Lynn M. Sibley

Two million intrapartum-related stillbirths and neonatal deaths: Where, why, and what can be done?

Intrapartum‐related neonatal deaths (“birth asphyxia”) are a leading cause of child mortality globally, outnumbering deaths from malaria. Reduction is crucial to meeting the fourth Millennium Development Goal (MDG), and is intimately linked to intrapartum stillbirths as well as maternal health and MDG 5, yet there is a lack of consensus on what works, especially in weak health systems.

60 million non-facility births: Who can deliver in community settings to reduce intrapartum-related deaths?

For the worlds 60 million non‐facility births, addressing who is currently attending these births and what effect they have on birth outcomes is a key starting point toward improving care during childbirth.

Association of antenatal care with facility delivery and perinatal survival – a population-based study in Bangladesh

BackgroundAntenatal Care (ANC) during pregnancy can play an important role in the uptake of evidence-based services vital to the health of women and their infants. Studies report positive effects of ANC on use of facility-based delivery and perinatal mortality. However, most existing studies are limited to cross-sectional surveys with long recall periods, and generally do not include population-based samples.MethodsThis study was conducted within the Health and Demographic Surveillance System (HDSS) of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) in Matlab, Bangladesh. The HDSS area is divided into an icddr,b service area (SA) where women and children receive care from icddr,b health facilities, and a government SA where people receive care from government facilities. In 2007, a new Maternal, Neonatal, and Child Health (MNCH) program was initiated in the icddr,b SA that strengthened the ongoing maternal and child health services including ANC. We estimated the association of ANC with facility delivery and perinatal mortality using prospectively collected data from 2005 to 2009. Using a before-after study design, we also determined the role of ANC services on reduction of perinatal mortality between the periods before (2005 – 2006) and after (2008–2009) implementation of the MNCH program.ResultsAntenatal care visits were associated with increased facility-based delivery in the icddr,b and government SAs. In the icddr,b SA, the adjusted odds of perinatal mortality was about 2-times higher (odds ratio (OR) 1.91; 95% confidence intervals (CI): 1.50, 2.42) among women who received ≤1 ANC compared to women who received ≥3 ANC visits. No such association was observed in the government SA. Controlling for ANC visits substantially reduced the observed effect of the intervention on perinatal mortality (OR 0.64; 95% CI: 0.52, 0.78) to non-significance (OR 0.81; 95% CI: 0.65, 1.01), when comparing cohorts before and after the MNCH program initiation (Sobel test of mediation P < 0.001).ConclusionsANC visits are associated with increased uptake of facility-based delivery and improved perinatal survival in the icddr,b SA. Further testing of the icddr,b approach to simultaneously improving quality of ANC and facility delivery care is needed in the existing health system in Bangladesh and in other low-income countries to maximize health benefits to mothers and newborns.

Community-level correlates of intimate partner violence against women globally: A systematic review

Intimate partner violence (IPV) against women is a problem facing women around the world, one that has implications for womens health and well-being. The relationship between communities and the occurrence of IPV is an expanding area of research. Although a large number of community characteristics have been examined in relation to IPV, the research as a whole lacks a coherent theoretical focus or perspective. In this systematic review, we provide a comprehensive synthesis of the evidence regarding the community-level correlates of IPV against women. In our review of peer-reviewed research published between January 1, 1990 and January 31, 2011, we identify key community-level correlates, detect gaps, and offer recommendations for future research. Recognizing a difference in approach between U.S. and non-U.S. based research and an over-reliance on a primarily urban, U.S.-based perspective on communities and IPV, we advocate for a global perspective that better reflects the social and economic fabric of communities around the world. Specifically, future research should focus on the most promising, but currently under-studied, community-level correlates of IPV against women, namely gender inequality, gender norms, and adapted measures of collective efficacy/social cohesion.

When There Is More than One Answer Key: Cultural Theories of Postpartum Hemorrhage in Matlab, Bangladesh

Individuals can acquire cultural knowledge from many sources, including personal experience, informal learning, and schooling. Identifying these distinct source models and describing personal variation in their use present ongoing theoretical and methodological challenges. Three questions are of particular importance: (1) how to determine if there is more than one cultural model, (2) how to characterize the differences between models, and (3) how to assess the degree to which individuals draw from these different models. This article addresses these questions by analyzing the theories endorsed by women and their maternal care providers about the causes, signs, and treatments of postpartum hemorrhage in rural Bangladesh. Two cultural models are identified, each associated with traditional birth attendants or professionally trained “skilled” birth attendants. More broadly, the article discusses the statistical issues involved in determining the existence of multiple cultural models in a population.

Improving Maternal and Newborn Health Care Delivery in Rural Amhara and Oromiya Regions of Ethiopia Through the Maternal and Newborn Health in Ethiopia Partnership

Introduction In Ethiopia, rural residence and limited access to skilled providers and health services pose challenges for maternal and newborn survival. The Maternal Health in Ethiopia Partnership (MaNHEP) developed a community-based model of maternal and newborn health focusing on birth and the early postnatal period and positioned it for scale-up. MaNHEPs 3-pronged intervention included community- and facility-based community maternal and newborn health training, continuous quality improvement, and behavior change communications. Methods Evaluation included baseline and endline surveys conducted with random samples of health extension workers, community health development agents, traditional birth attendants (TBAs), and women who gave birth the year prior to the survey; pretraining, posttraining, and postintervention clinical skills assessments conducted with health extension workers, community health development agents, and traditional birth attendants; endline surveys conducted with quality improvement teams; and a perinatal verbal autopsy study. Results There were significant improvements in the completeness of maternal and newborn health care provided by the team of health extension workers, community health development agents, and TBAs in their demonstrated capacity and confidence to provide care and a sense of being part of a maternal and newborn health care team. There were also significant improvements in womens awareness of and trust in the ability of these team members to provide maternal and newborn health care, in the completeness of care that women received, and in the use of skilled providers and health extension workers for antenatal and postnatal care. In addition, a shift occurred toward the use of providers with a higher level of skills for birth care. Successful local solutions for pregnancy identification, antenatal care registration, labor-birth notification, and postnatal follow-up were adopted across 51 project communities. The number of days between perinatal deaths increased over the duration of the project. Discussion MaNHEP was associated with more, and more complete, coverage of maternal and newborn health care and improved perinatal outcomes. The model is adaptable and potentially scalable, as indicated by the pilot test of its integration into the Ethiopian Ministry of Healths newly revised Primary Health Care Unit and Health Extension Program structures.

Home-based life saving skills in Matlab, Bangladesh: a process evaluation of a community-based maternal child health programme

OBJECTIVE to conduct and describe results from a process evaluation of home-based life saving skills (HBLSS) one year post-implementation. DESIGN a non-experimental, descriptive design was utilised employing both qualitative and quantitative techniques for data collection including: (1) key informant interviews, (2) group discussions, (3) performance testing, and (4) review of programme data. SETTING rural Matlab, Bangladesh in the sub-district of Chandpur. PARTICIPANTS 41 community health research workers (CHRW), five pregnant women, 14 support persons and four programme co-ordinators. INTERVENTION HBLSS is a family-centred approach to improving recognition of and referral for potentially life-threatening maternal and newborn complications. In June 2007, four HBLSS meetings were implemented in Matlab by 41 CHRW with all pregnant women in the study area. MEASUREMENTS (1) knowledge retention among CHRW, (2) programme coverage, and (3) strengths and challenges in HBLSS implementation. FINDINGS results revealed rapid integration of the programme into the Matlab community with nearly 4500 HBLSS contacts with 2409 pregnant women between 15 June 2007 and 31 March 2008. Over 51% of pregnant women attended all four HBLSS meetings. Knowledge testing of CHRW showed strong retention with an increase in mean scores between immediate post-training and one-year post-training (from 78.7% to 92.7% and from 77.8% to 97.7% for two different HBLSS modules). Strengths of the HBLSS programme include high satisfaction among pregnant women, dedication of CHRW to the community, and strong organisation and supervision by programme staff. Challenges include lack of involvement of men, loss of two master trainers, and limited access to comprehensive emergency obstetric care at some referral sites. KEY CONCLUSIONS the HBLSS programme was successfully implemented as a result of the high level of support and supervision by the maternal, newborn and child health staff at ICDDR,B. This evaluation highlights the value of community health workers in the fight against maternal and newborn mortality. Findings emphasise the strength of the HBLSS training approach in transferring knowledge from trainer to HBLSS guide.

Determinants of place of birth decisions in uncomplicated childbirth in Bangladesh: An empirical study

OBJECTIVE to test the predictive value of womens self-identified criteria in place of birth decisions in the event of uncomplicated childbirth in a setting where facility based skilled birth attendants are available. DESIGN a retrospective, cross-sectional study was conducted in two phases. The first phase used data from in-depth interviews. The second phase used data from semi-structured questionnaires. SETTING the service area of Matlab, Bangladesh. PARTICIPANTS women 18-49 years who had an uncomplicated pregnancy and delivery resulting in a live birth. FINDINGS a womens intention about where to deliver during pregnancy, her perception of labour progress, the availability of transportation at the time of labour, and the close proximity of a dai to the household were independent predictors of facility-based SBA use. Marital age was also significant predictor of use. KEY CONCLUSIONS the availability of delivery services does not guarantee use and instead specific considerations and conditions during pregnancy and in and around the time of birth influence the preventive health seeking behaviour of women during childbirth. Our findings have implications for birth preparedness and complication readiness initiatives that aim to strengthen timely use of SBAs for all births. Demand side strategies to reduce barriers to health seeking, as part of an overall health system strengthening approach, are needed to meet the Millennium Development 5 goal.

A Qualitative Study of Attitudes and Values Surrounding Stillbirth and Neonatal Mortality Among Grandmothers, Mothers, and Unmarried Girls in Rural Amhara and Oromiya Regions, Ethiopia: Unheard Souls in the Backyard

INTRODUCTION In Ethiopia, neonatal mortality and stillbirth are high and underreported. This study explored values related to neonatal mortality and stillbirth and the visibility of these deaths in rural Ethiopia among 3 generations of women. METHODS We conducted a qualitative study in 6 rural districts of the Oromiya and Amhara regional states during May 2012. We included 30 focus groups representing grandmothers, married women (mothers), and unmarried girls in randomly selected kebeles (villages). RESULTS Until the 40th day of life, neonates are considered to be strangers to the community (not human). Their deaths are not talked about; they are buried in the house or in the backyard. Mothers are forbidden to mourn their loss lest they offend God and bring on future neonatal losses. Women who repeatedly lose their neonates may be blamed, mistreated, and dishonored through divorce. Neonatal death and stillbirth are attributed to supernatural powers, although some women and girls associate these deaths with poverty and lack of education. The desire for increased visibility of neonatal death is mixed. Unlike the grandmothers and unmarried girls, most of the married women want death to be visible to draw the attention of policy makers. Women prefer home birth and consider themselves lucky to be able to give birth at home. At present, there is no national vital registration system. DISCUSSION Neonatal death and stillbirth are hidden and the magnitude is likely underrepresented. The delayed recognition of personhood, attribution of death to supernatural causes, social repercussions for women who experience a pregnancy loss, preference for home birth, and lack of a vital registration system all contribute to the invisibility of perinatal deaths. Increasing the visibility of (and counting) these deaths may require multifaceted behavior-change interventions.

Effectiveness of an integrated approach to reduce perinatal mortality: recent experiences from Matlab, Bangladesh

BackgroundImproving perinatal health is the key to achieving the Millennium Development Goal for child survival. Recently, several reviews suggest that scaling up available effective perinatal interventions in an integrated approach can substantially reduce the stillbirth and neonatal death rates worldwide. We evaluated the effect of packaged interventions given in pregnancy, delivery and post-partum periods through integration of community- and facility-based services on perinatal mortality.MethodsThis study took advantage of an ongoing health and demographic surveillance system (HDSS) and a new Maternal, Neonatal and Child Health (MNCH) Project initiated in 2007 in Matlab, Bangladesh in half (intervention area) of the HDSS area. In the other half, women received usual care through the government health system (comparison area). The MNCH Project strengthened ongoing maternal and child health services as well as added new services. The intervention followed a continuum of care model for pregnancy, intrapartum, and post-natal periods by improving established links between community- and facility-based services. With a separate pre-post samples design, we compared the perinatal mortality rates between two periods--before (2005-2006) and after (2008-2009) implementation of MNCH interventions. We also evaluated the difference-of-differences in perinatal mortality between intervention and comparison areas.ResultsAntenatal coverage, facility delivery and cesarean section rates were significantly higher in the post- intervention period in comparison with the period before intervention. In the intervention area, the odds of perinatal mortality decreased by 36% between the pre-intervention and post-intervention periods (odds ratio: 0.64; 95% confidence intervals: 0.52-0.78). The reduction in the intervention area was also significant relative to the reduction in the comparison area (OR 0.73, 95% CI: 0.56-0.95; P = 0.018).ConclusionThe continuum of care approach provided through the integration of service delivery modes decreased the perinatal mortality rate within a short period of time. Further testing of this model is warranted within the government health system in Bangladesh and other low-income countries.