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author:("Lori, joy R")
1.  A CASE SERIES STUDY OF PERINATAL DEATHS AT ONE REFERRAL CENTER IN RURAL POST-CONFLICT LIBERIA 
Maternal and child health journal  2014;18(1):10.1007/s10995-013-1232-y.
Objectives
The overall objective of this study was to further our understanding of the factors contributing to the high perinatal mortality rates at a busy rural, referral hospital in Liberia. The specific aims were to: 1) analyze the records of women who experienced a perinatal loss for both medical and nonmedical contributing factors; 2) describe the timing and causes of all documented stillbirths and early neonatal deaths; and 3) understand the factors surrounding stillbirth and early neonatal death in this context.
Methods
This case series study was conducted through a retrospective hospital-based record review of all perinatal deaths occurring at the largest rural referral hospital in north-central Liberia during the 2010 calendar year.
Results
A record review of 1656 deliveries identified 196 perinatal deaths; 143 classified as stillbirth and 53 were classified as early neonatal death. The majority of stillbirths (56.6%) presented as antenatal stillbirths with no fetal heart tones documented upon admission. Thirty-one percent of cases had no maternal or obstetrical diagnosis recorded in the chart when a stillbirth occurred. Of the 53 early neonatal deaths, 47.2% occurred on day one of the infant’s life with birth asphyxia/poor Apgar scores being the diagnosis listed most frequently.
Conclusions
Clear and concise documentation is key to understanding the high perinatal death rates in low resource countries. Standardized, detailed documentation is needed to inform changes to clinical practice and develop feasible solutions to reduce the number of perinatal deaths worldwide.
doi:10.1007/s10995-013-1232-y
PMCID: PMC3703491  PMID: 23417211
Perinatal mortality; stillbirth; early neonatal death; post-conflict; Liberia
2.  Maternity waiting homes and traditional midwives in rural Liberia 
Objective
Maternity waiting homes (MWHs) can reduce maternal morbidity and mortality by increasing access to skilled birth attendants (SBAs). The present analysis was conducted to determine whether MWHs increase the use of SBAs at rural primary health clinics in Liberia; to determine whether traditional midwives (TMs) are able to work with SBAs as a team and to describe the perceptions of TMs as they engage with SBAs; and to determine whether MWHs decrease maternal and child morbidity and mortality.
Methods
The present analysis was conducted halfway through a large cohort study in which 5 Liberian communities received the intervention (establishment of an MWH) and 5 Liberian communities did not (control group). Focus groups were conducted to examine the views of TMs on their integration into health teams.
Results
Communities with MWHs experienced a significant increase in team births from baseline to post-intervention (10.8% versus 95.2%, P<0.001), with greater TM engagement. Lower rates of maternal and perinatal death were reported from communities with MWHs.
Conclusion
The reduction in morbidity and mortality indicates that the establishment of MWHs is an effective strategy to increase the use of SBAs, improve the collaboration between SBAs and TMs, and improve maternal and neonatal health.
doi:10.1016/j.ijgo.2013.05.024
PMCID: PMC3795996  PMID: 23992657
Liberia; Maternal mortality; Maternity waiting homes; Midwifery
3.  Prenatal Psychosocial Risk Assessment using Event History Calendars with Black Women 
Objective
To explore the clinical acceptability and perceptions of use of a prenatal event history calendar (Prenatal EHC) for prenatal psychosocial risk assessment in Black pregnant women.
Design
A qualitative descriptive study focused on interviews and Prenatal EHCs completed by Black pregnant women.
Setting
Inner city hospital prenatal care clinic in Southeastern Michigan.
Participants
Thirty 18–35 year old pregnant Black women receiving prenatal care at the participating clinic.
Methods
Women completed the prenatal EHCs and their perceptions of its use were obtained through face to face interviews. The constant comparative method of analysis (Glaser, 1978, 1992) revealed themes from participants’ descriptions about use of a Prenatal EHC for prenatal psychosocial risk assessment.
Results
Three main themes emerged describing how the Prenatal EHC enhanced communication. The Prenatal EHC provided “an opening” for disclosure, “an understanding with you,” and a way for providers to “know you, your life, and future plans.” The participants’ completed Prenatal EHCs included information regarding their pre-pregnancies, trimester histories, and future plans. These completed Prenatal EHCs showed patterns of change in life events and behaviors that included worries, stressors, and risk behaviors. The participants perceived the Prenatal EHC as an easy to use tool that should be used to improve communication with health care providers.
Conclusions
The Prenatal EHC allows the patient and provider to “start on the same page” and provides an additional avenue for discussion of sensitive psychosocial issues with Black pregnant women. As a clinical tool, the Prenatal EHC facilitated patient-provider communication for pregnant women often marked by health disparities. The Prenatal EHC is a clinically acceptable tool to assess for psychosocial risk factors of Black women in a prenatal clinical setting.
doi:10.1111/j.1552-6909.2012.01382.x
PMCID: PMC3774780  PMID: 22697217
psychosocial risk assessment; prenatal care; event history calendars; Black pregnant women
4.  Cell Phones to Collect Pregnancy Data From Remote Areas in Liberia 
Purpose
To report findings on knowledge and skill acquisition following a 3-day training session in the use of short message service (SMS) texting with non- and low-literacy traditional midwives.
Design
A pre- and post-test study design was used to assess knowledge and skills acquisition with 99 traditional midwives on the use of SMS texting for real-time, remote data collection in rural Liberia, West Africa.
Methods
Paired sample t-tests were conducted to establish if overall mean scores varied significantly from pre-test to immediate post-test. Analysis of variance was used to compare means across groups. The nonparametric McNemar’s test was used to determine significant differences between the pre-test and post-test values of each individual step involved in SMS texting. Pearson’s chi-square test of independence was used to examine the association between ownership of cell phones within a family and achievement of the seven tasks.
Findings
The mean increase in cell phone knowledge scores was 3.67, with a 95% confidence interval ranging from 3.39 to 3.95. Participants with a cell phone in the family did significantly better on three of the seven tasks in the pre-test: “turns cell on without help” (χ2(1) = 9.15, p = .003); “identifies cell phone coverage” (χ2(1) = 5.37, p = .024); and “identifies cell phone is charged” (χ2(1) = 4.40, p = .042).
Conclusions
A 3-day cell phone training session with low- and nonliterate traditional midwives in rural Liberia improved their ability to use mobile technology for SMS texting.
Clinical Relevance
Mobile technology can improve data collection accessibility and be used for numerous healthcare and public health issues. Cell phone accessibility holds great promise for collecting health data in low-resource areas of the world.
doi:10.1111/j.1547-5069.2012.01451.x
PMCID: PMC3432659  PMID: 22672157
Cell phone; SMS texting; rural; pregnancy; Africa; low literacy; traditional midwives
5.  Behavior Change Following Implementation of Home-Based Life Saving Skills in Liberia, West Africa 
Introduction
Home-Based Life Saving Skills (HBLSS) has been fully integrated into Liberia’s long term plan to decrease maternal and newborn mortality and morbidity coordinated through the Ministry of Health and Social Welfare. The objective of this article is to disseminate evaluation data from project monitoring and documentation on translation of knowledge and skills obtained through HBLSS into behavior change at the community level.
Methods
One year after completion of HBLSS training, complication audits were conducted with 434 postpartum women in one rural county in Liberia.
Results
Sixty-two percent (n=269) of the women were attended during birth by either an HBLSS-trained traditional midwife or family member, while 38 percent (n=165) were attended by a traditional midwife or family member who did not receive HBLSS training. HBLSS trained birth attendants performed significantly more First Actions (lifesaving actions taught to be performed after every delivery) than the non HBLSS trained attendants. Fourteen percent of our sample (n=62) reported “too much bleeding” following the delivery. Of these women, approximately half (n=29) were attended by an HBLSS-trained traditional midwife or family member. There was a significant difference in Secondary Actions (those actions taught to be performed when a woman experiences “too much bleeding” following childbirth) that were reported to have been performed by HBLSS-trained attendants (mean = 5.26, SD = 1.88) and untrained attendants (mean = 2.73, SD = 1.97); p-value <.0001.
Conclusion
Our findings suggest HBLSS knowledge is being transferred into behavior change and used at the community-level by traditional midwives and family members.
doi:10.1111/j.1542-2011.2012.00172.x
PMCID: PMC3439168  PMID: 22954081
pregnancy; maternal survival; newborn survival; midwifery; post-conflict; community-based evaluation; traditional midwives; Home-Based Life Saving Skills; Liberia
6.  Provider Characteristics Desired by African American Women in Prenatal Care 
Purpose
The purpose of this study was to describe provider characteristics African American pregnant women identified as important when interacting with their prenatal care providers in an outpatient office setting.
Study Design and Method
A descriptive qualitative design was used to explore provider characteristics desired by African American women receiving prenatal care at two inner-city hospital–based obstetric clinics. A total of 22 African American women between the ages of 19 and 28 years participated in the study.
Findings
Four major provider characteristic themes emerged from the data: (a) demonstrating quality patient–provider communication, (b) providing continuity of care, (c) treating the women with respect, and (d) delivering compassionate care.
Discussion and Conclusion
An overarching theme revealed by the data analysis was the desire by African American women in this study to have their prenatal providers know and remember them. They wanted their providers to understand the context of their lives from their prenatal interactions. Incorporating findings from this study to improve patient–provider interactions during prenatal care could provide an increased understanding of the many complex variables affecting African American women’s lives.
Implications for Practice and Research
Prenatal care provides an opportunity for African American women to develop a trusting relationship with a provider. Developing models of prenatal care congruent with the realities of African American women’s lives has the potential to improve patient–provider interactions and potentially affect birth outcomes.
doi:10.1177/1043659610387149
PMCID: PMC3277208  PMID: 21191039
maternal/child; transcultural health; women’s health; focus group analysis; African American
7.  Promoting Access: The Use of Maternity Waiting Homes to Achieve Safe Motherhood 
Midwifery  2013;29(10):1095-1102.
doi:10.1016/j.midw.2013.07.020
PMCID: PMC3787070  PMID: 24012018
8.  The Ten Beads Method: A Novel Way to Collect Quantitative Data in Rural Uganda 
This paper illustrates how locally appropriate methods can be used to collect quantitative data from illiterate respondents. This method uses local beads to represent quantities, which is a novel yet potentially valuable methodological improvement over standard Western survey methods.
doi:10.4081/jphr.2013.e6
PMCID: PMC4140323  PMID: 25170477
survey methods; low literacy populations; developing countries; Uganda
9.  Factors that influence midwifery students in Ghana when deciding where to practice: a discrete choice experiment 
BMC Medical Education  2013;13:64.
Background
Mal-distribution of the health workforce with a strong bias for urban living is a major constraint to expanding midwifery services in Ghana. According to the UN Millennium Development Goals (MDG) report, the high risk of dying in pregnancy or childbirth continues in Africa. Maternal death is currently estimated at 350 per 100,000, partially a reflection of the low rates of professional support during birth. Many women in rural areas of Ghana give birth alone or with a non-skilled attendant. Midwives are key healthcare providers in achieving the MDGs, specifically in reducing maternal mortality by three-quarters and reducing by two-thirds the under 5 child mortality rate by 2015.
Methods
This quantitative research study used a computerized structured survey containing a discrete choice experiment (DCE) to quantify the importance of different incentives and policies to encourage service to deprived, rural and remote areas by upper-year midwifery students following graduation. Using a hierarchical Bayes procedure we estimated individual and mean utility parameters for two hundred and ninety eight third year midwifery students from two of the largest midwifery training schools in Ghana.
Results
Midwifery students in our sample identified: 1) study leave after two years of rural service; 2) an advanced work environment with reliable electricity, appropriate technology and a constant drug supply; and 3) superior housing (2 bedroom, 1 bathroom, kitchen, living room, not shared) as the top three motivating factors to accept a rural posting.
Conclusion
Addressing the motivating factors for rural postings among midwifery students who are about to graduate and enter the workforce could significantly contribute to the current mal-distribution of the health workforce.
doi:10.1186/1472-6920-13-64
PMCID: PMC3684532  PMID: 23642076
10.  Lessons learned in Liberia: preliminary examination of the psychometric properties of trust and teamwork among maternal healthcare workers 
Background
Post-conflict Liberia has one of the fastest growing populations on the continent and one of the highest maternal mortality rates among the world. However, in the rural regions, less than half of all births are attended by a skilled birth attendant. There is a need to evaluate the relationship between trained traditional healthcare providers and skilled birth attendants to improve maternal health outcomes. This evaluation must also take into consideration the needs and desires of the patients. The purpose of this pilot study was to establish the validity and reliability of a survey tool to evaluate trust and teamwork in the working relationships between trained traditional midwives and certified midwives in a post-conflict country.
Methods
A previously established scale, the Trust and Teambuilding Scale, was used with non- and low-literate trained traditional midwives (n=48) in rural Liberia to evaluate trust and teamwork with certified midwives in their communities. Initial results indicated that the scale and response keys were culturally inadequate for this population. A revised version of the scale, the Trust and Teamwork Scale – Liberia, was created and administered to an additional group of non- and low-literate, trained traditional midwives (n=42). Exploratory factor analysis using Mplus for dichotomous variables was used to determine the psychometric properties of the revised scale and was then confirmed with the full sample (n=90). Additional analyses included contrast validity, convergent validity, and Kuder-Richardson reliability.
Results
Exploratory factor analysis revealed two factors in the revised Trust and Teamwork Scale – Liberia. These two factors, labeled trust and teamwork, included eleven of the original eighteen items used in the Trust and Teamwork Scale and demonstrated contrast and convergent validity and adequate reliability.
Conclusions
The revised scale is suitable for use with non- and low-literate, trained traditional midwives in rural Liberia. Continued cross-cultural validation of tools is essential to ensure scale adequacy across populations. Future work should continue to evaluate the use of the Trust and Teamwork Scale – Liberia across cultures and additional work is needed to confirm the factor structure.
doi:10.1186/1472-6963-13-134
PMCID: PMC3635917  PMID: 23578288
Trust; Teamwork; Traditional birth attendants; Certified midwives; Psychometric testing
11.  Perceived barriers and motivating factors influencing student midwives’ acceptance of rural postings in Ghana 
Background
Research on the mal-distribution of health care workers has focused mainly on physicians and nurses. To meet the Millennium Development Goal Five and the reproductive needs of all women, it is predicted that an additional 334,000 midwives are needed. Despite the on-going efforts to increase this cadre of health workers there are still glaring gaps and inequities in distribution. The objectives of this study are to determine the perceived barriers and motivators influencing final year midwifery students’ acceptance of rural postings in Ghana, West Africa.
Methods
An exploratory qualitative study using focus group interviews as the data collection strategy was conducted in two of the largest midwifery training schools in Ghana. All final year midwifery students from the two training schools were invited to participate in the focus groups. A purposive sample of 49 final year midwifery students participated in 6 focus groups. All students were women. Average age was 23.2 years. Glaser’s constant comparative method of analysis was used to identify patterns or themes from the data.
Results
Three themes were identified through a broad inductive process: 1) social amenities; 2) professional life; and 3) further education/career advancement. Together they create the overarching theme, quality of life, we use to describe the influences on midwifery students’ decision to accept a rural posting following graduation.
Conclusions
In countries where there are too few health workers, deployment of midwives to rural postings is a continuing challenge. Until more midwives are attracted to work in rural, remote areas health inequities will exist and the targeted reduction for maternal mortality will remain elusive.
doi:10.1186/1478-4491-10-17
PMCID: PMC3438115  PMID: 22828497
Africa; West; Health care; Human resources for health; Maternal health; Midwifery; Qualitative Methods; Recruitment; Retention; Rural
12.  Husbands' involvement in delivery care utilization in rural Bangladesh: A qualitative study 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1471-2393-12-28
PMCID: PMC3364886  PMID: 22494576
13.  Malpractice Burden, Rural Location, and Discontinuation of Obstetric Care: A Study of Obstetric Providers in Michigan 
Context
It has long been a concern that professional liability problems disproportionately affect the delivery of obstetrical services to women living in rural areas. Michigan, a state with a large number of rural communities, is considered to be at risk for a medical liability crisis.
Purpose
This study examined whether higher malpractice burden on obstetric providers was associated with an increased likelihood of discontinuing obstetric care and whether there were rural-urban differences in the relationship.
Methods
Data on 500 obstetrician-gynecologists and family physicians who had provided obstetric care at some point in their career (either currently or previously) were obtained from a statewide survey in Michigan. Statistical tests and multivariate regression analyses were performed to examine the interrelationship among malpractice burden, rural location, and discontinuation of obstetric care.
Findings
After adjusting for other factors that might influence a physician’s decision about whether to stop obstetric care, our results showed no significant impact of malpractice burden on physicians’ likelihood to discontinue obstetric care. Rural-urban location of the practice did not modify the nature of this relationship. However, family physicians in rural Michigan had a nearly four fold higher likelihood of withdrawing obstetric care when compared to urban family physicians.
Conclusions
The higher likelihood of rural family physicians to discontinue obstetric care should be carefully weighed in future interventions to preserve obstetric care supply. More research is needed to better understand the practice environment of rural family physicians and the reasons for their withdrawal from obstetric care.
doi:10.1111/j.1748-0361.2009.00196.x
PMCID: PMC3063488  PMID: 19166559
Medical liability; obstetrics; rural; urban; Michigan
14.  Cost of Racial Disparity in Preterm Birth: Evidence from Michigan 
This study examined the economic costs associated with racial disparity in preterm birth and preterm fetal death in Michigan. Linked 2003 Michigan vital statistics and hospital discharge data were used for data analysis. Thirteen percent of the singleton births among non-Hispanic Blacks were before 37 completed weeks of gestation, compared to only 7.7% among non-Hispanic Whites (risk ratio = 1.66, 95% confidence interval: 1.59-1.72; p<0.0001). One thousand one hundred and eighty four non-Hispanic Black, singleton preterm births and preterm fetal deaths would have been avoided in 2003 had their preterm birth rate been the same as Michigan non-Hispanic Whites. Economic costs associated with these excess Black preterm births and preterm fetal deaths amounted to $329 million (range: $148 million - $598 million) across their lifespan over and above the costs if they were born at term, including costs associated with the initial hospitalization, productivity loss due to perinatal death, and major developmental disabilities. Hence, racial disparity in preterm birth and preterm fetal death has substantial cost implications for society. Improving pregnancy outcomes for African American women and reducing the disparity between Blacks and Whites should continue to be a focus of future research and interventions.
doi:10.1353/hpu.0.0180
PMCID: PMC2743129  PMID: 19648701
Disparities; preterm birth; cost; African American; race
15.  Development of Prenatal Event History Calendar for Black Women 
Objectives
To identify psychosocial factors that Black women think should be addressed in prenatal care assessment and develop a Prenatal Event History Calendar (EHC) to assess these factors.
Design
A qualitative descriptive study
Setting
Two inner city hospital prenatal care clinics in Southeastern Michigan.
Participants
Twenty two Black women who had attended at least two prenatal care visits.
Method
Three focus groups were conducted using a semi-structured interview guide.
Main Outcome Measure
Using the constant comparative method of analysis (Glaser, 1978; 1992) themes were identified that were relevant to Black women during prenatal care visits.
Results
The women in this study wanted to talk with their providers about psychosocial factors and not just the physical aspects of pregnancy. To “go off the pregnancy” represents pregnant women’s desire to discuss psychosocial factors that were important to them during prenatal care. Five themes emerged from the data and were used to develop categories for the Prenatal EHC: relationships, stress, routines, health history perceptions, and beliefs.
Conclusion
One vital component of prenatal care assessment is assessing for psychosocial risk factors. Prenatal EHC was specifically developed to provide a comprehensive and contextually-linked psychosocial risk assessment for use with pregnant Black women.
doi:10.1111/j.1552-6909.2008.00255.x
PMCID: PMC2569130  PMID: 18754984
prenatal care; event history calendar; birth outcome disparities
16.  The Impact of Malpractice Burden on Michigan Obstetrician-Gynecologists’ Career Satisfaction 
Background
Medical services for pregnancy and childbirth are inherently risky and unpredictable. In many states, obstetrician-gynecologists (ob-gyns) who attend the majority of childbirths in the U.S. and provide the most clinically complex obstetric procedures are struggling with increasing malpractice insurance premiums and litigation risk. Despite its significant implications for patient care, the potential impact of malpractice burden on ob-gyn physicians’ career satisfaction has not been rigorously tested in previous research.
Methods
Drawing on data from a statewide survey of obstetric providers in Michigan, this paper examined the association between medical liability burden and ob-gyns’ career satisfaction. Malpractice insurance premiums and malpractice claims experience were used as two objective measures for medical liability burden. Descriptive statistics were calculated and multivariable logistic regressions estimated for data analysis.
Results
Although most respondents reported satisfaction with their overall career in medicine, 43.7% had become less satisfied over the last five years and 34.0% would not recommend obstetrics/gynecology to students seeking career advice. Multivariable regression analysis showed that compared to coverage through an employer, paying $50,000/year or more for liability insurance premium was associated with lower career satisfaction among ob-gyns (odds ratio = 0.35, 95% confidence interval: 0.13–0.93). We found no significant impact of malpractice claims experience, including both recent malpractice claims (during the last five years, i.e., 2001–2006) and earlier malpractice claims (more than five years ago), on overall career satisfaction.
Conclusions
The findings of this study suggest that high malpractice premiums negatively affect ob-gyn physicians’ career satisfaction. The impact of the current medical liability climate on quality of care for pregnant women warrants further investigation.
doi:10.1016/j.whi.2008.02.007
PMCID: PMC2536603  PMID: 18590881
obstetrician-gynecologist; career satisfaction; malpractice; maternity care
17.  The Effects of Medical Liability on Obstetric Care Supply in Michigan 
Objective
To examine Michigan obstetric providers’ provision of obstetric care and the impact of malpractice concerns on their practice decisions.
Study Design
Data were obtained from 899 Michigan obstetrician-gynecologists, family physicians, and nurse-midwives via a statewide survey. Statistical tests were conducted to examine differences in obstetric care provision and the influence of various factors across specialties.
Results
Among providers currently practicing obstetrics, 18.3%, 18.7% and 11.9% of obstetrician-gynecologists, family physicians and nurse-midwives, respectively, planned to discontinue delivering babies in the next five years, and 35.5%, 24.5% and 12.6%, respectively, planned to reduce their provision of high-risk obstetric care. “Risk of malpractice litigation” was one of the most cited factors affecting providers’ decision to include obstetrics in their practice.
Conclusions
Litigation risk appears to be an important factor influencing Michigan obstetric providers’ decisions about provision of care. Its implications for obstetric care supply and patients’ access to care warrants further research.
doi:10.1016/j.ajog.2007.08.043
PMCID: PMC2259238  PMID: 17997388
medical liability; obstetrician-gynecologist; family physician; nurse-midwives; obstetric care

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