Suellen Miller

Quality of care in institutionalized deliveries: the paradox of the Dominican Republic

Objectives: To better understand the paradox in the Dominican Republic of a relatively high maternal mortality ratio despite nearly universal institutionalized deliveries with trained attendants, a rapid assessment using an adaptation of the strategic assessment method was conducted. Methods: A multi‐disciplinary team reviewed national statistics and hospital records, inventoried facilities, and observed peripartum client–provider interactions at 14 facilities. Results: The major referral hospitals, where more than 40% of births in the country occur, were overcrowded and understaffed, with inexperienced residents overseeing care provided by medical students, interns and nurses. Uncomplicated labor and deliveries were overmedicalized, while complicated ones were not managed appropriately; emergencies were not dealt with in a timely fashion. In the peripheral hospitals physicians were seldom present and clients were either turned away or delivered by unprepared nursing staff. Providers in the busiest facilities suffered from compassion fatigue, and were demoralized and overworked. In all facilities, quality of care was lacking and the delivery and birthing process was dehumanized. Conclusions: Access and availability of institutional delivery alone is not enough to decrease MMR, it is also the quality of emergency obstetric care that saves lives.

Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide

On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, categorising them as recommended, recommended only for clinical indications, and not recommended. We also present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and increasing TMTS. Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.

HIV/AIDS AND MATERNITY CARE IN KENYA: HOW FEARS OF STIGMA AND DISCRIMINATION AFFECT UPTAKE AND PROVISION OF LABOR AND DELIVERY SERVICES

Abstract Although policies and programs exist to promote safe motherhood in sub-Saharan Africa, maternal health has not improved and may be deteriorating in some countries. Part of the explanation may be the adverse effects of HIV/AIDS on maternity care. We conducted a study in Kisumu, Kenya to explore how fears related to HIV/AIDS affect womens uptake and health workers’ provision of labor and delivery services. In-depth qualitative interviews with 17 maternity workers, 14 pregnant or postpartum women, four male partners and two traditional birth attendants; as well as structured observations of 22 births; were conducted at four health facilities. Participants reported that fears of HIV testing; fears of involuntary disclosure of HIV status to others, including spouses; and HIV/AIDS stigma are among the reasons that women avoid delivering in health facilities. Maternity workers now have to take into account the HIV status of the women they serve (as well as their own fears of becoming infected and stigmatized) but do not seem to be adequately prepared to handle issues related to consent, confidentiality and disclosure. Importantly, it appeared that women of unknown HIV status during labor and delivery were likely to be targets of stigma and discriminatory practices and that these women were not receiving needed counseling services. The findings suggest that increasing infection control precautions will not be enough to address the challenges faced by maternity care providers in caring for women in high-HIV-prevalence settings. Maternity workers need enhanced culturally sensitive training regarding consent, confidentiality and disclosure. Furthermore, this study points to the necessity of paying more attention to the care of women of unknown HIV-serostatus during labor and delivery. Such interventions may improve the quality of maternity care, increase utilization and contribute to overall improvements in maternal health, while also enhancing prevention of mother-to-child-transmission and HIV care.

Where Is the "E" in MCH? The Need for an Evidence-Based Approach in Safe Motherhood

Measuring the impact of obstetric interventions on maternal mortality and/or morbidity is especially difficult in developing countries, where most maternal deaths occur. Therefore, program planning has been based on theory rather than proved effectiveness. After reviewing both the strategies that have been promoted to reduce maternal mortality and the adequacy of existing evidence used to justify their selection, the investigators highlight reasons why rigorous criteria for the selection and evaluation of interventions should be adopted. Adequate evaluation of intervention effectiveness under real-life conditions in developing countries is an efficient way to identify interventions for large-scale program replication and could speed progress in reducing maternal deaths.

The Role of HIV-Related Stigma in Utilization of Skilled Childbirth Services in Rural Kenya : A Prospective Mixed-Methods Study

Janet Turan and colleagues examined the role of the perception of women in rural Kenya of HIV-related stigma during pregnancy on their subsequent utilization of maternity services.

Misoprostol and declining abortion-related morbidity in Santo Domingo, Dominican Republic: a temporal association

Objective  To validate anecdotal reports that abortion‐related complications decreased in the Dominican Republic after the introduction of misoprostol into the country.

Having A “Safe Delivery”: Conflicting Views from Tibet

In the Tibetan Autonomous Region (TAR) of the Peoples Republic of China (PRC) maternal mortality ratios remain among the highest in the world. Although traditional Tibetan medical theory, practice, and pharmacology include information on maternal and child health care, Tibet is one of the few societies in the world that does not have traditional birth attendants or midwives. Using ethnographic methods, we gathered data from individual interviews with rural Tibetan women (N = 38) about their beliefs and behaviors surrounding pregnancy and childbirth. Additional data were gathered through interviews with prefecture, county, and township health care providers. These data were used to develop a culturally appropriate village birth attendant training program in rural Tibet. We describe Tibetan womens perspectives of “having a safe delivery” in relation to concepts about “safe delivery” according to evidence-based medicine in the West. Our work also provides an example of the benefits and challenges that arise when ethnographic research methods are used to design and implement health care interventions.

First aid for obstetric haemorrhage: the pilot study of the non-pneumatic anti-shock garment in Egypt.

Objective  To compare the effect of non‐pneumatic anti‐shock garment (NASG) on blood loss from obstetric haemorrhage with standard management of obstetric haemorrhage.

Community-based distribution of misoprostol for treatment or prevention of postpartum hemorrhage: Cost-effectiveness, mortality, and morbidity reduction analysis

To compare the cost‐effectiveness of community‐based distribution of misoprostol for prevention with misoprostol for treatment of postpartum hemorrhage (PPH).

Seroprevalence and correlates of HIV, syphilis, and hepatitis B and C virus among intrapartum patients in Kabul, Afghanistan.

BackgroundLittle current information is available for prevalence of vertically-transmitted infections among the Afghan population. The purpose of this study is to determine prevalence and correlates of human immunodeficiency virus (HIV), syphilis, and hepatitis B and C infection among obstetric patients and model hepatitis B vaccination approaches in Kabul, Afghanistan.MethodsThis cross-sectional study was conducted at three government maternity hospitals in Kabul, Afghanistan from June through September, 2006. Consecutively-enrolled participants completed an interviewer-administered survey and whole blood rapid testing with serum confirmation for antibodies to HIV, T. pallidum, and HCV, and HBsAg. Descriptive data and prevalence of infection were calculated, with logistic regression used to identify correlates of HBV infection. Modeling was performed to determine impact of current and birth dose vaccination strategies on HBV morbidity and mortality.ResultsAmong 4452 women, prevalence of HBsAg was 1.53% (95% CI: 1.18 – 1.94) and anti-HCV was 0.31% (95% CI: 0.17 – 0.53). No cases of HIV or syphilis were detected. In univariate analysis, HBsAg was associated with husbands level of education (OR = 1.13, 95% CI: 1.01 – 1.26). Modeling indicated that introduction of birth dose vaccination would not significantly reduce hepatitis-related morbidity or mortality for the measured HBsAg prevalence.ConclusionIntrapartum whole blood rapid testing for HIV, syphilis, HBV, and HCV was acceptable to patients in Afghanistan. Though HBsAg prevalence is relatively low, periodic assessments should be performed to determine birth dose vaccination recommendations for this setting.