An investigation of postpartum mothers’ readiness for hospital discharge and the affecting factors

Introduction: Postpartum period which contains important changes in the woman’s and newborn’s life, WHO recommends monitoring the mother and newborn in health care system, encouraging breastfeeding, monitoring the newborn’s development, and supporting and empowering parents about newborn care.Purpose: The purpose of this study is to identify postpartum mothers’ readiness for hospital discharge and the affecting factors. Method and material: The study was conducted with 190 mothers who gave birth between May and July, 2014 in a Maternity and Children Hospital located in Mersin. The data were collected through the Identification Form developed by the researcher in line with the related literature and Readiness for Hospital Discharge Scale-Postpartum Mother Form (RHDS-PMF).Results: Of all the participants, 84.7% were ready for discharge, 69.4% received information from midwives or nurses about their own care, and 68.7% received information about the baby’s care. Mean scores for the participants’ Readiness for Hospital Discharge Scale was found 50.47±12.16 for Personal State, 45.08±12.33 for Knowledge, 21.0±75.68 for Ability, 28.13± 8.91 for Expected Support and 144.76±30.15 for total score. The scores were found to be significantly higher for mothers who reported to be ready for discharge, who stated to have received information about their own care and the baby’s care, who were multiparous, and who would receive support for their care and the baby’s care after hospital discharge (p<0.05).Conclusion: Majority of the participants in this study were found to be ready for hospital discharge and factors affecting readiness for hospital discharge were identifed as informing mothers about their care and the baby’s care after delivery, mothers’ being multiparous, and receiving support about their care and the baby’s care after hospital discarge

Integrated studies addressing the incidence of severe maternal morbidity (SMM) in Kilombero district, Tanzania

Severe maternal morbidities (SMM ) are a diverse range o f serious complications which occur during pregnancy, childbirth and the post-natal period (six weeks after childbirth). They can affect any of the body organ systems, and their severity means that if untreated, or wrongly treated, maternal death is likely to result. Therefore prevention of maternal death requires better understanding of the epidemiology and outcome of the various forms of SMM. Tanzania is among developing countries in the world having a high maternal mortality ratio (454 per 100,000 live births), but there are few published evidence addressing all major forms of SMM in Tanzania. Not all pregnant Tanzanian women use health facilities for antenatal care or delivery, not even for treatment in the event of a complication. Therefore ascertaining the level of SMM in health facilities will not give a true estimation of the incidence among all pregnant women. While ascertaining SM M in the community would therefore seem to be a preferable approach, there are considerable practical barriers to executing such research in rural areas of developing countries. Furthermore previous studies have raised concerns about the reliability and validity of women’s self report of obstetric complications, especially when such report is retrospective.This PhD research has therefore taken two complementary approaches: (1) At St Francis Referral Hospital, Kilombero, Tanzania, using hospital routine data with case note review of all admissions experiencing complications, it has ascertained over the course of a full calendar year, the incidence and outcome of SMM , and associated risk factors (N= 5500 total admissions, n=1723 with case note review); (2) By undertaking a community interview survey in that hospital’ s rural catchment area, to determine the incidence of SMM via women’s self reporting of symptoms. This survey attempted to interview all women in selected villages that are subject to the Ifakara Centre Demographic Surveillance System (IC-DSS), and who were recorded by IC-DSS as having given birth over the same time-frame (690 were interviewed, while 663 had given birth during study period). Validation of self-reporting of SMM was undertaken using interview response data of the subset of 173 interviewees who had attended St Francis hospital for obstetric delivery/treatment during the study interval, and for whom hospital diagnosis made at that time were therefore also available.In the hospital study, the incidence of both intra partum (IP) and postpartum (PP) SMM (among all women delivering there or admitted postpartum) was 19.2%, with a case fatality rate of 1.7%. The incidence of solely intra partum SM M was 17.2%, the rate being higher among primigrávida than among multigravid (28% v 8%, p<0.001), among teenagers than older women (23% v 14%, p<0.001) and single women than among other women (68.1% v 48.7% , p<0.001). Among 909 intra partum SMM , the three commonest conditions were obstructed labour (69% ), eclampsia (14% ) and severe preeclampsia (9% ) while in the 258 postpartum SM M ; the three commonest conditions were postpartum eclampsia (26% ), puerperal sepsis (24% ) and postpartum haemorrhage (23% ). Neonatal death was more com m on among women with intra partum SM M than among other deliveries (4.7% v 1.1%, p<0.001). There were no intra partum maternal deaths, but across all antenatal, intra partum and postpartum admissions, maternal mortality was four-fold greater among women admitted in critical condition than among other women (2.1% v0.5%, p=0.006). The majority of the women who became maternal deaths were admitted in critical condition (11/17).Among Ifakara IC-DSS women interviewed, the majority had used health facilities at some level for obstetric care (64.7% ), and affirmed prior birth and emergency complication readiness plans (97.6% & 81.5% ). The incidence o f any SMM (antenatal to postnatal, derived from self reported symptoms by interviewees) was 16.7%; while for both intra partum and postpartum SMM , the incidence was 15.4%, lower than that of the hospital study (19.2% ). Considering solely intra partum (interview-ascertained) SMM, the rate was 8.1% (n=54), lower than the corresponding estimate of 17.2% from the hospital study. Validation interview-ascertained intra partum SMM classification could be undertaken in the subset of 173 who had delivered in St Francis hospital. Of these, 48 could be matched with the list of names of hospital admissions subjected to case note-review (i.e. all deliveries with any evidence of complications), while the remainder had no hospital-ascertained complication even (and hence must be presumed to be ‘normal deliveries’). In this group, interview-ascertained IP SM M rate was 21.4% , and the sensitivity and specificity for interview-ascertained IP SM M were 59.3% (16/27) and 85.6% (125/146) respectively.This is the first study in Tanzania to address the incidence of all intra partum and postpartum severe morbidities, using both retrospective review of referral hospital data/records and an interview survey in the surrounding rural community. The research findings have described the relative frequency of various subtypes of SMM , and the relationship of SMM to sociodemographic and obstetric factors and to maternal-foetal outcome. Such information will be helpful for clinicians and maternity staff to understand the pattern of SMM and how the hospital is performing in treating SMM cases. The finding that maternal death is so strongly associated with admission in critical condition emphasises the importance of addressing factors that delay admission of pregnancies that develop complications.In the thesis the findings from the research studies will be elaborated and the challenges of such research will be discussed. While the sample size for validation of intra partum SMM was too small to be able to make conclusive remarks, the finding of borderline sensitivity will be discussed in relation to specific morbidities and the reliability o f the hospital data ‘ gold standard’ comparator.With a pragmatic approach one can undertake research on SMM that enhances understanding of the complexities of SMM and its measurement, while also imparting knowledge on the epidemiology of the condition and potential actions that could be considered to improve outcome for SMM

Antepartum, Intrapartum, and Postpartum Predictors of Readiness for Hospital Discharge and Post-Discharge Outcomes

Pregnancy and childbirth are significant events in the lives of women and their families where the discharge decision-making process involves careful judgment in projecting the mom\u27s ability to cope with care needs after discharge. Research examining the predictors of discharge readiness and post-discharge outcomes taking into consideration antepartum and intrapartum factors influencing readiness for discharge has not been conducted. The purpose of this study was to explore the antepartum, intrapartum, and postpartum predictors of readiness for hospital discharge and post-discharge outcomes. The Adaptation to Transitions conceptual framework consisted of conceptually-related variables was developed and guided the descriptive correlational repeated measure design study. A purposive sample of English and Spanish-speaking postpartum mothers who experiences a vaginal or cesarean birth of a healthy infant (N = 185) completed demographic, quality of discharge teaching, and readiness for hospital discharge questionnaires prior to discharge. Four weeks post-discharge, participants completed a coping difficulty questionnaire and the quality of discharge teaching questionnaire to compare pre- and post- hospital perceptions of teaching. A final model was computed with all significant predictors for readiness for hospital discharge and post-discharge coping difficulty. Infant length of stay, the delivery of education, and the difference between educational content received and the education content needed, were the significant predictor variables accounting for 42% of the variance in readiness for hospital discharge (R2=0.44, R2adj =0.42, F(8,176) = 17.5, p \u3c 0.001). Participants with less than high school education and the difference between educational content received and needed were the two significant predictor variables accounting for 28% of the variance in post-discharge coping difficulty (R2=0.33, R2adj =0.28, F(6,60) = 5.1, p \u3c 0.001). Nurses\u27 skill in the delivery of education, the educational content received, and the post-discharge coping difficulty were predictive of utilization of post-discharge health care services. A statistically significant difference in the quality of discharge teaching between pre- and post- hospital discharge was also noted. The relationship between quality of discharge teaching, readiness for discharge, and post-discharge coping and utilization provides evidence of nurses\u27 critical role in educating patients and families to facilitate a smooth transition home after childbirth

Diagnosis and management of postpartum hemorrhage and intrapartum asphyxia in a quality improvement initiative using nurse-mentoring and simulation in Bihar, India.

BackgroundIn the state of Bihar, India a multi-faceted quality improvement nurse-mentoring program was implemented to improve provider skills in normal and complicated deliveries. The objective of this analysis was to examine changes in diagnosis and management of postpartum hemorrhage (PPH) of the mother and intrapartum asphyxia of the infant in primary care facilities in Bihar, during the program.MethodsDuring the program, mentor pairs visited each facility for one week, covering four facilities over a four-week period and returned for subsequent week-long visits once every month for seven to nine consecutive months. Between- and within-facility comparisons were made using a quasi-experimental and a longitudinal design over time, respectively, to measure change due to the intervention. The proportions of PPH and intrapartum asphyxia among all births as well as the proportions of PPH and intrapartum asphyxia cases that were effectively managed were examined. Zero-inflated negative binomial models and marginal structural methodology were used to assess change in diagnosis and management of complications after accounting for clustering of deliveries within facilities as well as time varying confounding.ResultsThis analysis included 55,938 deliveries from 320 facilities. About 2% of all deliveries, were complicated with PPH and 3% with intrapartum asphyxia. Between-facility comparisons across phases demonstrated diagnosis was always higher in the final week of intervention (PPH: 2.5-5.4%, intrapartum asphyxia: 4.2-5.6%) relative to the first week (PPH: 1.2-2.1%, intrapartum asphyxia: 0.7-3.3%). Within-facility comparisons showed PPH diagnosis increased from week 1 through 5 (from 1.6% to 4.4%), after which it decreased through week 7 (3.1%). A similar trend was observed for intrapartum asphyxia. For both outcomes, the proportion of diagnosed cases where selected evidence-based practices were used for management either remained stable or increased over time.ConclusionsThe nurse-mentoring program appears to have built providers' capacity to identify PPH and intrapartum asphyxia cases but diagnosis levels are still not on par with levels observed in Southeast Asia and globally

Providing Maternity Care to the Underserved: A Comparative Case Study of Three Maternity Care Models Serving Women in Washington, D.C.

Compares the content and structure of maternity care provided at a city birth center, a safety net clinic, and a not-for-profit teaching and research hospital; populations served; providers; costs; and the women's and providers' perceptions of each model

Postpartum Fatigue in the Active Duty Military Woman

Up to 16,000 military women annually experience the birth of a child. Barring complications, regulations require a return to work 42 days postpartum, making them susceptible to the effects of postpartum fatigue. The purpose of this descriptive, longitudinal study of 109 military women was to describe fatigue levels across the first 6–8 weeks postpartum; to describe the relationship among selected psychological, physiological, and situational variables of fatigue; and to examine the relationship between predictor variables, fatigue levels, and performance after childbirth. The majority of the sample were married or partnered enlisted women in the U.S. Navy with a mean age of 25 (±5) years. Descriptive statistics, repeated measures ANOVA, correlation, and regression were used to analyze the data. Women were found to be moderately fatigued across time and there was no change in fatigue levels from 2 to 6–8 weeks postpartum. Study variables of type of delivery, lactogenesis, depression, anxiety, maternal sleep, and infant temperament correlated with fatigue during hospitalization and at 2 weeks postpartum. Depression, anxiety, maternal sleep, and performance correlated with fatigue at 6–8 weeks postpartum. Regression analyses indicated that maternal anxiety during hospitalization and at 2 weeks postpartum explained 6% and 20% of the variance in fatigue at 6–8 weeks postpartum. Over half of the women had not regained full functional status when they returned to work and 40% still displayed symptoms of postpartum depression and anxiety. Future research is needed to examine issues surrounding depression and anxiety of military women, including exploration of its causes in both the prenatal and postpartum periods. Designing interventions to reduce fatigue symptoms among military postpartum women may result in improved parenting, decreased healthcare costs, workplace accidents, increased job satisfaction, breastfeeding rates, and physical readiness. Reducing fatigue in this population has the potential benefit of a significant cost-savings to the United States government as well as an improved quality of life for military families

Improving Quality of Care Through Discharge Planning

Providing good education for the new mother is key to improving the quality of care for both mom and baby. Since nurses are frontline health care providers who perform the most postpartum education, it is imperative they work to improve discharge education so information provided is consistent, appropriate, and evidence based (Suplee et al., 2016). The aim of this project is to improve the discharge planning process of a local community hospital utilizing evidence-based research (EBR) with the intent to increase patient satisfaction scores in care transitions to above 65% within 3 months. The community hospital is a 122-bed acute care facility, employing more than 450 doctors, nurses, and supporting staff, offering a wide range of services. The postpartum unit has a total of 10-beds private beds which can accommodate one couplet - mothers and their newborn babies. HCAHP scoring was chosen as a measure of the overall improvement of the quality of care. A questionnaire was created as a tool to measure and collect data on the change from printed discharge material to video app-based education. iPads will be loaded with customizable postpartum teaching software from our vendor Injoy. Due to Covid-19 and other factors relating to it, implementation of plan was put on hold till Spring 2021. To improve the current discharge planning process, discharge from hospital to home requires the successful transfer of information from clinicians to the patient and family to reduce adverse events and prevent readmissions

Postpartum Hemorrhage: A Change Strategy

Problem: Postpartum hemorrhage (PPH) is one of the leading causes of severe maternal morbidity and mortality. It is unpredictable and can occur with or without identified risk factors. A postpartum hemorrhage can happen rapidly, therefore it is important for the team to be trained and prepared to recognize and respond quickly to the situation, by quantifying blood loss at deliveries. Context:The California Maternal Quality Care Collaborative (CMQCC) has created a toolkit to better prepare maternal child health teams for readiness, recognition, response, and reporting when a hemorrhage occurs. This program was rolled out on the unit in 2015 resulting in a dramatic decrease in the postpartum hemorrhage rate, yet the unit was not able to sustain the changes. Intervention: 100% of staff from all disciplines were retrained with an educational presentation of evidence-based practice on quantifying blood loss and a review of postpartum hemorrhage medications. Education, skills stations with new scales and a weighing worksheet, followed with a hemorrhage drill were completed. The team was asked to begin quantifying with a birth pause after the neonate’s delivery. The expectation was to quantify at every delivery. Results: Since the completion of retraining and the roll out of the new equipment, there has been an increased adherence to the practice expectations, from 60% to 80%. The team is practicing the birth pause after the delivery of the neonate and quantifying blood loss. The fallouts for quantifying blood loss were emergency and precipitous deliveries, as the birth pause was not done. Conclusion: The collaborative efforts of the Family Birth Center team made this project a success. Sharing the evidenced-based “why” of a practice change, along with unit data motivated the team to adhere to the quantification process. With support from leadership and the unit-based council teams the sustainability of this project has great potential and feasibility. The practice changes made are a standard of care, based on CMQCC recommendations to ensure the patient has the safest and highest quality of care during their stay. The team will continue the quality improvement work until it becomes a standard of practice and a part of the daily culture in order to have a positive effect on morbidity and mortality of our perinatal population

Effectiveness of Nursing Guideline to Prevent Postpartum Hemorrhage on Blood Loss and Rate of Postpartum Hemorrhage after Cesarean Section

บทคัดย่อ วัตถุประสงค์: เพื่อประเมินผลการใช้แนวทางการพยาบาลเพื่อป้องกันตกเลือดหลังผ่าตัดคลอด ต่อปริมาณการสูญเสียเลือดและอัตราการเกิดตกเลือดหลังผ่าตัดคลอด ระหว่างกลุ่มก่อนและหลังการใช้แนวทางการพยาบาล วิธีการศึกษา: กลุ่มตัวอย่างคือมารดาหลังผ่าตัดคลอดที่เข้ารับการรักษาในหอผู้ป่วยสูติ-นรีเวชกรรมสามัญ โรงพยาบาลแห่งหนึ่ง ตั้งแต่เดือนกรกฎาคมถึงธันวาคม 2561 แบ่งเป็นกลุ่มควบคุม 60 ราย และกลุ่มทดลอง 66 ราย เครื่องมือที่ใช้ในการวิจัยประกอบด้วย 1) แนวทางการพยาบาลเพื่อป้องกันตกเลือดหลังผ่าตัดคลอด 2) แบบประเมินความเสี่ยงต่อการตกเลือดหลังผ่าตัดคลอด และ3) แบบบันทึกข้อมูลการตกเลือดหลังผ่าตัดคลอดจากเวชระเบียน แบบประเมินความเสี่ยงต่อการตกเลือดหลังผ่าตัดคลอดมีความตรงเชิงเนื้อหาดี (CVI = 0.93) วิเคราะห์ข้อมูลโดยใช้สถิติเชิงบรรยาย และทดสอบสมมติฐานการวิจัยด้วยสถิติ Mann-Whitney U test และ Chi-square test ผลการศึกษา: มารดาหลังผ่าตัดคลอดกลุ่มทดลองมีค่าเฉลี่ยปริมาณการสูญเสียเลือดหลังผ่าตัดต่ำกว่ากลุ่มควบคุมอย่างมีนัยสำคัญทางสถิติ (P-value &lt; 0.001) และไม่เกิดภาวะตกเลือดหลังผ่าตัดคลอด ส่วนกลุ่มควบคุมมีภาวะตกเลือดหลังผ่าตัดคลอด 1 ราย อัตราการเกิดตกเลือดหลังผ่าตัดคลอดรายใหม่ในสองกลุ่มไม่ต่างกัน สรุป: การใช้แนวทางการพยาบาลเพื่อป้องกันตกเลือดหลังผ่าตัดคลอดสามารถเพิ่มคุณภาพในการป้องกันการตกเลือดหลังผ่าตัดคลอดได้ คำสำคัญ: แนวทางการพยาบาล, ป้องกันตกเลือดหลังผ่าตัดคลอด, มารดาผ่าตัดคลอด, อัตราการตกเลือดหลังผ่าตัดคลอด Abstract Objective: To evaluate the effectiveness of nursing guideline to prevent postpartum hemorrhage on the amount of blood loss and the rate of the hemorrhage after Cesarean section between groups before and after using the guideline. Method: The sample consisted of mothers undergone Cesarean section who were admitted to the obstetric and gynecological ward of a hospital from July to December 2018. A total of 60 mothers were in the control group and 66 in the test group. The research instruments consisted of 1) a nursing guideline for preventing postpartum hemorrhage, 2) risk assessment checklist for post-Cesarean section hemorrhage, and 3) data collection form of postpartum hemorrhage from medical records. Risk assessment checklist had a high level of content validity (CVI = 0.93). Descriptive statistics, Mann-Whitney U test and Chi-square test were used in data analysis. Results: The test group had a significantly lower mean post-operative blood loss than the control group (P-value &lt; 0.001). No post-operative hemorrhage in the test group and 1 in the control group were found. Rates of new postpartum hemorrhage in the two groups were not different. Conclusion: Nursing guidelines to prevent postpartum hemorrhage could improve quality of post Cesarean section hemorrhage prevention. Keyword: nursing guideline, post-Cesarean section hemorrhage, Cesarean section, rate of post cesarean section hemorrhage

Effects of helping mothers survive bleeding after birth in-service training of maternity staff : a cluster-randomized trial and mixed-method evaluation

Background: Postpartum Haemorrhage (PPH) causes a significant amount of morbidity and mortality among mothers giving birth in sub-Saharan Africa, Tanzania included. One root cause is the insufficient health worker skills to address postpartum haemorrhage. To combat this in-service training using competency-based simulation is proposed. Aim: To assess the effectiveness of the Helping Mothers Survive Bleeding After Birth (HMS BAB) in-service training of maternity staff on PPH related health outcomes, and health workers’ skills. The thesis also assessed health workers’ perceptions of the training and facility preparedness to support care of women with PPH in Tanzania. Methods: Study I was conceptualised as a cluster-randomized trial. Interrupted time-series analysis was used to compare the following PPH related health outcomes i) PPH near miss and ii) PPH case fatality between 10 intervention and 10 comparison clusters. Study II was a before-after study of health workers (n=636), and assessed skills change immediately and ten months after the training, as well as the association between health workers’ characteristics and skill change. Study III was a qualitative study using seven Focus Group Discussions (FGD) of health workers to explore their perceptions of the training implementation. A deductive theory-driven analysis informed by integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework was used. Study IV explored health workers (FGDs, n=7) and health managers (In-depth interviews, n=12) perceptions of health facility preparedness to support care given to women with PPH. The data was analysed using thematic analysis. Results: There was a significant decline of severe PPH cases in intervention clusters compared to the comparison clusters observed immediately after the intervention. This was sustained in the post-intervention period (Study I). A small reduction in PPH case fatality was observed in intervention clusters during the post-intervention period. Health workers’ skills were significantly improved immediately after the training with a small decline at ten-months follow up (Study II). In Study III health workers reported positive perceptions of the training: the content, the training technique, use of simulated scenarios and peer practice facilitators enhanced learning. Challenges to successful training were related to organization of the training and allocating time for weekly skill practices. In Study IV health workers reported poor facility preparedness with inconsistencies and insufficiencies of resources, including few and overwhelmed maternity staff. This constrained their ability to use the new skills and to provide quality PPH-care. Additional challenges on human interactions such as communication, collaborations and leadership were highlighted. Conclusion: The HMS BAB one-day training followed by eight weekly drills was effective in reducing PPH morbidities and mortality and improved health workers skills. Implementational challenges included i) organizational aspects of in-facility training, and ii) protected time for health workers to engage in weekly drills. Health providers voiced their struggle to put their new knowledge into practice highlighting insufficiencies in health facility readiness, such as lack of drugs and blood products