Incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births in northwest Ethiopia

Background Of the 1010 reported maternal deaths in 2018, just over 65% occurred in hospitals in Ethiopia. However, there is a lack of standardised data about the contributing factors. This study aimed to investigate the incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births in northwest Ethiopia. Methods A retrospective cohort design was used; an audit of 1060 maternity care logbooks of adult women post-partum at Felege Hiwot Referral Hospital and University of Gondar Comprehensive Specialized Hospital. The data were abstracted between December 2018 and May 2019 using a systematic random sampling technique. We used the Facility Based Maternal Death Abstraction Form containing sociodemographic characteristics, women’s medical history, and partographs. Primary postpartum haemorrhage was defined as the estimated blood loss recorded by the staff greater or equal to 500 ml for vaginal births and 1000 ml for caesarean section births, or the medical doctor diagnosis and recording of the woman as having primary postpartum haemorrhage. The data analysis was undertaken using Stata version 15. Variables with P 0.10 for significance were selected to run multivariable logistic analyses. Variables that had associations with primary postpartum haemorrhage were identified based on the odds ratio, with 95% confidence interval (CI) and P-value less than 0.05. Results The incidence of primary postpartum haemorrhage in the hospitals was 8.8% (95% CI: 7.2, 10.6). Of these, there were 7.4% (95% CI: 2.1, 13.3) maternal deaths. Eight predictor variables were found to be independently associated with primary postpartum haemorrhage, including age 35 years (AOR: 2.20; 95% CI: 1.08, 4.46; P = 0.03), longer than 24 hours duration of labour (AOR: 7.18; 95% CI: 2.73, 18.90; P = 0.01), vaginal or cervical lacerations (AOR: 4.95; 95% CI: 2.49, 9.86; P = 0.01), instrumental (forceps or vacuum)-assisted birth (AOR: 2.92; 95% CI: 1.25, 6.81; P = 0.01), retained placenta (AOR: 21.83; 95% CI: 6.33, 75.20; P = 0.01), antepartum haemorrhage in recent pregnancy (AOR: 6.90; 95% CI: 3.43, 13. 84; p = 0.01), women in labour referred from primary health centres (AOR: 2.48; 95% CI: 1.39, 4.42; P = 0.02), and births managed by medical interns (AOR: 2.90; 95% CI: 1.55, 5.37; P = 0.01). Conclusion We found that while the incidence of primary postpartum haemorrhage appeared to be lower than in other studies in Africa the associated maternal mortality was higher. Although most factors associated with primary postpartum haemorrhage were consistent with those identified in the literature, two additional specific factors, were found to be prevalent among women in Ethiopia; the factors were referred women in labour from primary health facilities and births managed by medical interns. Maternal healthcare providers in these hospitals require training on the management of a birthing emergency. © 2022 Tiruneh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Exclusive breastfeeding continuation and associated factors among employed women in North Ethiopia : a cross-sectional study

Background Exclusive Breastfeeding (EBF) can prevent up to 13% of under-five mortality in developing countries. In Sub-Saharan Africa the rate of EBF at six months remains very low at 36%. Different types of factors such as maternal, family and work-related factors are responsible for the low rate of EBF among employed women. This study aimed to assess the prevalence of EBF continuation and associated factors among employed women in North Ethiopia. Materials and methods A community-based, cross-sectional study was conducted in two towns of Tigray region, North Ethiopia. Employed women who had children between six months and two years were surveyed using multistage, convenience sampling. Women filled in a paper based validated questionnaire adopted from the Breastfeeding and Employment Study toolkit (BESt). The questions were grouped into four parts of sociodemographic characteristics, maternal characteristics, family support and work-related factors. Factors associated with EBF continuation as a binary outcome (yes/no) were determined using multivariable logistic regression. Results Four-hundred and forty-nine women participated in this study with a mean (SD) age 30.4 (4.2) years. Two hundred and fifty-four (56.4%) participants exclusively breastfed their children for six months or more. The main reason for discontinuation of EBF was the requirement of women to return to paid employment (31.5%). Four-hundred and forty (98.2%) participants believed that breastfeeding has benefits either to the infant or to the mother. Three hundred and seventy-one (82.8%) of the participants received support from their family at home to assist with EBF, most commonly from their husbands and mothers. Having family support (adjusted odds ratio [AOR] = 2.1, 95%, CI 1.2–3.6; P = 0.005), having frequent breaks at work (AOR = 2.6, 95% CI, 1.4–4.8; P = 0.002) and the possibility of buying or borrowing required equipment for expressing breast milk (AOR = 1.7, 95% CI, 1.0–3.0; P = 0.033) were statistically associated with an increased chance of EBF. Conclusion Although returning to work was reported by the study participants as the main reason for discontinuation of EBF, families and managers’ support play significant roles in EBF continuation, which in the absence of six-month’s maternity leave for employed women in Ethiopia would be of benefit to both mothers and children. © 2021 Gebrekidan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Barriers to effective management of primary postpartum haemorrhage following in-hospital births in northwest Ethiopia: healthcare providers’ views using a qualitative approach

Abstract Background Data showed that postpartum haemorrhage contributed to over 40% of in-hospital deaths of Ethiopian women. However, little is known about the barriers to effective management of primary postpartum haemorrhage. This study aims to explore the views and experiences of maternity healthcare professionals about the barriers to managing primary postpartum haemorrhage following in-hospital births in northwest Ethiopia using the ‘Three Delays’ model as a conceptual framework. Methods A qualitative descriptive study was employed at two tertiary referral hospitals between December 2018 and May 2019. Forty-one maternal healthcare providers, including midwives, midwifery unit managers, and obstetricians, participated in this study. Individual face-to-face interviews, focus group discussions, and self-administered open-ended questionnaires were used to collect data. A framework analysis approach was used for the qualitative data analysis. Themes were identified based on the Three Delays model of ‘delay the decision to seek care’, ‘delay arrival at a health facility’, and ‘delay the provision of appropriate and quality care’. Results Participants reported several modifiable issues when managing primary postpartum haemorrhage, and all were linked to a delay in receiving appropriate and quality care due to limited resources. Five sub-themes were identified: ‘workforce’, ‘communication issues between healthcare providers’, ‘systemic issues’, ‘education, training, and resourcing issues’, and ‘lack of identification and referral’. Conclusion Maternal healthcare providers in these hospitals require training in managing a birthing emergency. In addition, the birth units need adequate supplies and continuous essential services

Attitudes and experiences of employed women when combining exclusive breastfeeding and work : a qualitative study among office workers in Northern Ethiopia

Evidence from different countries shows that the level of support given to mothers who return to paid employment can significantly determine the duration of exclusive breastfeeding (EBF). However, little is known about how returning to work impacts Ethiopian women's EBF practice. The aim of this study was to explore women's attitudes and experiences of EBF when they returned to work. Mothers who had an infant of less than 12 months, working in government institutions in Tigray region, Ethiopia, were invited to participate in this study. Semi-structured, face-to-face interviews were used to explore mothers' perspectives of the factors that influenced EBF when they returned to work. The interview data were transcribed verbatim and thematically analysed. Twenty mothers were interviewed from 10 organizations. Three themes were identified from their accounts: mother's knowledge, attitudes and practice towards breastfeeding; workplace context and employment conditions; and support received at home. Most participants were familiar with the benefits of EBF. Most participants reported that their colleagues had more positive attitudes towards breastfeeding than their managers. In almost all the workplaces, there was no specific designated breastfeeding space. Participants reported that close family members including husbands and mothers were supportive. Mothers' knowledge and attitude towards breastfeeding, workplace and employment conditions and support received at home were found to be the main factors determining the duration of EBF among employed women. Participants reported that the overall support given to breastfeeding women from their employers was insufficient to promote EBF. © 2021 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd

Factors that promote a positive childbearing experience : a qualitative study

Introduction: Experiences of pregnancy and birth are important and have long-term impacts on the well-being of women and their families. Perinatal services should aim for care that promotes a positive childbearing experience, as well as optimizing health outcomes for the woman and newborn. This study aimed to understand the health system factors that promote a positive childbearing experience. Methods: Women who had a positive experience and had given birth in Australia in the previous 12 months were recruited for individual semistructured interviews. The interview guide focused on health system factors that participants credited with contributing to their positive experience of perinatal care. Interviews were conducted until data saturation was reached. Qualitative data were transcribed verbatim and analyzed using inductive thematic analysis. Results: Data from 36 interviews were thematically analyzed, and 4 major themes were generated: health care provider attributes, health system attributes, communication and decision-making, and experience of care. The salient factors that promoted positive experiences included care that was respectful and individualized with effective communication, access to midwifery continuity of care models, and good integration between services. Competent and professional health care providers who facilitated shared decision-making were also essential. Discussion: Although women often sought out care that promoted physiologic birth, they emphasized that the way they were cared for was more important than fulfilling specific birth aspirations. Quality maternity care has the capacity to support a woman's confidence in her own abilities and promote a positive, and sometimes transformative, childbearing experience. © 2022 The Authors. Journal of Midwifery & Women's Health published by Wiley Periodicals LLC on behalf of American College of Nurse Midwives (ACNM)

Antidepressant-associated sexual dysfunction in women at midlife

Selective serotonin re-uptake inhibitors (SSRIs) and serotonin noradrenaline re-uptake inhibitors (SNRIs) are commonly prescribed antidepressants in women. These treatments are associated with a high rate of female sexual dysfunction (FSD). There is a concern that emergence of sexual dysfunction in women treated with SSRI/SNRIs contributes to treatment discontinuation and relapse of depression. Evidence-based data to guide the treatment for SSRI/SNRI-associated FSD is sparse, leaving clinicians uncertain as to how to manage this condition effectively and patients susceptible to unproven pharmacological approaches. The overall aim of this thesis was to investigate transdermal testosterone as a treatment option for antidepressant-emergent FSD. Accordingly, the background literature in this area was reviewed and then three original studies were conducted. I found that the current management strategies for SSRI/SNRI-associated FSD are limited, with a lack of evidence for the efficacy of transdermal testosterone in this clinical population. Therefore, I examined the efficacy of transdermal testosterone therapy for antidepressant-emergent loss of libido in women at midlife in a randomised, double-blind, placebo-controlled trial. 44 women, aged 35 to 55 years, with antidepressant-emergent loss of libido were randomly allocated to treatment with a testosterone patch delivering 300 mcg of testosterone/day or an identical placebo patch for 12 weeks. The primary outcome was the change in sexual function over 12 weeks assessed by the Sabbatsberg Sexual Self-rating Scale (SSS). The 4-week frequency of satisfactory sexual events (SSEs), sexual distress, general wellbeing, depression and mood states were also measured. Testosterone therapy resulted in a significant increase in the number of SSEs compared with placebo therapy. The effect of testosterone therapy on distress associated with low desire approached statistical significance. There was no treatment effect seen for general wellbeing, mood or depression. The lack of improvement in the SSS total score reflects lack of sensitivity of this instrument for the measurement of change in sexual function. This study provides the first evidence that testosterone therapy may be a treatment option for women with SSRI/SNRI-emergent loss of libido. As the testosterone patch used in the RCT is no longer commercially available, I investigated the pharmacokinetic profile of an available 1% transdermal testosterone cream (TTC). Healthy naturally postmenopausal women were randomly allocated to the order of treatment with 5 mg or 10 mg of the TTC to the upper arm for each of two study periods in a cross-over design. The pharmacokinetic analysis showed the 5-mg dose restores total testosterone levels to above, and free testosterone levels to within the normal range for premenopausal women. This formulation would appear a suitable option for the treatment of women when testosterone therapy is indicated. My third study was undertaken to elucidate women’s expectations of medical treatment for sexual dysfunction and their self-appraisal of treatment outcomes utilising a qualitative approach. Women referred to an endocrinologist for their sexual difficulties were interviewed before and after their medical consultation. The themes that emerged from this study were that women had 1) personal psychological distress associated with FSD, (2) concerned about the negative effect of sexual dysfunction on the relationship with their sexual partner, (3) a belief in a relationship between sexual dysfunction and “hormone deficiency”, and (4) an expectation of treatment, which included positive physical and sexual changes. Several conclusions can be drawn from this thesis. Women presenting for treatment of sexual dysfunction are distressed about their sexual problem, concerned about the negative impact of their sexual difficulties on their relationship and are hopeful that they will be offered a treatment for their problem which could bring about physical and sexual changes. Transdermal testosterone improves sexual function in women with SSRI/SNRI-emergent libido disorder and a 5mg dose of a 1% TTC provides a therapeutic option for women seeking treatment

Antidepressant-associated sexual dysfunction in women at midlife

Selective serotonin re-uptake inhibitors (SSRIs) and serotonin noradrenaline re-uptake inhibitors (SNRIs) are commonly prescribed antidepressants in women. These treatments are associated with a high rate of female sexual dysfunction (FSD). There is a concern that emergence of sexual dysfunction in women treated with SSRI/SNRIs contributes to treatment discontinuation and relapse of depression. Evidence-based data to guide the treatment for SSRI/SNRI-associated FSD is sparse, leaving clinicians uncertain as to how to manage this condition effectively and patients susceptible to unproven pharmacological approaches. The overall aim of this thesis was to investigate transdermal testosterone as a treatment option for antidepressant-emergent FSD. Accordingly, the background literature in this area was reviewed and then three original studies were conducted. I found that the current management strategies for SSRI/SNRI-associated FSD are limited, with a lack of evidence for the efficacy of transdermal testosterone in this clinical population. Therefore, I examined the efficacy of transdermal testosterone therapy for antidepressant-emergent loss of libido in women at midlife in a randomised, double-blind, placebo-controlled trial. 44 women, aged 35 to 55 years, with antidepressant-emergent loss of libido were randomly allocated to treatment with a testosterone patch delivering 300 mcg of testosterone/day or an identical placebo patch for 12 weeks. The primary outcome was the change in sexual function over 12 weeks assessed by the Sabbatsberg Sexual Self-rating Scale (SSS). The 4-week frequency of satisfactory sexual events (SSEs), sexual distress, general wellbeing, depression and mood states were also measured. Testosterone therapy resulted in a significant increase in the number of SSEs compared with placebo therapy. The effect of testosterone therapy on distress associated with low desire approached statistical significance. There was no treatment effect seen for general wellbeing, mood or depression. The lack of improvement in the SSS total score reflects lack of sensitivity of this instrument for the measurement of change in sexual function. This study provides the first evidence that testosterone therapy may be a treatment option for women with SSRI/SNRI-emergent loss of libido. As the testosterone patch used in the RCT is no longer commercially available, I investigated the pharmacokinetic profile of an available 1% transdermal testosterone cream (TTC). Healthy naturally postmenopausal women were randomly allocated to the order of treatment with 5 mg or 10 mg of the TTC to the upper arm for each of two study periods in a cross-over design. The pharmacokinetic analysis showed the 5-mg dose restores total testosterone levels to above, and free testosterone levels to within the normal range for premenopausal women. This formulation would appear a suitable option for the treatment of women when testosterone therapy is indicated. My third study was undertaken to elucidate women’s expectations of medical treatment for sexual dysfunction and their self-appraisal of treatment outcomes utilising a qualitative approach. Women referred to an endocrinologist for their sexual difficulties were interviewed before and after their medical consultation. The themes that emerged from this study were that women had 1) personal psychological distress associated with FSD, (2) concerned about the negative effect of sexual dysfunction on the relationship with their sexual partner, (3) a belief in a relationship between sexual dysfunction and “hormone deficiency”, and (4) an expectation of treatment, which included positive physical and sexual changes. Several conclusions can be drawn from this thesis. Women presenting for treatment of sexual dysfunction are distressed about their sexual problem, concerned about the negative impact of their sexual difficulties on their relationship and are hopeful that they will be offered a treatment for their problem which could bring about physical and sexual changes. Transdermal testosterone improves sexual function in women with SSRI/SNRI-emergent libido disorder and a 5mg dose of a 1% TTC provides a therapeutic option for women seeking treatment

Work-related factors affecting exclusive breastfeeding among employed women in ethiopia:Managers’ perspective using a qualitative approach

Background: Only 21% of employed mothers in Ethiopia breastfeed exclusively until six months. Evidence from other countries has shown that support from managers encourages mothers to continue breastfeeding. Whereas lack of physical resources, time for breastfeed-ing and supportive policies adversely impact the continuation of breastfeeding. The aim of this study was to explore the perspective of managers regarding breastfeeding in the Ethiopian context. Methods: Managers of district level, government institutions were interviewed in the Tigray region of North Ethiopia. Semi-structured, face to face interviews were used to explore managers’ perspectives and views about breastfeeding, the level of support they provide to breastfeeding mothers, and the challenges they faced. The data were transcribed verbatim and thematically analysed. Results: Fifteen managers were interviewed from 12 organizations. The data were categor-ized into three themes. The first theme related to the attitudes and preference of managers and revealed that overall participants had positive views towards breastfeeding. The second theme highlighted managers’ concern about the impact of breastfeeding on staffing and workplace productivity. The third theme focused on managers’ assertions that, despite improvements, there were still inadequate policies and government strategies to support employed breastfeeding women in North Ethiopia. Conclusion: It is promising that managers in North Ethiopia expressed a positive attitude towards supporting breastfeeding mothers. Managers raised concern about the impact of breastfeeding on work performance, as well as the lack of physical facilities and government resources that affects the level of support they can provide. © 2020 Gebrekidan et al