Jody R. Lori

Cultural Childbirth Practices, Beliefs, and Traditions in Postconflict Liberia

In this qualitative study we used an interpretive, critical ethnographic approach to provide an understanding of childbirth and maternal illness and death in Liberia through the lens of women, families, and communities. We identified three major themes from the data: (a) secrecy surrounding pregnancy and childbirth; (b) power and authority; and (c) distrust of the health care system. The interpretive theory, Behind the House, generated from data analysis provides an understanding of the larger social and cultural context of childbirth in Liberia. Our findings provide a more complete understanding of the contextual factors that impact on the intractable problem of maternal mortality.

A critical analysis of maternal morbidity and mortality in Liberia, West Africa

OBJECTIVE To conduct a secondary analysis of maternal death and near-miss audits conducted at the community and facility level to explore the causes and circumstances surrounding maternal mortality and severe morbidity in one rural county in Liberia, West Africa. DESIGN A non-experimental, descriptive design utilising maternal death and near-miss audit surveys was utilised for data collection. Thaddeus and Maines Three Delays Model was used as a framework for analysis. SETTING One rural county in north-central Liberia. PARTICIPANTS Interviews were conducted with (1) women who suffered a severe morbidity or nearmiss event, (2) family members of women who died or presented with a severe morbidity, and (3) community members or health workers involved in the care of the woman. MEASUREMENTS (1) Maternal mortality, (2) near-miss events, and (3) delays related to problem identification, transportation challenges and delays after reaching the referral site. FINDINGS 120 near-miss events and 28 maternal mortalities were analysed. 16% of all deliveries at the referral hospital were classified as near-miss events. Near-miss events were six times more common than deaths. The majority of women experiencing a near-miss event (85%) were in critical condition upon arrival at the hospital suggesting important delays were encountered in reaching the facility. KEY CONCLUSIONS Maternal mortality and near-miss audits allow exploration of medical and non-medical factors leading up to a severe complication or maternal death. Delays in reaching a referral hospital can have a significant impact on maternal survival rates. IMPLICATIONS FOR PRACTICE Audits can stimulate a change in clinical practice and help identify areas for county health departments to focus their scant resources. Audits can be used as a quality improvement tool in facilities. Results can be used to identify communities with high rates of delay to target educational programmes.

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.

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 skill 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 McNemars test was used to determine significant differences between the pre-test and post-test values of each individual step involved in SMS texting. Pearsons 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 health care and public health issues. Cell phone accessibility holds great promise for collecting health data in low-resource areas of the world. Journal of Nursing Scholarship, 2012; 00:0, 1–8.

Maternity waiting homes and traditional midwives in rural Liberia

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.

Promoting Access: The Use of Maternity Waiting Homes to Achieve Safe Motherhood

OBJECTIVE to examine the structural and sociocultural factors influencing maternity waiting home (MWH) use through the lens of women, families, and communities in one rural county in postconflict Liberia. DESIGN an exploratory, qualitative descriptive design using focus groups and in-depth, individual interviews was employed. Content analysis of data was performed using Penchansky and Thomass (1981) five As of access as a guiding framework. SETTING rural communities in north-central Liberia. PARTICIPANTS a convenience sampling was used to recruit participants. Eight focus groups were held with 75 participants from congruent groups of (1) MWH users, (2) MWH non-users, (3) family members of MWH users, and (4) family members of MWH non-users. Eleven individual interviews were conducted with clinic staff or community leaders. FINDINGS the availability of MWHs decreased the barrier of distance for women to access skilled care around the time of childbirth. Food insecurity while staying at a MWH was identified as a potential barrier by participants. KEY CONCLUSIONS examining access as a general concept within the specific dimensions of availability, accessibility, accommodation, affordability, and acceptability provides a way to describe the structural and sociocultural factors that influence access to a MWH and skilled attendance for birth. IMPLICATIONS FOR PRACTICE MWHs can address the barrier of distance in accessing skilled care for childbirth in a rural setting with long distances to a facility.

Perceived barriers and motivating factors influencing student midwives’ acceptance of rural postings in Ghana

BackgroundResearch 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.MethodsAn 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.ResultsThree 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.ConclusionsIn 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.

Forced migration: Health and human rights issues among refugee populations

Undocumented migration is a global phenomenon that is manifest in diverse contexts. In this article, we examine the situations that precipitate the movement of large numbers of people across several African countries, producing a unique type of undocumented migrant--the refugee. These refugee movements impact already fragile African health care systems and often involve human rights violations that are of particular concern, such as gender-based violence and child soldiers. We use examples from several countries in sub-Saharan Africa, including the Democratic Republic of the Congo, Rwanda, Liberia, Sierra Leone, and Mozambique. Drawing on key documents from the United Nations High Commissioner for Refugees, current research, and our personal international experiences, we provide an overview of forced migration and discuss implications and opportunities for nurses to impact research, practice, and policy related to refugee health.

Factors that influence midwifery students in Ghana when deciding where to practice: a discrete choice experiment

BackgroundMal-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.MethodsThis 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.ResultsMidwifery 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.ConclusionAddressing 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.

Home-Based Life-Saving Skills in Liberia: Acquisition and Retention of Skills and Knowledge

INTRODUCTION In 2006, Home-Based Life-Saving Skills was introduced in three Liberian counties, in partnership with Africare-Liberia and the Liberian Ministry of Health and with funding by the United States Agency for International Development. METHODS Traditional midwives and trained traditional midwives (N = 412) underwent pre- and immediate posttesting on four topics. Three hundred eighty-nine (94%) of the original participants also completed 1-year follow-up posttesting. RESULTS Mean scores significantly improved between pre- and immediate posttests and knowledge improvement was stable at 1 year. Correct responses on individual steps for each of four topics significantly increased over the course of training. The data demonstrate a major change in the knowledge base of the traditional and trained traditional midwives acting as village guides. DISCUSSION Home-Based Life-Saving Skills is a viable means by which to improve community knowledge and decrease maternal and neonatal morbidity and mortality.