Women with type 1 diabetes are at high risk of complications during both pregnancy and childbirth. Stringent monitoring of blood sugar is required in order to improve the chance of giving birth to a healthy child; however, this increases the incidence of severe hypoglycaemia. The aim of this study was to explore the need for and experience of professional support during pregnancy and childbirth among women with type 1 diabetes.
The study has a lifeworld research approach. Six focus groups and four individual interviews were conducted with 23 women, 6–24 months after delivery. The participants were encouraged to narrate their experiences of pregnancy and childbirth in relation to glycaemic control, well-being and provided care. Data analysis was directed towards discovering qualitative meanings by identifying and clustering meaning units in the text. Further analysis identified eight themes of meaning, classified under pregnancy or childbirth, forming a basis for a final whole interpretation of the explored phenomenon.
The women felt worry about jeopardizing the baby's health and this was sometimes made worse by care providers' manner and lack of competence and support. The increased attention from care providers during pregnancy was experienced as related to the health of the unborn child; not the mothers. Women who during pregnancy received care in a disconnected diabetes organisation were forced to act as messengers between different care providers.
Clarity in terms of defining responsibilities is necessary during pregnancy and childbirth, both among care providers and between the woman and the care provider. Furthermore, a decision must be made concerning how to delegate, transfer or share diabetes responsibility during labour between the care providers and the parents-to-be.
Development of appropriate interventions to increase male involvement in pregnancy and childbirth is vital to strategies for improving health outcomes of women with obstetric complications. The objective was to gain a deeper understanding of their experiences of male involvement in their partners’ healthcare during pregnancy and childbirth. The findings might inform interventions for increasing men’s involvement in reproductive health issues.
We conducted 16 in-depth interviews with men who came to the hospital to attend to their spouses/partners admitted to Mulago National Referral Hospital. All the spouses/partners had developed severe obstetric complications and were admitted in the high dependency unit. We sought to obtain detailed descriptions of men’s experiences, their perception of an ideal “father” and the challenges in achieving this ideal status. We also assessed perceived strategies for increasing male participation in their partners’ healthcare during pregnancy and childbirth. Data was analyzed by content analysis.
The identified themes were: Men have different descriptions of their relationships; responsibility was an obligation; ideal fathers provide support to mothers during childbirth; the health system limits male involvement in childbirth; men have no clear roles during childbirth, and exclusion and alienation in the hospital environment. The men described qualities of the ideal father as one who was available, easily reached, accessible and considerate. Most men were willing to learn about their expected roles during childbirth and were eager to support their partners/wives/spouses during this time. However, they identified personal, relationship, family and community factors as barriers to their involvement. They found the health system unwelcoming, intimidating and unsupportive. Suggestions to improve men’s involvement include creating more awareness for fathers, male-targeted antenatal education and support, and changing provider attitudes.
This study generates information on perceived roles, expectations, experiences and challenges faced by men who wish to be involved in maternal health issues, particularly during pregnancy and childbirth. There is discord between the policy and practice on male involvement in pregnancy and childbirth. Health system factors that are critical to promoting male involvement in women’s health issues during pregnancy and childbirth need to be addressed.
Early involvement of fathers with their children has increased in recent times and this is associated with improved cognitive and socio-emotional development of children. Research in the area of father’s engagement with pregnancy and childbirth has mainly focused on white middle-class men and has been mostly qualitative in design. Thus, the aim of this study was to understand who was engaged during pregnancy and childbirth, in what way, and how paternal engagement may influence a woman’s uptake of services, her perceptions of care, and maternal outcomes.
This study involved secondary analysis of data on 4616 women collected in a 2010 national maternity survey of England asking about their experiences of maternity care, health and well-being up to three months after childbirth, and their partners’ engagement in pregnancy, labour and postnatally. Data were analysed using descriptive statistics, chi-square, binary logistic regression and generalised linear modelling.
Over 80% of fathers were ‘pleased or ‘overjoyed’ in response to their partner’s pregnancy, over half were present for the pregnancy test, for one or more antenatal checks, and almost all were present for ultrasound examinations and for labour. Three-quarters of fathers took paternity leave and, during the postnatal period, most fathers helped with infant care. Paternal engagement was highest in partners of primiparous white women, those living in less deprived areas, and in those whose pregnancy was planned. Greater paternal engagement was positively associated with first contact with health professionals before 12 weeks gestation, having a dating scan, number of antenatal checks, offer and attendance at antenatal classes, and breastfeeding. Paternity leave was also strongly associated with maternal well-being at three months postpartum.
This study demonstrates the considerable sociodemographic variation in partner support and engagement. It is important that health professionals recognise that women in some sociodemographic groups may be less supported by their partner and more reliant on staff and that this may have implications for how women access care.
Fathers; Pregnancy; Childbirth; Paternal engagement
After more than two decades of the Safe Motherhood Initiative and Millennium Development Goals aimed at reducing maternal mortality, women continue to die in childbirth at unacceptably high rates in Pakistan. While an extensive literature describes various programmatic strategies, it neglects the rigorous analysis of the reasons these strategies have been unsuccessful, especially for women living at the economic and social margins of society. A critical gap in current knowledge is a detailed understanding of the root causes of disparities in maternal health care, and in particular, how gender and class influence policy formulation and the design and delivery of maternal health care services. Taking Pakistan as a case study, this research builds upon two distinct yet interlinked conceptual approaches to understanding the phenomenon of inequity in access to maternal health care: social exclusion and health systems as social institutions.
This four year project consists of two interrelated modules that focus on two distinct groups of participants: (1) poor, disadvantaged women and men and (2) policy makers, program managers and health service providers. Module one will employ critical ethnography to understand the key axes of social exclusion as related to gender, class and zaat and how they affect women’s experiences of using maternal health care. Through health care setting observations, interviews and document review, Module two will assess policy design and delivery of maternal health services.
This research will provide theoretical advances to enhance understanding of the power dynamics of gender and class that may underlie poor women’s marginalization from health care systems in Pakistan. It will also provide empirical evidence to support formulation of maternal health care policies and health care system practices aimed at reducing disparities in maternal health care in Pakistan. Lastly, it will enhance inter-disciplinary research capacity in the emerging field of social exclusion and maternal health and help reduce social inequities and achieve the Millennium Development Goal No. 5.
Social exclusion; Maternal health; Gender; Caste system; Pakistan; Health care system; Class; Health policy; Pregnancy and childbirth; Antenatal care
Normal and abnormal processes of pregnancy and childbirth are poorly understood. This second article in a global report explains what is known about the etiologies of preterm births and stillbirths and identifies critical gaps in knowledge. Two important concepts emerge: the continuum of pregnancy, beginning at implantation and ending with uterine involution following birth; and the multifactorial etiologies of preterm birth and stillbirth. Improved tools and data will enable discovery scientists to identify causal pathways and cost-effective interventions.
Pregnancy and parturition continuum
The biological process of pregnancy and childbirth begins with implantation and, after birth, ends with the return of the uterus to its previous state. The majority of pregnancy is characterized by rapid uterine and fetal growth without contractions. Yet most research has addressed only uterine stimulation (labor) that accounts for <0.5% of pregnancy.
The etiologies of preterm birth and stillbirth differ by gestational age, genetics, and environmental factors. Approximately 30% of all preterm births are indicated for either maternal or fetal complications, such as maternal illness or fetal growth restriction. Commonly recognized pathways leading to preterm birth occur most often during the gestational ages indicated: (1) inflammation caused by infection (22-32 weeks); (2) decidual hemorrhage caused by uteroplacental thrombosis (early or late preterm birth); (3) stress (32-36 weeks); and (4) uterine overdistention, often caused by multiple fetuses (32-36 weeks). Other contributors include cervical insufficiency, smoking, and systemic infections. Many stillbirths have similar causes and mechanisms. About two-thirds of late fetal deaths occur during the antepartum period; the other third occur during childbirth. Intrapartum asphyxia is a leading cause of stillbirths in low- and middle-income countries.
Utilizing new systems biology tools, opportunities now exist for researchers to investigate various pathways important to normal and abnormal pregnancies. Improved access to quality data and biological specimens are critical to advancing discovery science. Phenotypes, standardized definitions, and uniform criteria for assessing preterm birth and stillbirth outcomes are other immediate research needs.
Preterm birth and stillbirth have multifactorial etiologies. More resources must be directed toward accelerating our understanding of these complex processes, and identifying upstream and cost-effective solutions that will improve these pregnancy outcomes.
Maternity care is all care in relation to pregnancy, childbirth and the postpartum period. In the Netherlands maternity care is provided by midwives and general practitioners (GPs) in primary care and midwives and gynecologists in secondary care. To be able to interpret women's experience with the quality of maternity care, it is necessary to take into account their 'care path', that is: their route through the care system.
In the Netherlands a new tool is being developed to evaluate the quality of care from the perspective of clients. The tool is called: 'Consumer Quality Index' or CQI and is, within a standardized and systematic framework, tailored to specific health care issues.
Within the framework of developing a CQI Maternity Care, data were gathered about the care women in the Netherlands received during pregnancy, childbirth, and the postpartum period. In this paper the quality of maternity care in the Netherlands is presented, as experienced by women at different stages of their care path.
A sample of 1,248 pregnant clients of four insurance companies, with their due date in early April 2007, received a postal survey in the third trimester of pregnancy (response 793). Responders to the first questionnaire received a second questionnaire twelve weeks later, on average four weeks after delivery (response 632). Based on care provider and place of birth the 'care path' of the women is described. With factor analysis and reliability analysis five composite measures indicating the quality of treatment by the care provider at different stages of the care path have been constructed. Overall ratings relate to eight different aspects of care, varying from antenatal care by a midwife or GP to care related to neonatal screening.
41.5 percent of respondents remained in primary care throughout pregnancy, labor, birth and the postpartum period, receiving care from a midwife or general practitioner, 31.3% of respondents gave birth at home. The majority of women (58.5%) experienced referral from one care provider to another, i.e. from primary to secondary care or reverse, at least once. All but two percent of women had one or more ultrasound scans during pregnancy. The composite measures for the quality of treatment in different settings and by different care providers showed that women, regardless of parity, were very positive about the quality of the maternity care they received. Quality-of-treatment scores were high: on average 3.75 on a scale ranging from 1 to 4. Overall ratings on a 0 – 10 scale for quality of care during the antenatal period and during labor, birth and the postpartum period were high as well, on average 8.36.
The care path of women in maternity care was seldom straight forward. The majority of pregnant women switched from primary to secondary care and back at least once, during pregnancy or during labor and birth or both.
The results of the quality measures indicate that the quality of care as experienced by women is high throughout the care system. But with regard to the care during labor and birth the quality of care scores are higher when women know their care provider, when they give birth at home, when they give birth in primary care and when they are assisted by their own midwife.
The editors of BMC Pregnancy and Childbirth would like to thank all our reviewers who have contributed to the journal in Volume 13 (2013).
Abuse in health care (AHC) has been associated with potential severe health consequences, and has further been related to maternal morbidity and mortality in childbirth. To improve our understanding of what qualifies as AHC and to support and optimise the health of women with these experiences, the objective of this study was to describe how women, who had previously endured AHC, gave meaning to and managed their experience during pregnancy, childbirth, and in the early postnatal period.
Women, who had reported substantial suffering as a result of a previous experience of abuse within the healthcare system, were purposefully selected from a Danish sample of a multinational cohort study on negative life events among pregnant women (the BIDENS Study). Eleven women were interviewed individually by means of a semi-structured interview guide. Transcripts of the interviews were analysed by means of qualitative systematic text condensation analysis.
Four categories were identified to describe the women’s experience of AHC and its consequences on pregnancy and childbirth: abusive acts of unintentional harm, dehumanization, bodily remembrance, and finding the strength to move on. Abuse in health care may have profound consequences on the reproductive lives of the women, among others affecting sexuality, the desire to have children and the expectations of mode of delivery. However, the women described constructive ways to manage the experience, to which healthcare professionals could also contribute significantly.
Regardless of whether AHC is experienced in childhood or adulthood, it can influence the lives of women during pregnancy and childbirth. By recognising the potential existence of AHC, healthcare professionals have a unique opportunity to support women who have experienced AHC.
Abuse in health care; Pregnancy; Childbirth; Dehumanization; Empathy
The editors of BMC Pregnancy and Childbirth would like to thank all our reviewers who have contributed to the journal in Volume 12 (2012).
A primary cause of high maternal mortality in Bangladesh is lack of access to professional delivery care. Examining the role of the family, particularly the husband, during pregnancy and childbirth is important to understanding women's access to and utilization of professional maternal health services that can prevent maternal mortality. This qualitative study examines husbands' involvement during childbirth and professional delivery care utilization in a rural sub-district of Netrokona district, Bangladesh.
Using purposive sampling, ten households utilizing a skilled attendant during the birth of the youngest child were selected and matched with ten households utilizing an untrained traditional birth attendant, or dhatri. Households were selected based on a set of inclusion criteria, such as approximate household income, ethnicity, and distance to the nearest hospital. Twenty semi-structured interviews were conducted in Bangla with husbands in these households in June 2010. Interviews were transcribed, translated into English, and analyzed using NVivo 9.0.
By purposefully selecting households that differed on the type of provider utilized during delivery, common themes--high costs, poor transportation, and long distances to health facilities--were eliminated as sufficient barriers to the utilization of professional delivery care. Divergent themes, namely husbands' social support and perceived social norms, were identified as underlying factors associated with delivery care utilization. We found that husbands whose wives utilized professional delivery care provided emotional, instrumental and informational support to their wives during delivery and believed that medical intervention was necessary. By contrast, husbands whose wives utilized an untrained dhatri at home were uninvolved during delivery and believed childbirth should take place at home according to local traditions.
This study provides novel evidence about male involvement during childbirth in rural Bangladesh. These findings have important implications for program planners, who should pursue culturally sensitive ways to involve husbands in maternal health interventions and assess the effectiveness of education strategies targeted at husbands.
Interventions directed toward mothers before and during pregnancy and childbirth may help reduce preterm births and stillbirths. Survival of preterm newborns may also be improved with interventions given during these times or soon after birth. This comprehensive review assesses existing interventions for low- and middle-income countries (LMICs).
Approximately 2,000 intervention studies were systematically evaluated through December 31, 2008. They addressed preterm birth or low birth weight; stillbirth or perinatal mortality; and management of preterm newborns. Out of 82 identified interventions, 49 were relevant to LMICs and had reasonable amounts of evidence, and therefore selected for in-depth reviews. Each was classified and assessed by the quality of available evidence and its potential to treat or prevent preterm birth and stillbirth. Impacts on other maternal, fetal, newborn or child health outcomes were also considered. Assessments were based on an adaptation of the Grades of Recommendation Assessment, Development and Evaluation criteria.
Most interventions require additional research to improve the quality of evidence. Others had little evidence of benefit and should be discontinued. The following are supported by moderate- to high-quality evidence and strongly recommended for LMICs:
• Two interventions prevent preterm births—smoking cessation and progesterone
• Eight interventions prevent stillbirths—balanced protein energy supplementation, screening and treatment of syphilis, intermittant presumptive treatment for malaria during pregnancy, insecticide-treated mosquito nets, birth preparedness, emergency obstetric care, cesarean section for breech presentation, and elective induction for post-term delivery
• Eleven interventions improve survival of preterm newborns—prophylactic steroids in preterm labor, antibiotics for PROM, vitamin K supplementation at delivery, case management of neonatal sepsis and pneumonia, delayed cord clamping, room air (vs. 100% oxygen) for resuscitation, hospital-based kangaroo mother care, early breastfeeding, thermal care, and surfactant therapy and application of continued distending pressure to the lungs for respiratory distress syndrome
The research paradigm for discovery science and intervention development must be balanced to address prevention as well as improve morbidity and mortality in all settings. This review also reveals significant gaps in current knowledge of interventions spanning the continuum of maternal and fetal outcomes, and the critical need to generate further high-quality evidence for promising interventions.
Every year, nearly half a million women and girls needlessly die as a result of complications during pregnancy, childbirth or the 6 weeks following delivery. Almost all (99%) of these deaths occur in developing countries. The study aim was to describe the factors related to low visits for antenatal care (ANC) services among pregnant women in Indonesia.
A total of 145 of 200 married women of reproductive age who were pregnant or had experienced birth responded to the questionnaire about their ANC visits. We developed a questionnaire containing 35 items and four sections. Section one and two included the women's socio demographics, section three about basic knowledge of pregnancy and section four contained two subsections about preferences about midwives and preferences about Traditional Birth Attendant (TBA) and the second subsections were traditional beliefs. Data were collected using a convenience sampling strategy during July and August 2010, from 10 villages in the Tanjung Emas. Multiple regression analysis was used for preference for types of providers.
Three-quarter of respondents (77.9%) received ANC more than four times. The other 22.1% received ANC less than four times. 59.4% received ANC visits during pregnancy, which was statistically significant compared to multiparous (p = 0.001). Women who were encouraged by their family to receive ANC had statistically significant higher traditional belief scores compared to those who encouraged themselves (p = 0.003). Preference for TBAs was most strongly affected by traditional beliefs (p < 0.001). On the contrary, preference for midwives was negatively correlated with traditional beliefs (p < 0.001).
Parity was the factor influencing women's receiving less than the recommended four ANC visits during pregnancy. Women who were encouraged by their family to get ANC services had higher traditional beliefs score than women who encouraged themselves. Moreover, traditional beliefs followed by lower income families had the greater influence over preferring TBAs, with the opposite trend for preferring midwives. Increased attention needs to be given to the women; it also very important for exploring women's perceptions about health services that they received.
Pregnant women; Traditional birth attendant and traditional beliefs
Pregnancy and childbirth are associated with weight gain in women, and retention of weight gained during pregnancy can lead to obesity in later life. Diet and physical activity are factors that can influence the loss of retained pregnancy weight after birth. Exercise guidelines exist for pregnancy, but recommendations for exercise after childbirth are virtually nonexistent. The aim of this study was to evaluate the effect of physical activity intervention based on pedometer on physical activity level and anthropometric measures of women after childbirth.
We conducted a randomized controlled trial in which 66 women who had given birth 6 weeks to 6 months prior were randomly assigned to receive either a 12 week tailored program encouraging increased walking using a pedometer (intervention group, n = 32) or routine postpartum care (control group, n = 34). During the 12-week study period, each woman in the intervention group wore a pedometer and recorded her daily step count. The women were advised to increase their steps by 500 per week until they achieved the first target of 5000 steps per day and then continued to increase it to minimum of 10,000 steps per day by the end of 12th week. Assessed outcomes included anthropometric measures, physical activity level, and energy expenditure per week. Data were analyzed using the paired t-test, independent t-test, Mann-Whitney, chi-square, Wilcoxon, covariance analysis, and the general linear model repeated measures procedure as appropriate.
After 12 weeks, women in the intervention group had significantly increased their physical activity and energy expenditure per week (4394 vs. 1651 calorie, p < 0.001). Significant differences between-group in weight (P = 0.001), Body Mass Index (P = 0.001), waist circumference (P = 0.001), hip circumference (P = 0.032) and waist-hip ratio (P = 0.02) were presented after the intervention. The intervention group significantly increased their mean daily step count over the study period (from 3249 before, to 9960 after the intervention, p < 0.001).
A physical activity intervention based on pedometer is an effective means to increase physical activity; reducing retention of weight gained during pregnancy and can improve anthropometric measures in postpartum women.
Analysis of severe maternal morbidity (maternal near misses) provides information on the quality of care. We assessed the prevalence/incidence of maternal near miss, maternal mortality and case fatality ratio through systematic review of studies on severe maternal morbidity in sub-Saharan Africa.
We examined studies that reported prevalence/incidence of severe maternal morbidity (maternal near misses) during pregnancy, childbirth and postpartum period between 1996 and 2010. We evaluated the quality of studies (objectives, study design, population studied, setting and context, definition of severe acute obstetric morbidity and data collection instruments). We extracted data, using a pre-defined protocol and criteria, and estimated the prevalence or incidence of maternal near miss. The case-fatality ratios for reported maternal complications were estimated.
We identified 12 studies: six were cross-sectional, five were prospective and one was a retrospective review of medical records. There was variation in the setting: while some studies were health facility-based (at the national referral hospital, regional hospital or various district hospitals), others were community-based studies. The sample size varied from 557 women to 23,026. Different definitions and terminologies for maternal near miss included acute obstetric complications, severe life threatening obstetric complications and severe obstetric complications. The incidence/prevalence ratio and case-fatality ratio for maternal near misses ranged from 1.1%-10.1% and 3.1%-37.4% respectively. Ruptured uterus, sepsis, obstructed labor and hemorrhage were the commonest morbidities that were analyzed. The incidence/prevalence ratio of hemorrhage ranged from 0.06% to 3.05%, while the case fatality ratio for hemorrhage ranged from 2.8% to 27.3%. The prevalence/incidence ratio for sepsis ranged from 0.03% to 0.7%, while the case fatality ratio ranged from 0.0% to 72.7%.
The incidence/prevalence ratio and case fatality ratio of maternal near misses are very high in studies from sub-Saharan Africa. Large differences exist between countries on the prevalence/incidence of maternal near misses. This could be due to different contexts/settings, variation in the criteria used to define the maternal near misses morbidity, or rigor used carrying out the study. Future research on maternal near misses should adopt the WHO recommendation on classification of maternal morbidity and mortality.
Antenatal care is widely established and provides an opportunity to inform and educate pregnant women about pregnancy, childbirth and care of the newborn. It is expected that this would assist the women in making choices that would contribute to good pregnancy outcome. We examined the provision of information and education in antenatal clinics from the perspective of pregnant women attending these clinics.
A cross sectional survey of 457 pregnant women attending six urban and six rural antenatal clinics in the largest health division in The Gambia was undertaken. The women were interviewed using modified antenatal client exit interview and antenatal record review questionnaires from the WHO Safe Motherhood Needs Assessment kit. Differences between women attending urban and rural clinics were assessed using the Chi-square test. Relative risks with 95% confidence intervals are presented.
Ninety percent of those interviewed had attended the antenatal clinic more than once and 52% four or more times. Most pregnant women (70.5%) said they spent 3 minutes or less with the antenatal care provider. About 35% recalled they were informed or educated on diet and nutrition, 30.4% on care of the baby, 23.6% on family planning, 22.8% on place of birth and 19.3% on what to do if there was a complication.
About 25% of pregnant women said they were given information about the progress of their pregnancy after consultation and only 12.8% asked their provider any question. Awareness of danger signs was low. The proportions of women that recognised signs of danger were 28.9% for anaemia, 24.6% for hypertension, 14.8% for haemorrhage, 12.9% for fever and 5% for puerperal sepsis. Prolonged labour was not recognised as a danger sign. Women attending rural antenatal clinics were 1.6 times more likely to recognise signs of anaemia and hypertension as indicative of danger compared to women attending urban antenatal clinics.
Information, education and communication during antenatal care in the largest health division are poor. Pregnant women are ill-equipped to make appropriate choices especially when they are in danger. This contributes to the persistence of high maternal mortality ratios in the country.
The majority of adolescents in Africa experience pregnancy, childbirth and enter motherhood without adequate information about maternal health issues. Information about these issues could help them reduce their pregnancy related health risks. Existing studies have concentrated on adolescents' knowledge of other areas of reproductive health, but little is known about their awareness and knowledge of safe motherhood issues. We sought to bridge this gap by assessing the knowledge of school pupils regarding safe motherhood in Mtwara Region, Tanzania.
We used qualitative and quantitative descriptive methods to assess school pupils' knowledge of safe motherhood and HIV/AIDS in pregnancy. An anonymous questionnaire was used to assess the knowledge of 135 pupils ranging in age from 9 to 17 years. The pupils were randomly selected from 3 primary schools. Underlying beliefs and attitudes were assessed through focus group interviews with 35 school children. Key informant interviews were conducted with six schoolteachers, two community leaders, and two health staffs.
Knowledge about safe motherhood and other related aspects was generally low. While 67% of pupils could not mention the age at which a girl may be able to conceive, 80% reported it is safe for a girl to be married before she reaches 18 years. Strikingly, many school pupils believed that complications during pregnancy and childbirth are due to non-observance of traditions and taboos during pregnancy. Birth preparedness, important risk factors, danger signs, postpartum care and vertical transmission of HIV/AIDS and its prevention measures were almost unknown to the pupils.
Poor knowledge of safe motherhood issues among school pupils in rural Tanzania is related to lack of effective and coordinated interventions to address reproductive health and motherhood. For long-term and sustained impact, school children must be provided with appropriate safe motherhood information as early as possible through innovative school-based interventions.
A randomised controlled trial of participatory women's groups in rural Nepal previously showed reductions in maternal and newborn mortality. In addition to the outcome data we also collected previously unreported information from the subgroup of women who had been pregnant prior to study commencement and conceived during the trial period. To determine the mechanisms via which the intervention worked we here examine the changes in perinatal care of these women. In particular we use the information to study factors affecting positive behaviour change in pregnancy, childbirth and newborn care.
Women's groups focusing on perinatal care were introduced into 12 of 24 study clusters (average cluster population 7000). A total of 5400 women of reproductive age enrolled in the trial had previously been pregnant and conceived during the trial period.
For each of four outcomes (attendance at antenatal care; use of a boiled blade to cut the cord; appropriate dressing of the cord; not discarding colostrum) each of these women was classified as BETTER, GOOD, BAD or WORSE to describe whether and how she changed her pre-trial practice. Multilevel multinomial models were used to identify women most responsive to intervention.
Among those not initially following good practice, women in intervention areas were significantly more likely to do so later for all four outcomes (OR 1.92 to 3.13). Within intervention clusters, women who attended groups were more likely to show a positive change than non-group members with regard to antenatal care utilisation and not discarding colostrum, but non-group members also benefited.
Women's groups promoted significant behaviour change for perinatal care amongst women not previously following good practice. Positive changes attributable to intervention were not restricted to specific demographic subgroups.
There is a high association between disturbed (poor quality) sleep and depression, which has lead to a consensus that there is a bidirectional relationship between sleep and mood. One time in a woman’s life when sleep is commonly disturbed is during pregnancy and following childbirth. It has been suggested that sleep disturbance is another factor that may contribute to the propensity for women to become depressed in the postpartum period compared to other periods in their life. Post Natal Depression (PND) is common (15.5%) and associated with sleep disturbance, however, no studies have attempted to provide a sleep-focused intervention to pregnant women and assess whether this can improve sleep, and consequently maternal mood post-partum. The primary aim of this research is to determine the efficacy of a brief psychoeducational sleep intervention compared with a control group to improve sleep management, with a view to reduce depressive symptoms in first time mothers.
This randomised controlled trial will recruit 214 first time mothers during the last trimester of their pregnancy. Participants will be randomised to receive either a set of booklets (control group) or a 3hour psychoeducational intervention that focuses on sleep. The primary outcomes of this study are sleep-related, that is sleep quality and sleepiness for ten months following the birth of the baby. The secondary outcome is depressive symptoms. It is hypothesised that participants in the intervention group will have better sleep quality and sleepiness in the postpartum period than women in the control condition. Further, we predict that women who receive the sleep intervention will have lower depression scores postpartum compared with the control group.
This study aims to provide an intervention that will improve maternal sleep in the postpartum period. If sleep can be effectively improved through a brief psychoeducational program, then it may have a protective role in reducing maternal postpartum depressive symptoms.
This trial is registered with the Australian New Zealand Clinical Trials Register under the registration number ACTRN12611000859987
Sleep; New mothers; Postnatal; Postpartum; Depression; Psychoeducation
Bangladesh is one of the few countries that may actually achieve the fifth Millennium Development Goal (MDG) in time, despite skilled birth attendance remaining low. The purpose of this paper is to examine the potential role misoprostol can play in the decline of maternal deaths attributed to postpartum hemorrhage (PPH) in Bangladesh.
Using data from a misoprostol and blood loss measurement tool feasibility study in Bangladesh, observed cause specific maternal mortality ratios (MMRs) were estimated and contrasted with expected ratios using estimates from the Bangladesh Maternal Mortality Survey (BMMS) data. Using Crystal Ball 7 we employ Monte Carlo simulation techniques to estimate maternal deaths in four scenarios, each with different levels of misoprostol coverage. These scenarios include project level misoprostol coverage (69%), no (0%), low (40%), and high (80%) misoprostol coverage. Data on receipt of clean delivery kit, use of misoprostol, experience of PPH, and cause of death were used in model assumptions.
Using project level misoprostol coverage (69%), the mean number of PPH deaths expected was 40 (standard deviation = 8.01) per 100,000 live births. Assuming no misoprostol coverage (0%), the mean number of PPH deaths expected was 51 (standard deviation = 9.30) per 100,000 live births. For low misoprostol coverage (40%), the mean number of PPH deaths expected was 45 (standard deviation = 8.26) per 100,000 live births, and for high misoprostol coverage (80%), the mean number of PPH deaths expected was 38 (standard deviation = 7.04) per 100,000 live births.
This theoretical exercise hypothesizes that prophylactic use of misoprostol at home births may contribute to a reduction in the risk of death due to PPH, in addition to reducing the incidence of PPH. If findings from this modeling exercise are accurate and uterotonics can prevent maternal death, misoprostol could be the tool countries need to further reduce maternal mortality at home births.
Traditional birth attendant; Bangladesh; Postpartum hemorrhage; Maternal mortality; Misoprostol; Delivery mat; Monte Carlo
In pregnancy, violence can have serious health consequences that could affect both mother and child. In Ghana there are limited data on this subject. We sought to assess the relationship between physical violence during pregnancy and pregnancy outcomes (early pregnancy loss, perinatal mortality and neonatal mortality) in Ghana.
The 2008 Ghana Demographic and Health Survey data were used. For the domestic violence module, 2563 women were approached of whom 2442 women completed the module. After excluding missing values and applying the weight factor, 1745 women remained. Logistic regression analysis was performed to assess the relationship between physical violence in pregnancy and adverse pregnancy outcomes with adjustments for potential confounders.
About five percent of the women experienced violence during their pregnancy. Physical violence in pregnancy was positively associated with perinatal mortality and neonatal mortality, but not with early pregnancy loss. The differences remained largely unchanged after adjustment for age, parity, education level, wealth status, marital status and place of residence: adjusted odds ratios were 2.32; 95% CI: 1.34-4.01 for perinatal mortality, 1.86; 95% CI: 1.05-3.30 for neonatal mortality and 1.16; 95% CI: 0.60-2.24 for early pregnancy loss.
Our findings suggest that violence during pregnancy is related to adverse pregnancy outcomes in Ghana. Major efforts are needed to tackle violence during pregnancy. This can be achieved through measures that are directed towards the right target groups. Measures should include education, empowerment and improving socio-economic status of women.
Domestic violence; Intimate partner violence; Early pregnancy loss; Perinatal mortality; Neonatal mortality
Maternal overweight, obesity and consequently the incidence of gestational diabetes are increasing rapidly worldwide. The objective of the study was to assess the efficacy and cost-effectiveness of a combined diet and physical activity intervention implemented before, during and after pregnancy in a primary health care setting for preventing gestational diabetes, later type 2 diabetes and other metabolic consequences.
RADIEL is a randomized controlled multi-center intervention trial in women at high risk for diabetes (a previous history of gestational diabetes or prepregnancy BMI ≥30 kg/m2). Participants planning pregnancy or in the first half of pregnancy were parallel-group randomized into an intervention arm which received lifestyle counseling and a control arm which received usual care given at their local antenatal clinics. All participants visited a study nurse every three months before and during pregnancy, and at 6 weeks, 6 and 12 months postpartum. Measurements and laboratory tests were performed on all participants with special focus on dietary and exercise habits and metabolic markers.
Of the 728 women [mean age 32.5 years (SD 4.7); median parity 1 (range 0-9)] considered to be eligible for the study 235 were non-pregnant and 493 pregnant [mean gestational age 13 (range 6 to 18) weeks] at the time of enrollment. The proportion of nulliparous women was 29.8% (n = 217). Out of all participants, 79.6% of the non-pregnant and 40.4% of the pregnant women had previous gestational diabetes and 20.4% of the non-pregnant and 59.6% of the pregnant women were recruited because of a prepregnancy BMI ≥30 kg/m2. Mean BMI at first visit was 30.1 kg/m2 (SD 6.2) in the non-pregnant and 32.7 kg/m2 (SD 5.6) in the pregnant group.
To our knowledge, this is the first randomized lifestyle intervention trial, which includes, besides the pregnancy period, both the prepregnancy and the postpartum period. This study design also provides an opportunity to focus upon the health of the next generation. The study is expected to produce novel information on the optimal timing and setting of interventions and for allocating resources to prevent obesity and diabetes in women of reproductive age.
Gestational diabetes; Type 2 diabetes; Diet and exercise intervention; Obesity; BMI; Pregnancy
Although an increased risk of preeclampsia in pregnancies conceived by in vitro fertilization (IVF) has been reported, it remains unknown whether IVF is associated with preeclampsia. In the present study, we sought to investigate whether IVF is associated with preeclampsia in pregnant women using propensity score matching analysis.
This study included 3,084 pregnant women who visited the National Center for Child Health and Development before 20 weeks of gestation without hypertension or renal disease and delivered a singleton after 22 weeks of gestation between 2009 and 2011. Of the 3084 patients, 474 (15.4%) conceived by IVF (IVF group) and 2,610 (84.6%) conceived without IVF (non-IVF group). The propensity score for receiving IVF was estimated using multiple logistic regression with 27 maternal and paternal variables. This model yielded a c-statistic of 0.852, indicating a strong ability to differentiate between those conceiving with and without IVF. The association between IVF and onset of preeclampsia was assessed by the propensity matched sample (pair of N = 474).
There were 46 preeclampsia cases (1.5%) in the total study population, with a higher proportion of cases in the IVF group (15 cases, 3.2%) than the non-IVF group (31 cases, 1.2%). Before propensity score matching, the IVF group was 2.72 (95% confidence intervals [CI]: 1.46-5.08) times more likely to have preeclampsia when unadjusted, and 2.32 (95% CI: 1.08-4.99) times more likely to have preeclampsia when adjusted for maternal and paternal variables by logistic regression. After propensity score matching, the IVF group did not show a significantly greater association with preeclampsia compared to the non-IVF group (odds ratio: 2.50, 95% CI: 0.49-12.89), although point estimates showed a positive direction.
Propensity score matching analysis revealed that the association between IVF and preeclampsia became weaker than when conventional adjustments are made in multivariate logistic regression analysis, suggesting that the association between IVF and preeclampsia might be confounded by residual unmeasured factors.
Blood pressure; In vitro fertilization; Preeclampsia; Propensity score; Assisted reproductive technology
Male partner participation is a crucial component to optimize antenatal care/prevention of mother to child transmission of HIV(ANC/PMTCT) service. It creates an opportunity to capture pregnant mothers and their male partners to reverse the transmission of HIV during pregnancy, labour and breast feeding. Thus involving male partners during HIV screening of pregnant mothers at ANC is key in the fight against mother to child transmission of HIV(MTCT). So, the aim of this study is to determine the level of male partner involvement in PMTCT and factors that affecting it.
A Cross-sectional study was conducted among 473 pregnant mothers attending ANC/PMTCT in Mekelle town health facilities in January 2011. Systematic sampling was used to select pregnant mothers attending ANC/PMTCT service after determination of the client load at each health facility. Clinic exit structured interviews were used to collect the data. Finally multiple logistic regression was used to identify factors that affect male involvement in ANC/PMTCT.
Twenty percent of pregnant mothers have been accompanied by their male partner to the ANC/PMTCT service. Knowledge of HIV sero status [Adj.OR (95% CI) = 0.43 (0.18- 0.66)], maternal willingness to inform their husband about the availability of voluntary counselling and testing services in ANC/PMTCT [Adj.OR (95% CI) =3.74(1.38-10.17)] and previous history of couple counselling [Adj.OR (95% CI) =4.68 (2.32-9.44)] were found to be the independent predictors of male involvement in ANC/PMTCT service.
Male partner involvement in ANC/PMTCT is low. Thus, comprehensive strategy should be put in place to sensitize and advocate the importance of male partner involvement in ANC/PMTCT in order to reach out male partners.
Male and PMTCT; Male and ANC; Male and HIV; HIV and ANC
Interventions given to women admitted in latent or active phase of labor may influence the outcomes of labor and ameliorate complications which can affect the mother and fetus. Labour management, maternal and fetal outcomes among low risk women presenting both in latent phase and active phase of labour in Tanzania have not recently been explored.
This was a descriptive cross-sectional study. It was done from February to April 2013. Case notes were collected serially until the sample size was reached. A structured checklist was used to extract data. Data was analyzed using SPSS version 17. A p < 0.05 was considered significant at 95% confidence interval.
Five hundred case notes of low risk pregnant women were collected, half of each presented in latent phase and active phase of labour. Key interventions including augmentation with oxytocin, artificial rupture of membranes and caesarean section were significantly higher in the latent phase group than the active phase group 84(33.6%) versus 52(20.8%) p < 0.05; 96(38.6%) versus 56(22.4%) p < 0.05 and 87(34.8%) versus 60(24.0%) p < 0.05 respectively. Spontaneous vertex delivery was higher among pregnant women admitted initially in active phase than in latent phase groups 180(72.0%), versus 153(61.2%) p > 0.01). There were more women in the active phase group who sustained genital tract tear and postpartum haemorrhage than in the latent phase group 101(18.6%), versus 38(15.6%) p < 0.01 and 46(18.4%), versus 17(6.6%) p < 0.05 respectively.
Pregnant women admitted at BMC in latent phase of labour are subjected to more obstetric interventions than those admitted in the active phase. There is need to produce guidelines on management of women admitted in latent phase of labour at BMC to reduce the risk of unnecessary interventions.
Latent phase of labour; Active phase of labour; Interventions; Low risk pregnancy