of which were due to infections.
PDF
