ObjectiveMaternal morbidity affects millions of women, the burden of which is highest in low resource settings. We sought to explore when this ill-health occurs and is most significant.SettingsA ...descriptive observational cross-sectional study at primary and secondary-level healthcare facilities in India, Pakistan, Kenya and Malawi.ParticipantsWomen attending for routine antenatal care, childbirth or postnatal care at the study healthcare facilities.Primary and secondary outcomesPhysical morbidity (infectious, medical, obstetrical), psychological and social comorbidity were assessed at five stages: first half of pregnancy (≤20 weeks), second half of pregnancy (>20 weeks), at birth (within 24 hours of childbirth), early postnatal (day 1–7) and late postnatal (week 2–12).Results11 454 women were assessed: India (2099), Malawi (2923), Kenya (3145) and Pakistan (3287) with similar numbers assessed at each of the five assessment stages in each country. Infectious morbidity and anaemia are highest in the early postnatal stage (26.1% and 53.6%, respectively). For HIV, malaria and syphilis combined, prevalence was highest in the first half of pregnancy (10.0%). Hypertension, pre-eclampsia and urinary incontinence are most common in the second half of pregnancy (4.6%, 2.1% and 6.6%). Psychological (depression, thoughts of self-harm) and social morbidity (domestic violence, substance misuse) are significant at each stage but most commonly reported in the second half of pregnancy (26.4%, 17.6%, 40.3% and 5.9% respectively). Of all women assessed, maternal morbidity was highest in the second half of pregnancy (81.7%), then the early postnatal stage (80.5%). Across the four countries, maternal morbidity was highest in the second half of pregnancy in Kenya (73.8%) and Malawi (73.8%), and in the early postnatal stage in Pakistan (92.2%) and India (87.5%).ConclusionsWomen have significant maternal morbidity across all stages of the continuum of pregnancy and childbirth, and especially in the second half of pregnancy and after childbirth.
to examine the transition of care in the postnatal period from a regional hospital to a remote health service and describe the quality and safety implications for remote dwelling Aboriginal mothers ...and infants.
a retrospective cohort study of maternal health service utilisation and birth outcomes, key informant interviews with health service providers and participant observation in a hospital and two remote health centres. Data were analysed using descriptive statistics and content analysis.
a maternity unit in a regional public hospital and two remote health centres within large Aboriginal communities in the Top End of the Northern Territory, Australia.
poor discharge documentation, communication and co-ordination between hospital and remote health centre staff occurred. In addition, the lack of clinical governance and a specific position holding responsibility for the postnatal discharge planning process in the hospital system were identified as serious risks to the safety of the mother and infant.
the quality and safety of discharge practices for remote dwelling mothers and their infants in the transition from hospital to their remote health service following birth need to be improved. The discharge process and service delivery model must be restructured to reduce the adverse effects of poor standards of care on mothers and infants.
Problem: In the Northern Territory, 64% of Indigenous births are to remote‐dwelling mothers. Delivering high‐quality health care in remote areas is challenging, but service improvements, informed by ...participative action research, are under way. Evaluation of these initiatives requires appropriate indicators. Few of the many existing maternal and infant health indicators are specifically framed for the remote context or exemplify an Indigenous consumer perspective. We aimed to identify an indicator framework with appropriate indicators to demonstrate improvements in health outcomes, determinants of health and health system performance for remote‐dwelling mothers and infants from pregnancy to first birthday. Design: We reviewed existing indicators; invited input from experts; investigated existing administrative data collections and examined findings from a record audit, ethnographic work and the evaluation of the Darwin Midwifery Group Practice. Setting: Northern Territory. Process: About 660 potentially relevant indicators were identified. We adapted the Aboriginal and Torres Strait Islander Health Performance Framework and populated the resulting framework with chosen indicators. We chose the indicators best able to monitor the impact of changes to remote service delivery by eliminating duplicated or irrelevant indicators using expert opinion, triangulating data and identifying key issues for remote maternal and infant health service improvements. Lessons learnt: We propose 31 indicators to monitor service delivery to remote‐dwelling Indigenous mothers and infants. Our inclusive indicator framework covers the period from pregnancy to the first year of life and includes existing indicators, but also introduces novel ones. We also attempt to highlight an Indigenous consumer.
Improving access to emergency obstetric and newborn care (EmONC) improves maternal and newborn health. However, there is evidence that the pre-service midwifery training curriculum is deficient in ...developing countries.
This study measured the effectiveness of pre-service Emergency obstetric care training intervention package on the knowledge and skills of final year midwifery students in Kenya.
The study was a quasi-experimental controlled trial (ISRCTN 74563398) with one control and two intervention arms (full and partial), involving 12 Kenya Medical Training Colleges (KMTCs) and 381 final year midwifery students. Intervention arms’ KMTCs received EmONC skills training equipment, training of lecturers on teaching methods, EmONC and clinical supervision skills, (and 12 months of mentoring for full intervention arm). Control arm KMTCs had no intervention. Students’ knowledge and practical skills scores 12 months after the bundle of interventions were analysed using mixed effects linear models.
A statistically significant difference was detected between the study arms for the practical skills test (p < 0.001) but not for the knowledge test (p = 0.23). The odds of achieving scores of 80 % or higher in the knowledge test was significantly higher in the full intervention group A compared to the control group OR 3.2 (1.1 – 9.8), p < 0.05. The scores in the skills tests were significantly higher in the intervention groups A and B compared to the control group 14.5 (4.2 – 24.9), p < 0.001 and 24.9 (14.5–35.2) respectively.
The pre-service EmONC intervention package was effective in improving the knowledge and skills of final year midwifery students.
Common perinatal mental disorders are the most frequent complications of pregnancy, childbirth and the postpartum period, and the prevalence among women in low- and middle-income countries is the ...highest at nearly 20%. Women are the cornerstone of a healthy and prosperous society and until their mental health is taken as seriously as their physical wellbeing, we will not improve maternal mortality, morbidity and the ability of women to thrive. On the heels of several international efforts to put perinatal mental health on the global agenda, we propose seven urgent actions that the international community, governments, health systems, academia, civil society, and individuals should take to ensure that women everywhere have access to high-quality, respectful care for both their physical and mental wellbeing. Addressing perinatal mental health promotion, prevention, early intervention and treatment of common perinatal mental disorders must be a global priority.
Midwifery education is under-invested in developing countries with limited opportunities for midwifery educators to improve/maintain their core professional competencies. To improve the quality of ...midwifery education and capacity for educators to update their competencies, a blended midwifery educator-specific continuous professional development (CPD) programme was designed with key stakeholders. This study evaluated the feasibility of this programme in Kenya and Nigeria.
This was a mixed methods intervention study using a concurrent nested design. 120 randomly selected midwifery educators from 81 pre-service training institutions were recruited. Educators completed four self-directed online learning (SDL) modules and three-day practical training of the blended CPD programme on teaching methods (theory and clinical skills), assessments, effective feedback and digital innovations in teaching and learning. Pre- and post-training knowledge using multiple choice questions in SDL; confidence (on a 0-4 Likert scale) and practical skills in preparing a teaching a plan and microteaching (against a checklist) were measured. Differences in knowledge, confidence and skills were analysed. Participants' reaction to the programme (relevance and satisfaction assessed on a 0-4 Likert scale, what they liked and challenges) were collected. Key informant interviews with nursing and midwifery councils and institutions' managers were conducted. Thematic framework analysis was conducted for qualitative data.
116 (96.7%) and 108 (90%) educators completed the SDL and practical components respectively. Mean knowledge scores in SDL modules improved from 52.4% (± 10.4) to 80.4% (± 8.1), preparing teaching plan median scores improved from 63.6% (IQR 45.5) to 81.8% (IQR 27.3), and confidence in applying selected pedagogy skills improved from 2.7 to 3.7, p < 0.001. Participants rated the SDL and practical components of the programme high for relevance and satisfaction (median, 4 out of 4 for both). After training, 51.4% and 57.9% of the participants scored 75% or higher in preparing teaching plans and microteaching assessments. Country, training institution type or educator characteristics had no significant associations with overall competence in preparing teaching plans and microteaching (p > 0.05). Qualitatively, educators found the programme educative, flexible, convenient, motivating, and interactive for learning. Internet connectivity, computer technology, costs and time constraints were potential challenges to completing the programme.
The programme was feasible and effective in improving the knowledge and skills of educators for effective teaching/learning. For successful roll-out, policy framework for mandatory midwifery educator specific CPD programme is needed.
Remote dwelling Aboriginal infants from northern Australia have a high burden of disease and frequently use health services. Little is known about the quality of infant care provided by remote health ...services. This study describes the adherence to infant guidelines for anaemia and growth faltering by remote health staff and barriers to effective service delivery in remote settings.
A mixed method study drew data from 24 semi-structured interviews with clinicians working in two remote communities in northern Australia and a retrospective cohort study of Aboriginal infants from these communities, born 2004-2006 (n = 398). Medical records from remote health centres were audited. The main outcome measures were the period prevalence of infants with anaemia and growth faltering and management of these conditions according to local guidelines. Qualitative data assessed clinicians' perspectives on barriers to effective remote health service delivery.
Data from 398 health centre records were analysed. Sixty eight percent of infants were anaemic between six and twelve months of age and 42% had documented growth faltering by one year. Analysis of the growth data by the authors however found 86% of infants experienced growth faltering over 12 months. Clinical management and treatment completion was poor for both conditions. High staff turnover, fragmented models of care and staff poorly prepared for their role were barriers perceived by clinicians' to impact upon the quality of service delivery.
Among Aboriginal infants in northern Australia, malnutrition and anaemia are common and occur early. Diagnosis of growth faltering and clinicians' adherence to management guidelines for both conditions was poor. Antiquated service delivery models, organisation of staff and rapid staff turnover contributed to poor quality of care. Service redesign, education and staff stability must be a priority to redress serious deficits in quality of care provided for these infants.
Abstract
Background:
International Confederation of Midwives and World Health Organization recommend core competencies for midwifery educators for effective theory and practical teaching and ...practice. Deficient curricula and lack of skilled midwifery educators are important factors affecting the quality of graduates from midwifery programmes. The objective of the study was to assess the capacity of university midwifery educators to deliver the updated competency-based curriculum after the capacity strengthening workshop in Kenya.
Methods:
The study used a quasi-experimental (pre-post) design. A four-day training to strengthen the capacity of educators to deliver emergency obstetrics and newborn care (EmONC) within the updated curriculum was conducted for 30 midwifery educators from 27 universities in Kenya. Before-after training assessments in knowledge, two EmONC skills and self-perceived confidence in using different teaching methodologies to deliver the competency-based curricula were conducted. Wilcoxon signed-rank test was used to compare the before-after knowledge and skills mean scores. McNemar test was used to compare differences in the proportion of educators’ self-reported confidence in applying the different teaching pedagogies. P-values < 0.05 were considered statistically significant.
Findings:
Thirty educators (7 males and 23 females) participated, of whom only 11 (37%) had participated in a previous hands-on basic EmONC training – with 10 (91%) having had the training over two years beforehand. Performance mean scores increased significantly for knowledge (60.3% − 88. %), shoulder dystocia management (51.4 – 88.3%), newborn resuscitation (37.9 − 89.1%), and overall skill score (44.7 − 88.7%), p < 0.0001. The proportion of educators with confidence in using different stimulatory participatory teaching methods increased significantly for simulation (36.7 – 70%, p = 0.006), scenarios (53.3 – 80%, p = 0.039) and peer teaching and support (33.3 – 63.3%, p = 0.022). There was improvement in use of lecture method (80 – 90%, p = 0.289), small group discussions (73.3 – 86.7%, p = 0.344) and giving effective feedback (60 – 80%, p = 0.146), although this was not statistically significant.
Conclusion:
Training improved midwifery educators’ knowledge, skills and confidence to deliver the updated EmONC-enhanced curriculum. To ensure that midwifery educators maintain their competence, there is need for structured regular mentoring and continuous professional development. Besides, there is need to cascade the capacity strengthening to reach more midwifery educators for a competent midwifery workforce.
To examine the accuracy of birth counts for two remote Aboriginal communities in the Top End of the Northern Territory.
We compared livebirth counts from community birth records with birth ...registration numbers and perinatal counts.
For 2004–06, for Community 1, there were 204 recorded local livebirths, 190 birth registrations and 172 livebirths in perinatal data. In Community 2, the counts were 244, 222 and 208, respectively. The mean annual number of babies, indicating service requirements for babies and their mothers, ranged from 57 to 68 (depending on source) in Community 1, and from 69 to 81 in Community 2. Most differences were for births to Aboriginal mothers. Births to ‘visitors’ accounted for 16 births in Community 1 and 30 cases in Community 2.
Birth registration and perinatal data apparently underestimate community birth counts at a local level. Mobility of Aboriginal women seems to partly explain this.
The differences in birth counts have important implications for local planning in relation to demand on housing, health and education services. The number of births is also a critical data requirement for measuring infant health status, including mortality rates, with measures of disadvantage strongly influenced by the number of births. Aboriginal mobility is not a ‘data problem’, but an integral part of Aboriginal life that needs to be catered for in administrative data collections in the Northern Territory.
Background The least developed countries, which include those affected by fragility and humanitarian crises, account for 44% of all maternal deaths globally.1 Postpartum haemorrhage (PPH) is a ...leading cause of maternal mortality in these low-resource settings.2 Because uterine atony accounts for approximately two-thirds of PPH cases, WHO recommends that every woman receives a prophylactic uterotonic immediately after birth to prevent PPH as part of the active management of the third stage of labour.3 4 Some PPH prevention and treatment medicines are well evidenced with a long implementation history, including oxytocin, misoprostol and ergometrine.5 Heat-stable carbetocin (HSC), a uterotonic recommended for PPH prevention and tranexamic acid (TXA), an antifibrinolytic recommended for PPH treatment, were recently added to the core list of reproductive health medicines in the 2019 Model List of Essential Medicines by the WHO.4 6 7 Since 2021, both medications have been made available at public sector pricing through the Product Catalogue of the United Nations Population Fund.8 Unlike heat-sensitive oxytocin or ergometrine, HSC and TXA have the operational advantage of overcoming the logistic costs and challenges inherent to ensuring a cold chain system. ...they could play a critical role in resource-challenged and warm climate settings, where cold chain transport and storage is often not available, which compromises the quality of oxytocin. Notably, some uterotonics, for example, oxytocin and misoprostol, have multiple obstetric and gynaecological applications, such as labour induction and augmentation as well as abortion and postabortion care.9 In contrast, HSC and TXA have currently a single obstetric application.Table 1 Summary of clinical indications and health system requirements of uterotonics and tranexamic acid Use and health system requirements Uterotonics Non-uterotonic Oxytocin Misoprostol Heat-stable carbetocin* Ergometrine† Tranexamic acid PPH prevention Recommended‡ Recommended Recommended Recommended Not recommended PPH treatment Recommended‡ Recommended Not recommended Recommended Recommended Labour induction Recommended Recommended Not recommended Contraindicated Not recommended Labour augmentation Recommended Contraindicated Contraindicated Contraindicated Not recommended Abortion care Not recommended Recommended§ Not recommended Not recommended Not recommended Postabortion care Not recommended Recommended Not recommended Not recommended Not recommended Administration route Intravenous, IM Oral, sublingual, vaginal¶ Intravenous, IM Intravenous, IM Intravenous Skilled health provider requirement Yes No Yes Yes Yes Cold chain transport and storage requirement Yes (2°C–8°C) No (but ≤25°C) in double aluminium blisters No (but ≤30°C) Yes (2°C–8°C) away from light No Presentation** 10 IU ampoule 200 mcg tablet†† 100 mcg in 1 mL ampoule Ergometrine maleate 0.2 mg/mL in 1 mL ampoule 100 mg/mL in 10 mL ampoule Price per unit** US$0.334 per ampoule US$0.054 per oral tablet of 200 mcg US$0.413 per ampoule US$0.219 per ampoule US$1.30 per ampoule The colour shadings reflecting a traffic light approach (red, orange and green) were used to give the reader an instant recognition of the level of caution that is needed in regards to the use of the uterotonics and non-uterotonics in different clinical situations. For PPH prevention, the following uterotonic hierarchy is recommended: (1) in settings where multiple uterotonics are available, oxytocin (10 IU, intramuscular/intravenous) is the recommended uterotonic in all births, (2) in settings where oxytocin is unavailable (or its quality cannot be guaranteed), the use of other injectable uterotonics (HSC, or, if appropriate, ergometrine/methylergometrine or oxytocin-ergometrine fixed-dose combination) or oral misoprostol is recommended and (3) in settings where skilled health personnel are not present to administer injectable uterotonics, the administration of misoprostol (400 μg or 600 μg orally) by community healthcare workers and lay health workers is recommended.4 As for PPH treatment, (1) intravenous oxytocin is the recommended uterotonic; (2) the early use of intravenous TXA within 3 hours of birth in addition to standard care is recommended in all cases of PPH, regardless of whether the bleeding is due to genital tract trauma or other causes and (3) if intravenous oxytocin is unavailable, or if the bleeding does not respond to oxytocin, the use of intravenous ergometrine, oxytocin-ergometrine fixed-dose, or a prostaglandin drug (including misoprostol) is recommended (ergometrine and oxytocin-ergometrine are not recommended in case of hypertensive disorder).6 Third, these recommendations must, in practice, account for various health system requirements, as summarised in table 1. To help programme managers operationalise the information in table 1, the different health system requirements can be streamlined by focusing on the availability of skilled providers and cold chain transport and storage of 2°C–8°C, two critical constraints often encountered in resource-challenged settings (figure 1).
PDF
