PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (104)
 

Clipboard (0)
None
Journals
Year of Publication
Document Types
1.  Maternal mortality in Kassala State - Eastern Sudan: community-based study using Reproductive age mortality survey (RAMOS) 
Background
The maternal mortality ratio in Sudan was estimated at 750/100,000 live births. Sudan was one of eleven countries that are responsible for 65% of global maternal deaths according to a recent World Health Organization (WHO) estimate. Maternal mortality in Kassala State was high in national demographic surveys. This study was conducted to investigate the causes and contributing factors of maternal deaths and to identify any discrepancies in rates and causes between different areas.
Methods
A reproductive age mortality survey (RAMOS) was conducted to study maternal mortality in Kassala State. Deaths of women of reproductive age (WRA) in four purposively selected areas were identified by interviewing key informants in each village followed by verbal autopsy.
Results
Over a three-year period, 168 maternal deaths were identified among 26,066 WRA. Verbal autopsies were conducted in 148 (88.1%) of these cases. Of these, 64 (43.2%) were due to pregnancy and childbirth complications. Maternal mortality rates and ratios were 80.6 per 100,000 WRA and 713.6 per 100,000 live births (LB), respectively. There was a wide discrepancy between urban and rural maternal mortality ratios (369 and 872\100,000 LB, respectively). Direct obstetric causes were responsible for 58.4% of deaths. Severe anemia (20.3%) and acute febrile illness (9.4%) were the major indirect causes of maternal death whereas obstetric hemorrhage (15.6%), obstructed labor (14.1%) and puerperal sepsis (10.9%) were the major obstetric causes.
Of the contributing factors, we found delay of referral in 73.4% of cases in spite of a high problem recognition rate (75%). 67.2% of deaths occurred at home, indicating under utilization of health facilities, and transportation problems were found in 54.7% of deaths.
There was a high illiteracy rate among the deceased and their husbands (62.5% and 48.4%, respectively).
Conclusions
Maternal mortality rates and ratios were found to be high, with a wide variation between urban and rural populations. Direct causes of maternal death were similar to those in developing countries. To reduce this high maternal mortality rate we recommend improving provision of emergency obstetric care (Emoc) in all health facilities, expanding midwifery training and coverage especially in rural areas.
doi:10.1186/1471-2393-11-102
PMCID: PMC3260097  PMID: 22171988
2.  Effect of physical activity intervention based on a pedometer on physical activity level and anthropometric measures after childbirth: a randomized controlled trial 
Background
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.
Methods
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.
Results
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).
Conclusion
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.
Trial registration
ISRCTN: IRCT201105026362N1
doi:10.1186/1471-2393-11-103
PMCID: PMC3292461  PMID: 22176722
3.  Systematic review of the magnitude and case fatality ratio for severe maternal morbidity in sub-Saharan Africa between 1995 and 2010 
Background
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.
Methods
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.
Results
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%.
Conclusion
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.
doi:10.1186/1471-2393-11-65
PMCID: PMC3203082  PMID: 21955698
4.  High maternal mortality estimated by the sisterhood method in a rural area of Mali 
Background
Maternal mortality is high in Mali. Nevertheless, there are few studies on this topic from rural areas, and current estimates are mostly based on studies from urban settings. Our objective was to estimate the maternal mortality ratio in Kita, rural Mali.
Methods
Using the "sisterhood method", we interviewed participants aged 15-50 years from 20 villages in Kita, Mali, and thereby created a retrospective cohort of their sisters in reproductive age. Based on population and fertility estimates, we calculated the lifetime risk of maternal death, and from that the estimated approximate maternal mortality ratio.
Results
The 2,039 respondents reported 4,628 sisters who had reached reproductive age. Of these 4,628 sisters, almost a third (1,233; 27%) had died, and 429 (9%) had died during pregnancy or childbirth. This corresponded to a lifetime risk of maternal death of 20% and a maternal mortality ratio of 3,131 per 100,000 live births (95% confidence interval 2,967-3,296), with a time reference around 1999.
Conclusions
We found a very high maternal mortality in rural Mali and this highlights the urgent need for obstetric services in the remote rural areas.
doi:10.1186/1471-2393-11-56
PMCID: PMC3161002  PMID: 21812951
maternal mortality; rural; sisterhood method; Mali
5.  Overweight and obesity knowledge prior to pregnancy: a survey study 
Background
Overweight and obesity are associated with increased risk for pregnancy complications. Knowledge about increased risks in overweight and obese women could contribute to successful prevention strategies and the aim of this study is to assess current levels of knowledge in a pregnant population.
Methods
Cross sectional survey of 412 consecutive unselected women in early pregnancy in Brisbane, Australia: 255 public women attending their first antenatal clinic visit and 157 women at private maternal fetal medicine clinics undergoing a routine ultrasound evaluation prior to 20 weeks gestation. The cohort was stratified according to pre pregnancy BMI (< 25.0 or ≥ 25.0). The main outcome measure was knowledge regarding the risks of overweight and obesity in pregnancy.
Results
Over 75% of respondents identified that obese women have an increased risk of overall complications, including gestational diabetes and hypertensive disorders of pregnancy compared to women of normal weight. More than 60% of women asserted that obesity would increase the risk of caesarean section and less than half identified an increased risk of adverse neonatal outcomes. Women were less likely to know about neonatal complications (19.7% did not know about the effect of obesity on these) than maternal complications (7.4%). Knowledge was similar amongst women recruited at the public hospital and those recruited whilst attending for an ultrasound scan at a private clinic. For most areas they were also similar between women of lower and higher BMI, but women with BMI < 25.0 were less likely to know that obesity was associated with increased rate of Caesarean section than those with higher BMI (16.8% versus 4.5%, P < 0.001). Higher educational status was associated with more knowledge of the risks of overweight and obesity in pregnancy.
Conclusions
Many women correctly identify that overweight and obesity increases the overall risk of complications of pregnancy and childbirth. The increased risks of maternal complications associated with being obese are better known than the increased risk of neonatal complications. Maternal education status is a main determinant of the extent of knowledge and this should be considered when designing education campaigns.
doi:10.1186/1471-2393-11-96
PMCID: PMC3240826  PMID: 22103736
6.  Limiting weight gain in overweight and obese women during pregnancy to improve health outcomes: the LIMIT randomised controlled trial 
Background
Obesity is a significant global health problem, with the proportion of women entering pregnancy with a body mass index greater than or equal to 25 kg/m2 approaching 50%. Obesity during pregnancy is associated with a well-recognised increased risk of adverse health outcomes both for the woman and her infant, however there is more limited information available regarding effective interventions to improve health outcomes.
The aims of this randomised controlled trial are to assess whether the implementation of a package of dietary and lifestyle advice to overweight and obese women during pregnancy to limit gestational weight gain is effective in improving maternal, fetal and infant health outcomes.
Methods/Design
Design: Multicentred randomised, controlled trial.
Inclusion Criteria: Women with a singleton, live gestation between 10+0-20+0 weeks who are obese or overweight (defined as body mass index greater than or equal to 25 kg/m2), at the first antenatal visit.
Trial Entry & Randomisation: Eligible, consenting women will be randomised between 10+0 and 20+0 weeks gestation using a central telephone randomisation service, and randomisation schedule prepared by non-clinical research staff with balanced variable blocks. Stratification will be according to maternal BMI at trial entry, parity, and centre where planned to give birth.
Treatment Schedules: Women randomised to the Dietary and Lifestyle Advice Group will receive a series of inputs from research assistants and research dietician to limit gestational weight gain, and will include a combination of dietary, exercise and behavioural strategies.
Women randomised to the Standard Care Group will continue to receive their pregnancy care according to local hospital guidelines, which does not currently include routine provision of dietary, lifestyle and behavioural advice.
Outcome assessors will be blinded to the allocated treatment group.
Primary Study Outcome: infant large for gestational age (defined as infant birth weight ≥ 90th centile for gestational age).
Sample Size: 2,180 women to detect a 30% reduction in large for gestational age infants from 14.40% (p = 0.05, 80% power, two-tailed).
Discussion
This is a protocol for a randomised trial. The findings will contribute to the development of evidence based clinical practice guidelines.
Trial Registration
Australian and New Zealand Clinical Trials Registry ACTRN12607000161426
doi:10.1186/1471-2393-11-79
PMCID: PMC3219553  PMID: 22026403
7.  Waiting for attention and care: birthing accounts of women in rural Tanzania who developed obstetric fistula as an outcome of labour 
Background
Obstetric fistula is a physically and socially disabling obstetric complication that affects about 3,000 women in Tanzania every year. The fistula, an opening that forms between the vagina and the bladder and/or the rectum, is most frequently caused by unattended prolonged labour, often associated with delays in seeking and receiving appropriate and adequate birth care. Using the availability, accessibility, acceptability and quality of care (AAAQ) concept and the three delays model, this article provides empirical knowledge on birth care experiences of women who developed fistula after prolonged labour.
Methods
We used a mixed methods approach to explore the birthing experiences of women affected by fistula and the barriers to access adequate care during labour and delivery. Sixteen women were interviewed for the qualitative study and 151 women were included in the quantitative survey. All women were interviewed at the Comprehensive Community Based Rehabilitation Tanzania in Dar es Salaam and Bugando Medical Centre in Mwanza.
Results
Women experienced delays both before and after arriving at a health facility. Decisions on where to seek care were most often taken by husbands and mothers-in-law (60%). Access to health facilities providing emergency obstetric care was inadequate and transport was a major obstacle. About 20% reported that they had walked or were carried to the health facility. More than 50% had reported to a health facility after two or more days of labour at home. After arrival at a health facility women experienced lack of supportive care, neglect, poor assessment of labour and lack of supervision. Their birth accounts suggest unskilled birth care and poor referral routines.
Conclusions
This study reveals major gaps in access to and provision of emergency obstetric care. It illustrates how poor quality of care at health facilities contributes to delays that lead to severe birth injuries, highlighting the need to ensure women's rights to accessible, acceptable and adequate quality services during labour and delivery.
doi:10.1186/1471-2393-11-75
PMCID: PMC3221614  PMID: 22013991
8.  Accounts of severe acute obstetric complications in Rural Bangladesh 
Background
As maternal deaths have decreased worldwide, increasing attention has been placed on the study of severe obstetric complications, such as hemorrhage, eclampsia, and obstructed labor, to identify where improvements can be made in maternal health. Though access to medical care is considered to be life-saving during obstetric emergencies, data on the factors associated with health care decision-making during obstetric emergencies are lacking. We aim to describe the health care decision-making process during severe acute obstetric complications among women and their families in rural Bangladesh.
Methods
Using the pregnancy surveillance infrastructure from a large community trial in northwest rural Bangladesh, we nested a qualitative study to document barriers to timely receipt of medical care for severe obstetric complications. We conducted 40 semi-structured, in-depth interviews with women reporting severe acute obstetric complications and purposively selected for conditions representing the top five most common obstetric complications. The interviews were transcribed and coded to highlight common themes and to develop an overall conceptual model.
Results
Women attributed their life-threatening experiences to societal and socioeconomic factors that led to delays in seeking timely medical care by decision makers, usually husbands or other male relatives. Despite the dominance of male relatives and husbands in the decision-making process, women who underwent induced abortions made their own decisions about their health care and relied on female relatives for advice. The study shows that non-certified providers such as village doctors and untrained birth attendants were the first-line providers for women in all categories of severe complications. Coordination of transportation and finances was often arranged through mobile phones, and referrals were likely to be provided by village doctors.
Conclusions
Strategies to increase timely and appropriate care seeking for severe obstetric complications may consider targeting of non-certified providers for strengthening of referral linkages between patients and certified facility-based providers. Future research may characterize the treatments and appropriateness of emergency care provided by ubiquitous village doctors and other non-certified treatment providers in rural South Asian settings. In addition, future studies may explore the use of mobile phones in decreasing delays to certified medical care during obstetric emergencies.
doi:10.1186/1471-2393-11-76
PMCID: PMC3250923  PMID: 22018330
9.  Methods of induction of labour: a systematic review 
Background
Rates of labour induction are increasing. We conducted this systematic review to assess the evidence supporting use of each method of labour induction.
Methods
We listed methods of labour induction then reviewed the evidence supporting each. We searched MEDLINE and the Cochrane Library between 1980 and November 2010 using multiple terms and combinations, including labor, induced/or induction of labor, prostaglandin or prostaglandins, misoprostol, Cytotec, 16,16,-dimethylprostaglandin E2 or E2, dinoprostone; Prepidil, Cervidil, Dinoprost, Carboprost or hemabate; prostin, oxytocin, misoprostol, membrane sweeping or membrane stripping, amniotomy, balloon catheter or Foley catheter, hygroscopic dilators, laminaria, dilapan, saline injection, nipple stimulation, intercourse, acupuncture, castor oil, herbs. We performed a best evidence review of the literature supporting each method. We identified 2048 abstracts and reviewed 283 full text articles. We preferentially included high quality systematic reviews or large randomised trials. Where no such studies existed, we included the best evidence available from smaller randomised or quasi-randomised trials.
Results
We included 46 full text articles. We assigned a quality rating to each included article and a strength of evidence rating to each body of literature. Prostaglandin E2 (PGE2) and vaginal misoprostol were more effective than oxytocin in bringing about vaginal delivery within 24 hours but were associated with more uterine hyperstimulation. Mechanical methods reduced uterine hyperstimulation compared with PGE2 and misoprostol, but increased maternal and neonatal infectious morbidity compared with other methods. Membrane sweeping reduced post-term gestations. Most included studies were too small to evaluate risk for rare adverse outcomes.
Conclusions
Research is needed to determine benefits and harms of many induction methods.
doi:10.1186/1471-2393-11-84
PMCID: PMC3224350  PMID: 22032440
10.  A randomised controlled trial of caseload midwifery care: M@NGO (Midwives @ New Group practice Options) 
Background
Australia has an enviable record of safety for women in childbirth. There is nevertheless growing concern at the increasing level of intervention and consequent morbidity amongst childbearing women. Not only do interventions impact on the cost of services, they carry with them the potential for serious morbidities for mother and infant.
Models of midwifery have proliferated in an attempt to offer women less fragmented hospital care. One of these models that is gaining widespread consumer, disciplinary and political support is caseload midwifery care. Caseload midwives manage the care of approximately 35-40 a year within a small Midwifery Group Practice (usually 4-6 midwives who plan their on call and leave within the Group Practice.) We propose to compare the outcomes and costs of caseload midwifery care compared to standard or routine hospital care through a randomised controlled trial.
Methods/design
A two-arm RCT design will be used. Women will be recruited from tertiary women's hospitals in Sydney and Brisbane, Australia. Women allocated to the caseload intervention will receive care from a named caseload midwife within a Midwifery Group Practice. Control women will be allocated to standard or routine hospital care. Women allocated to standard care will receive their care from hospital rostered midwives, public hospital obstetric care and community based general medical practitioner care. All midwives will collaborate with obstetricians and other health professionals as necessary according to the woman's needs.
Discussion
Data will be collected at recruitment, 36 weeks antenatally, six weeks and six months postpartum by web based or postal survey. With 750 women or more in each of the intervention and control arms the study is powered (based on 80% power; alpha 0.05) to detect a difference in caesarean section rates of 29.4 to 22.9%; instrumental birth rates from 11.0% to 6.8%; and rates of admission to neonatal intensive care of all neonates from 9.9% to 5.8% (requires 721 in each arm). The study is not powered to detect infant or maternal mortality, however all deaths will be reported. Other significant findings will be reported, including a comprehensive process and economic evaluation.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12609000349246
doi:10.1186/1471-2393-11-82
PMCID: PMC3235961  PMID: 22029746
11.  Mothers' satisfaction with referral hospital delivery service in Amhara Region, Ethiopia 
Background
A woman's satisfaction with the delivery service may have immediate and long-term effects on her health and subsequent utilization of the services. Providing satisfying delivery care increases service utilization. The objective of this study is to assess the satisfaction of mothers with referral hospitals' delivery service and identify some possible factors affecting satisfaction in Amhara region of Ethiopia.
Methods
A hospital-based cross-sectional survey that involved an exit interview was conducted from September to November 2009 in three referral hospitals in Ethiopia. A total of 417 delivering mothers were enrolled in the study. Client satisfaction was measured using a survey instrument adopted from the Donabedian quality assessment framework. We collect data systematically from every other postnatal woman who delivered in the referral hospitals. Multivariate and binary logistic regression was applied to identify the relative effect of each explanatory variable on the outcome (satisfaction).
Results
The proportion of mothers who were satisfied with delivery care in this study was 61.9%. Women's satisfaction with delivery care was associated with wanted status of the pregnancy, immediate maternal condition after delivery, waiting time to see the health worker, availability of waiting area, care providers' measure taken to assure privacy during examinations, and amount of cost paid for service.
Conclusions
The overall satisfaction of hospital delivery services in this study is found to be suboptimal. The study strongly suggests that more could be done to assure that services provided are more patient centered.
doi:10.1186/1471-2393-11-78
PMCID: PMC3254067  PMID: 22023913
12.  Maternal near-miss in a rural hospital in Sudan 
Background
Investigation of maternal near-miss is a useful complement to the investigation of maternal mortality with the aim of meeting the United Nations' fifth Millennium Development Goal. The present study was conducted to investigate the frequency of near-miss events, to calculate the mortality index for each event and to compare the socio-demographic and obstetrical data (age, parity, gestational age, education and antenatal care) of the near-miss cases with maternal deaths.
Methods
Near-miss cases and events (hemorrhage, infection, hypertensive disorders, anemia and dystocia), maternal deaths and their causes were retrospectively reviewed and the mortality index for each event was calculated in Kassala Hospital, eastern Sudan over a 2-year period, from January 2008 to December 2010. Disease-specific criteria were applied for these events.
Results
There were 9578 deliveries, 205 near-miss cases, 228 near-miss events and 40 maternal deaths. Maternal near-miss and maternal mortality ratio were 22.1/1000 live births and 432/100 000 live births, respectively. Hemorrhage accounted for the most common event (40.8%), followed by infection (21.5%), hypertensive disorders (18.0%), anemia (11.8%) and dystocia (7.9%). The mortality index were 22.2%, 10.0%, 10.0%, 8.8% and 2.4% for infection, dystocia, anemia, hemorrhage and hypertensive disorders, respectively.
Conclusion
There is a high frequency of maternal morbidity and mortality at the level of this facility. Therefore maternal health policy needs to be concerned not only with averting the loss of life, but also with preventing or ameliorating maternal-near miss events (hemorrhage, infections, hypertension and anemia) at all care levels including primary level.
doi:10.1186/1471-2393-11-48
PMCID: PMC3141596  PMID: 21714881
13.  Concurrent analysis of choice and control in childbirth 
Background
This paper reports original research on choice and control in childbirth. Eight women were interviewed as part of a wider investigation into locus of control in women with pre-labour rupture of membranes at term (PROM) [1].
Methods
The following study uses concurrent analysis to sample and analyse narrative aspects of relevant literature along with these interviews in order to synthesise a generalisable analysis of the pertinent issues. The original PROM study had found that women experienced a higher degree of control in hospital, a finding that appeared at odds with contemporary notions of choice. However, this paper contextualises this finding by presenting narratives that lucidly subscribe to the dominant discourse of hospital as the safest place to give birth, under the premise of assuring a live healthy baby irrespective of their management type.
Results
This complex narrative is composed of the following themes: 'perceiving risk', 'being prepared', 'reflecting on experience', maintaining control' and relinquishing control'. These themes are constructed within and around the medical, foetocentric, risk averse cultural context. Primary data are presented throughout to show the origins and interconnected nature of these themes.
Conclusions
Within this context it is clear that there is a highly valued role for competent health professionals that respect, understand and are capable of facilitating genuine choice for women.
doi:10.1186/1471-2393-11-40
PMCID: PMC3123250  PMID: 21631910
Choice; control; pregnancy; narrative; qualitative; generalisable; concurrent analysis
14.  Maternal health interventions in resource limited countries: a systematic review of packages, impacts and factors for change 
Background
The burden of maternal mortality in resource limited countries is still huge despite being at the top of the global public health agenda for over the last 20 years. We systematically reviewed the impacts of interventions on maternal health and factors for change in these countries.
Methods
A systematic review was carried out using the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles published in the English language reporting on implementation of interventions, their impacts and underlying factors for maternal health in resource limited countries in the past 23 years were searched from PubMed, Popline, African Index Medicus, internet sources including reproductive health gateway and Google, hand-searching, reference lists and grey literature.
Results
Out of a total of 5084 articles resulting from the search only 58 qualified for systematic review. Programs integrating multiple interventions were more likely to have significant positive impacts on maternal outcomes. Training in emergency obstetric care (EmOC), placement of care providers, refurbishment of existing health facility infrastructure and improved supply of drugs, consumables and equipment for obstetric care were the most frequent interventions integrated in 52% - 65% of all 54 reviewed programs. Statistically significant reduction of maternal mortality ratio and case fatality rate were reported in 55% and 40% of the programs respectively. Births in EmOC facilities and caesarean section rates increased significantly in 71% - 75% of programs using these indicators. Insufficient implementation of evidence-based interventions in resources limited countries was closely linked to a lack of national resources, leadership skills and end-users factors.
Conclusions
This article presents a list of evidenced-based packages of interventions for maternal health, their impacts and factors for change in resource limited countries. It indicates that no single magic bullet intervention exists for reduction of maternal mortality and that all interventional programs should be integrated in order to bring significant changes. State leaders and key actors in the health sectors in these countries and the international community are proposed to translate the lessons learnt into actions and intensify efforts in order to achieve the goals set for maternal health.
doi:10.1186/1471-2393-11-30
PMCID: PMC3090370  PMID: 21496315
15.  The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review 
Background
Infant mortality has shown a steady decline in recent years but a marked socioeconomic gradient persists. Antenatal care is generally thought to be an effective method of improving pregnancy outcomes, but the effectiveness of specific antenatal care programmes as a means of reducing infant mortality in socioeconomically disadvantaged and vulnerable groups of women has not been rigorously evaluated.
Methods
We conducted a systematic review, focusing on evidence from high income countries, to evaluate the effectiveness of alternative models of organising or delivering antenatal care to disadvantaged and vulnerable groups of women vs. standard antenatal care. We searched Medline, Embase, Cinahl, PsychINFO, HMIC, CENTRAL, DARE, MIDIRS and a number of online resources to identify relevant randomised and observational studies. We assessed effects on infant mortality and its major medical causes (preterm birth, congenital anomalies and sudden infant death syndrome (SIDS))
Results
We identified 36 distinct eligible studies covering a wide range of interventions, including group antenatal care, clinic-based augmented care, teenage clinics, prenatal substance abuse programmes, home visiting programmes, maternal care coordination and nutritional programmes. Fifteen studies had adequate internal validity: of these, only one was considered to demonstrate a beneficial effect on an outcome of interest. Six interventions were considered 'promising'.
Conclusions
There was insufficient evidence of adequate quality to recommend routine implementation of any of the programmes as a means of reducing infant mortality in disadvantaged/vulnerable women. Several interventions merit further more rigorous evaluation.
doi:10.1186/1471-2393-11-13
PMCID: PMC3050773  PMID: 21314944
16.  Utilization of maternal health services among young women in Kenya: Insights from the Kenya Demographic and Health Survey, 2003 
Background
Use of maternal health services is an effective means for reducing the risk of maternal morbidity and mortality, especially in places where the general health status of women is poor. This study was guided by the following objectives: 1) To determine the relationship between timing of first antenatal care (ANC) visit and type of delivery assistance 2) To establish the determinants of timing of first ANC visit and type delivery assistance.
Methods
Data used were drawn from the 2003 Kenya Demographic and Health Survey, with a focus on young women aged 15-24. The dependent variables were: Timing of first ANC visit coded as "None"; "Late" and "Early", and type of delivery assistance coded as "None"; "Traditional Birth Attendant (TBA)" and "Skilled professional". Control variables included: education, household wealth, urban-rural residence, ethnicity, parity, age at birth of the last child and marital status. Multivariate ordered logistic regression model was used.
Results
The study results show that place of residence, household wealth, education, ethnicity, parity, marital status and age at birth of the last child had strong influences on timing of first ANC visit and the type of delivery assistance received. The major finding is an association between early timing of the first ANC visit and use of skilled professionals at delivery.
Conclusion
This study confirms that timing of first antenatal care is indeed an important entry point for delivery care as young women who initiated antenatal care early were more likely to use skilled professional assistance at delivery than their counterparts who initiated ANC late. The results indicate that a large percentage of young pregnant women do not seek ANC during their first trimester as is recommended by the WHO, which may affect the type of assistance they receive during delivery. It is important that programs aimed at improving maternal health include targeting young women, especially those from rural areas, with low levels of education, higher parity and from poor households, given their high risk during pregnancy. The finding that a considerably high proportion of young women use TBAs as opposed to use of skilled professionals is baffling and calls for further research.
doi:10.1186/1471-2393-11-1
PMCID: PMC3022772  PMID: 21214960
17.  The mothers, Omega-3 and mental health study 
Background
Major depressive disorder (MDD) during pregnancy and postpartum depression are associated with significant maternal and neonatal morbidity. While antidepressants are readily used in pregnancy, studies have raised concerns regarding neurobehavioral outcomes in exposed infants. Omega-3 fatty acid supplementation, most frequently from fish oil, has emerged as a possible treatment or prevention strategy for MDD in non-pregnant individuals, and may have beneficial effects in pregnant women. Although published observational studies in the psychiatric literature suggest that maternal docosahexaenoic acid (DHA) deficiency may lead to the development of MDD in pregnancy and postpartum, there are more intervention trials suggesting clinical benefit for supplementation with eicosapentaenoic acid (EPA) in MDD.
Methods/Design
The Mothers, Omega-3 and Mental Health study is a double blind, placebo-controlled, randomized controlled trial to assess whether omega-3 fatty acid supplementation may prevent antenatal and postpartum depressive symptoms among pregnant women at risk for depression. We plan to recruit 126 pregnant women at less than 20 weeks gestation from prenatal clinics at two health systems in Ann Arbor, Michigan and the surrounding communities. We will follow them prospectively over the course of their pregnancies and up to 6 weeks postpartum. Enrolled participants will be randomized to one of three groups: a) EPA-rich fish oil supplement (1060 mg EPA plus 274 mg DHA) b) DHA-rich fish oil supplement (900 mg DHA plus 180 mg EPA; or c) a placebo. The primary outcome for this study is the Beck Depression Inventory (BDI) score at 6 weeks postpartum. We will need to randomize 126 women to have 80% power to detect a 50% reduction in participants' mean BDI scores with EPA or DHA supplementation compared with placebo. We will also gather information on secondary outcome measures which will include: omega-3 fatty acid concentrations in maternal plasma and cord blood, pro-inflammatory cytokine levels (IL-1β, IL-6, and TNF-α) in maternal and cord blood, need for and dosage of antidepressant medications, and obstetrical outcomes. Analyses will be by intent to treat.
Discussion
This study compares the relative effectiveness of DHA and EPA at preventing depressive symptoms among pregnant women at risk.
Trial registration
Clinical trial registration number: NCT00711971
doi:10.1186/1471-2393-11-46
PMCID: PMC3146889  PMID: 21696635
18.  Diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand, and the United States: a method for systematic review of studies with different designs 
Background
Diabetes in pregnancy, which includes gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM), is associated with poor outcomes for both mother and infant during pregnancy, at birth and in the longer term. Recent international guidelines recommend changes to the current GDM screening criteria. While some controversy remains, there appears to be consensus that women at high risk of T2DM, including indigenous women, should be offered screening for GDM early in pregnancy, rather than waiting until 24-28 weeks as is current practice. A range of criteria should be considered before changing screening practice in a population sub-group, including: prevalence, current practice, acceptability and whether adequate treatment pathways and follow-up systems are available. There are also specific issues related to screening in pregnancy and indigenous populations. The evidence that these criteria are met for indigenous populations is yet to be reported. A range of study designs can be considered to generate relevant evidence for these issues, including epidemiological, observational, qualitative, and intervention studies, which are not usually included within a single systematic review. The aim of this paper is to describe the methods we used to systematically review studies of different designs and present the evidence in a pragmatic format for policy discussion.
Methods/Design
The inclusion criteria will be broad to ensure inclusion of the critical perspectives of indigenous women. Abstracts of the search results will be reviewed by two persons; the full texts of all potentially eligible papers will be reviewed by one person, and 10% will be checked by a second person for validation. Data extraction will be standardised, using existing tools to identify risks for bias in intervention, measurement, qualitative studies and reviews; and adapting criteria for appraising risk for bias in descriptive studies. External validity (generalisability) will also be appraised. The main findings will be synthesised according to the criteria for population-based screening and summarised in an adapted "GRADE" tool.
Discussion
This will be the first systematic review of all the published literature on diabetes in pregnancy among indigenous women. The method provides a pragmatic approach for synthesizing relevant evidence from a range of study designs to inform the current policy discussion.
doi:10.1186/1471-2393-11-104
PMCID: PMC3260090  PMID: 22196083
19.  Effects of chronic carbon monoxide exposure on fetal growth and development in mice 
Background
Carbon monoxide (CO) is produced endogenously, and can also be acquired from many exogenous sources: ie. cigarette smoking, automobile exhaust. Although toxic at high levels, low level production or exposure lends to normal physiologic functions: smooth muscle cell relaxation, control of vascular tone, platelet aggregation, anti- inflammatory and anti-apoptotic events. In pregnancy, it is unclear at what level maternal CO exposure becomes toxic to the fetus. In this study, we hypothesized that CO would be embryotoxic, and we sought to determine at what level of chronic CO exposure in pregnancy embryo/fetotoxic effects are observed.
Methods
Pregnant CD1 mice were exposed to continuous levels of CO (0 to 400 ppm) from conception to gestation day 17. The effect on fetal/placental growth and development, and fetal/maternal CO concentrations were determined.
Results
Maternal and fetal CO blood concentrations ranged from 1.12- 15.6 percent carboxyhemoglobin (%COHb) and 1.0- 28.6%COHb, respectively. No significant difference was observed in placental histological morphology or in placental mass with any CO exposure. At 400 ppm CO vs. control, decreased litter size and fetal mass (p < 0.05), increased fetal early/late gestational deaths (p < 0.05), and increased CO content in the placenta and the maternal spleen, heart, liver, kidney and lung (p < 0.05) were observed.
Conclusions
Exposure to levels at or below 300 ppm CO throughout pregnancy has little demonstrable effect on fetal growth and development in the mouse.
doi:10.1186/1471-2393-11-101
PMCID: PMC3297534  PMID: 22168775
20.  Food choices and practices during pregnancy of immigrant and Aboriginal women in Canada: a study protocol 
Background
Facilitating the provision of appropriate health care for immigrant and Aboriginal populations in Canada is critical for maximizing health potential and well-being. Numerous reports describe heightened risks of poor maternal and birth outcomes for immigrant and Aboriginal women. Many of these outcomes may relate to food consumption/practices and thus may be obviated through provision of resources which suit the women's ethnocultural preferences. This project aims to understand ethnocultural food and health practices of Aboriginal and immigrant women, and how these intersect with respect to the legacy of Aboriginal colonialism and to the social contexts of cultural adaptation and adjustment of immigrants. The findings will inform the development of visual tools for health promotion by practitioners.
Methods/Design
This four-phase study employs a case study design allowing for multiple means of data collection and different units of analysis. Phase 1 consists of a scoping review of the literature. Phases 2 and 3 incorporate pictorial representations of food choices (photovoice in Phase 2) with semi-structured photo-elicited interviews (in Phase 3). The findings from Phases 1-3 and consultations with key stakeholders will generate key understandings for Phase 4, the production of culturally appropriate visual tools. For the scoping review, an emerging methodological framework will be utilized in addition to systematic review guidelines. A research librarian will assist with the search strategy and retrieval of literature. For Phases 2 and 3, recruitment of 20-24 women will be facilitated by team member affiliations at perinatal clinics in one of the city's most diverse neighbourhoods. The interviews will reveal culturally normative practices surrounding maternal food choices and consumption, including how women negotiate these practices within their own worldview and experiences. A structured and comprehensive integrated knowledge translation plan has been formulated.
Discussion
The findings of this study will provide practitioners with an understanding of the cultural differences that affect women's dietary choices during maternity. We expect that the developed resources will be of immediate use within the women's units and will enhance counseling efforts. Wide dissemination of outputs may have a greater long term impact in the primary and secondary prevention of these high risk conditions.
doi:10.1186/1471-2393-11-100
PMCID: PMC3252281  PMID: 22152052
21.  Perception and practice of Kangaroo Mother Care after discharge from hospital in Kumasi, Ghana: A longitudinal study 
Background
The practice of Kangaroo Mother Care (KMC) is life saving in babies weighing less than 2000 g. Little is known about mothers' continued unsupervised practice after discharge from hospitals. This study aimed to evaluate its in-hospital and continued practice in the community among mothers of low birth weight (LBW) infants discharged from two hospitals in Kumasi, Ghana.
Methods
A longitudinal study of 202 mothers and their inpatient LBW neonates was conducted from November 2009 to May 2010. Mothers were interviewed at recruitment to ascertain their knowledge of KMC, and then oriented on its practice. After discharge, the mothers reported at weekly intervals for four follow up visits where data about their perceptions, attitudes and practices of KMC were recorded. A repeated measure logistic regression analysis was done to assess variability in the binary responses at the various reviews visits.
Results
At recruitment 23 (11.4%, 95%CI: 7.4 to 16.6%) mothers knew about KMC. At discharge 95.5% were willing to continue KMC at home with 93.1% willing to practice at night. 95.5% thought KMC was beneficial to them and 96.0% beneficial to their babies. 98.0% would recommend KMC to other mothers with 71.8% willing to practice KMC outdoors.
At first follow up visit 99.5% (181) were still practicing either intermittent or continuous KMC. This proportion did not change significantly over the four weeks (OR: 1.4, 95%CI: 0.6 to 3.3, p-value: 0.333). Over the four weeks, increasingly more mothers practiced KMC at night (OR: 1.7, 95%CI: 1.2 to 2.6, p = 0.005), outside their homes (OR: 2.4, 95%CI: 1.7 to 3.3, p < 0.001) and received spousal help (OR: 1.6, 95%CI: 1.1 to 2.4, p = 0.007). Household chores and potentially negative community perceptions of KMC did not affect its practice with odds of 0.8 (95%CI: 0.5 to 1.2, p = 0.282) and 1.0 (95%CI: 0.6 to 1.7, p = 0.934) respectively. During the follow-up period the neonates gained 23.7 sg (95%CI: 22.6 g to 24.7 g) per day.
Conclusion
Maternal knowledge of KMC was low at outset. Once initiated mothers continued practicing KMC in hospital and at home with their infants gaining optimal weight. Continued KMC practice was not affected by perceived community attitudes.
doi:10.1186/1471-2393-11-99
PMCID: PMC3266193  PMID: 22133462
22.  Informal support to first-parents after childbirth: a qualitative study in low-income suburbs of Dar es Salaam, Tanzania 
Background
In Tanzania, and many sub-Saharan African countries, postpartum health programs have received less attention compared to other maternity care programs and therefore new parents rely on informal support. Knowledge on how informal support is understood by its stakeholders to be able to improve the health in families after childbirth is required. This study aimed to explore discourses on health related informal support to first-time parents after childbirth in low-income suburbs of Dar es Salaam, Tanzania.
Methods
Thirteen focus group discussions with first-time parents and female and male informal supporters were analysed by discourse analysis.
Results
The dominant discourse was that after childbirth a first time mother needed and should be provided with support for care of the infant, herself and the household work by the maternal or paternal mother or other close and extended family members. In their absence, neighbours and friends were described as reconstructing informal support. Informal support was provided conditionally, where poor socio-economic status and non-adherence to social norms risked poor support. Support to new fathers was constructed as less prominent, provided mainly by older men and focused on economy and sexual matters. The discourse conveyed stereotypic gender roles with women described as family caretakers and men as final decision-makers and financial providers. The informal supporters regulated the first-time parents' contacts with other sources of support.
Conclusions
Strong and authoritative informal support networks appear to persist. However, poverty and non-adherence to social norms was understood as resulting in less support. Family health in this context would be improved by capitalising on existing informal support networks while discouraging norms promoting harmful practices and attending to the poorest. Upholding stereotypic notions of femininity and masculinity implies great burden of care for the women and delimited male involvement. Men's involvement in reproductive and child health programmes has the potential for improving family health after childbirth. The discourses conveyed contradicting messages that may be a source of worry and confusion for the new parents. Recognition, respect and raising awareness for different social actors' competencies and limitations can potentially create a health-promoting environment among families after childbirth.
doi:10.1186/1471-2393-11-98
PMCID: PMC3252242  PMID: 22126899
23.  Inability to predict postpartum hemorrhage: insights from Egyptian intervention data 
Background
Knowledge on how well we can predict primary postpartum hemorrhage (PPH) can help policy makers and health providers design current delivery protocols and PPH case management. The purpose of this paper is to identify risk factors and determine predictive probabilities of those risk factors for primary PPH among women expecting singleton vaginal deliveries in Egypt.
Methods
From a prospective cohort study, 2510 pregnant women were recruited over a six-month period in Egypt in 2004. PPH was defined as blood loss ≥ 500 ml. Measures of blood loss were made every 20 minutes for the first 4 hours after delivery using a calibrated under the buttocks drape. Using all variables available in the patients' charts, we divided them in ante-partum and intra-partum factors. We employed logistic regression to analyze socio-demographic, medical and past obstetric history, and labor and delivery outcomes as potential PPH risk factors. Post-model predicted probabilities were estimated using the identified risk factors.
Results
We found a total of 93 cases of primary PPH. In multivariate models, ante-partum hemoglobin, history of previous PPH, labor augmentation and prolonged labor were significantly associated with PPH. Post model probability estimates showed that even among women with three or more risk factors, PPH could only be predicted in 10% of the cases.
Conclusions
The predictive probability of ante-partum and intra-partum risk factors for PPH is very low. Prevention of PPH to all women is highly recommended.
doi:10.1186/1471-2393-11-97
PMCID: PMC3276439  PMID: 22123123
24.  Risk of placenta previa in second birth after first birth cesarean section: a population-based study and meta-analysis 
Background
Objective: To compare the risk of placenta previa at second birth among women who had a cesarean section (CS) at first birth with women who delivered vaginally.
Methods
Retrospective cohort study of 399,674 women who gave birth to a singleton first and second baby between April 2000 and February 2009 in England. Multiple logistic regression was used to adjust the estimates for maternal age, ethnicity, deprivation, placenta previa at first birth, inter-birth interval and pregnancy complications. In addition, we conducted a meta-analysis of the reported results in peer-reviewed articles since 1980.
Results
The rate of placenta previa at second birth for women with vaginal first births was 4.4 per 1000 births, compared to 8.7 per 1000 births for women with CS at first birth. After adjustment, CS at first birth remained associated with an increased risk of placenta previa (odds ratio = 1.60; 95% CI 1.44 to 1.76). In the meta-analysis of 37 previously published studies from 21 countries, the overall pooled random effects odds ratio was 2.20 (95% CI 1.96-2.46). Our results from the current study is consistent with those of the meta-analysis as the pooled odds ratio for the six population-based cohort studies that analyzed second births only was 1.51 (95% CI 1.39-1.65).
Conclusions
There is an increased risk of placenta previa in the subsequent pregnancy after CS delivery at first birth, but the risk is lower than previously estimated. Given the placenta previa rate in England and the adjusted effect of previous CS, 359 deliveries by CS at first birth would result in one additional case of placenta previa in the next pregnancy.
doi:10.1186/1471-2393-11-95
PMCID: PMC3247856  PMID: 22103697
25.  Using audit to enhance quality of maternity care in resource limited countries: lessons learnt from rural Tanzania 
Background
Although clinical audit is an important instrument for quality care improvement, the concept has not yet been adequately taken on board in rural settings in most resource limited countries where the problem of maternal mortality is immense. Maternal mortality and morbidity audit was established at Saint Francis Designated District Hospital (SFDDH) in rural Tanzania in order to generate information upon which to base interventions.
Methods
Methods are informed by the principles of operations research. An audit system was established, all patients fulfilling the inclusion criteria for maternal mortality and severe morbidity were reviewed and selected cases were audited from October 2008 to July 2010. The causes and underlying factors were identified and strategic action plans for improvement were developed and implemented.
Results
There were 6572 deliveries and 363 severe maternal morbidities of which 36 women died making institutional case fatality rate of 10%. Of all morbidities 341 (94%) had at least one area of substandard care. Patients, health workers and administration related substandard care factors were identified in 50% - 61% of women with severe morbidities. Improving responsiveness to obstetric emergencies, capacity building of the workforce for health care, referral system improvement and upgrading of health centres located in hard to reach areas to provide comprehensive emergency obstetric care (CEmOC) were proposed and implemented as a result of audit.
Conclusions
Our findings indicate that audit can be implemented in rural resource limited settings and suggest that the vast majority of maternal mortalities and severe morbidities can be averted even where resources are limited if strategic interventions are implemented.
doi:10.1186/1471-2393-11-94
PMCID: PMC3226647  PMID: 22088168

Results 1-25 (104)