Why do women not use antenatal services in low and middle income countries? A metasynthesis of qualitative studies

Background: Almost 50% of women in low & middle income countries (LMIC’s) don’t receive adequate antenatal care. Women’s views can offer important insights into this problem. Qualitative studies exploring inadequate use of antenatal services have been undertaken in a range of countries, but the findings are not easily transferable. We aimed to inform the development of future antenatal care programmes through a synthesis of findings in all relevant qualitative studies. Methods and Findings: Using a pre-determined search strategy, we identified robust qualitative studies reporting on the views and experiences of women in LMIC’s who received inadequate antenatal care. We used meta-ethnographic techniques to generate themes and a line of argument synthesis. We derived policy relevant hypotheses from the findings. We included 21 papers representing the views of more than 1230 women from 15 countries. Three key themes were identified: ‘Pregnancy as socially risky and physiologically healthy’; ‘Resource use and survival in conditions of extreme poverty’and ‘Not getting it right first time’. The line of argument synthesis describes a dissonance between programme design and cultural contexts that may restrict access and discourage return visits. We hypothesize that centralized, risk-focused antenatal care programmes may be at odds with the resources, beliefs and experiences of pregnant women who underuse antenatal services. Conclusions: Our findings suggest that there may be a mis-alignment between current antenatal provision and the social and cultural context of some women in LMIC’s. Antenatal care provision that is theoretically and contextually at odds with local contextual beliefs and experiences are likely to be underused, especially when attendance generates increased personal risks of lost family resource or physical danger during travel; when the promised care is not delivered due to resource constraints; and when women experience covert or overt abuse in care settings

After surgery: the effects of life-saving caesarean sections in Burkina Faso:BMC Pregnancy Childbirth

Background In African countries, caesarean sections are usually performed to save mothers and babies’ lives, sometimes in extremis and at considerable costs. Little is known about the health and lives of women once discharged after such surgery. We investigated the long-term effects of life-saving caesarean section on health, economic and social outcomes in Burkina Faso. Methods We conducted a 4 year prospective cohort study of women and their babies using mixed methods. The quantitative sample was selected in seven hospitals and included 950 women: 100 women with a caesarean section associated with near-miss complication (life-saving caesareans); 173 women with a vaginal birth associated with near-miss complication; and 677 women with uncomplicated vaginal childbirth. Structured interviews were conducted at 3 months, 6 months, 12 months and 3 and 4 years postpartum. These were supplemented by medical record data on delivery and physical examinations at 6 and 12 months postpartum. The lives and experiences of 21 women were documented ethnographically. Data were analysed with multivariable logistic regressions, using survival analysis and thematic analysis. Results The physical effects of life-saving caesareans appeared to be similar to women who had an uncomplicated childbirth, although 55 % of women with life-saving caesareans had another caesarean in their next pregnancy. The negative effects were generally economic, social and reproductive when compared to vaginal births, including increased debts (AOR = 3.91 (1.46–10.48) and sexual violence (AOR = 4.71 (1.04–21.3)) and lower fertility (AOR = 0.44 (0.24–0.80)) 4 years after life-saving caesareans. In the short and medium term, women with life-saving caesareans appeared to suffer increased psychological distress compared to uncomplicated births. They were more likely to use contraceptives (AOR = 5.95 (1.53–23.06); 3 months). Mortality of the index child was increased in both near-miss groups, independent of delivery mode. Ethnographic data suggest that these consequences are significant for Burkinabe women, whose well-being and social standing are mostly determined by their fertility, marriage strength and family links. Conclusions Life-saving caesareans have broad consequences beyond clinical sequelae. The recent policy to subsidise emergency obstetric care costs implemented in Burkina Faso should help avoid the majority of catastrophic costs, shown to be problematic for women undergoing emergency caesarean section

Maternal and neonatal factors associated with mode of delivery under a universal newborn hearing screening programme in Lagos, Nigeria

<p>Abstract</p> <p>Background</p> <p>Emerging evidence from a recent pilot universal newborn hearing screening (UNHS) programme suggests that the burden of obstetric complications associated with mode of delivery is not limited to maternal and perinatal mortality but may also include outcomes that undermine optimal early childhood development of the surviving newborns. However, the potential pathways for this association have not been reported particularly in the context of a resource-poor setting. This study therefore set out to establish the pattern of delivery and the associated neonatal outcomes under a UNHS programme.</p> <p>Methods</p> <p>A cross-sectional study in which all consenting mothers who delivered in an inner-city tertiary maternity hospital in Lagos, Nigeria from May 2005 to December 2007 were enrolled during the UNHS programme. Socio-demographic, obstetric and neonatal factors independently associated with vaginal, elective and emergency caesarean deliveries were determined using multinomial logistic regression analyses.</p> <p>Results</p> <p>Of the 4615 mothers enrolled, 2584 (56.0%) deliveries were vaginal, 1590 (34.4%) emergency caesarean and 441 (9.6%) elective caesarean section. Maternal age, parity, social class and all obstetric factors including lack of antenatal care, maternal HIV and multiple gestations were associated with increased risk of emergency caesarean delivery compared with vaginal delivery. Only parity, lack of antenatal care and prolonged/obstructed labour were associated with increased risk of emergency compared with elective caesarean delivery. Infants delivered by vaginal method or by emergency caesarean section were more likely to be associated with the risk of sensorineural hearing loss but less likely to be associated with hyperbilirubinaemia compared with infants delivered by elective caesarean section. Emergency caesarean delivery was also associated with male gender, low five-minute Apgar scores and admission into special care baby unit compared with vaginal or elective caesarean delivery.</p> <p>Conclusions</p> <p>The vast majority of caesarean delivery in this population occur as emergencies and are associated with socio-demographic factors as well as several obstetric complications. Mode of delivery is also associated with the risk of sensorineural hearing loss and other adverse birth outcomes that lie on the causal pathways for potential developmental deficits.</p

Social differentiation and embodied dispositions: a qualitative study of maternal care-seeking behaviour for near-miss morbidity in Bolivia

<p>Abstract</p> <p>Background</p> <p>Use of maternal health care in low-income countries has been associated with several socioeconomic and demographic factors, although contextual analyses of the latter have been few. A previous study showed that 75% of women with severe obstetric morbidity (near-miss) identified at hospitals in La Paz, Bolivia were in critical conditions upon arrival, underscoring the significance of pre-hospital barriers also in this setting with free and accessible maternal health care. The present study explores how health care-seeking behaviour for near-miss morbidity is conditioned in La Paz, Bolivia.</p> <p>Methods</p> <p>Thematic interviews with 30 women with a near-miss event upon arrival at hospital. Near-miss was defined based on clinical and management criteria. Modified analytic induction was applied in the analysis that was further influenced by theoretical views that care-seeking behaviour is formed by predisposing characteristics, enabling factors, and perceived need, as well as by socially shaped habitual behaviours.</p> <p>Results</p> <p>The self-perception of being fundamentally separated from "others", meaning those who utilise health care, was typical for women who customarily delivered at home and who delayed seeking medical assistance for obstetric emergencies. Other explanations given by these women were distrust of authority, mistreatment by staff, such as not being kept informed about their condition or the course of their treatment, all of which reinforced their dissociation from the health-care system.</p> <p>Conclusion</p> <p>The findings illustrate health care-seeking behaviour as a practise that is substantially conditioned by social differentiation. Social marginalization and the role health institutions play in shaping care-seeking behaviour have been de-emphasised by focusing solely on endogenous cultural factors in Bolivia.</p

Please understand when I cry out in pain: women's accounts of maternity services during labour and delivery in Ghana

BACKGROUND: This study was undertaken to investigate women's accounts of interactions with health care providers during labour and delivery and to assess the implications for acceptability and utilisation of maternity services in Ghana. METHODS: Twenty-one individual in-depth interviews and two focus group discussions were conducted with women of reproductive age who had delivered in the past five years in the Greater Accra Region. The study investigated women's perceptions and experiences of care in terms of factors that influenced place of delivery, satisfaction with services, expectations of care and whether they would recommend services. RESULTS: One component of care which appeared to be of great importance to women was staff attitudes. This factor had considerable influence on acceptability and utilisation of services. Otherwise, a successful labour outcome and non-medical factors such as cost, perceived quality of care and proximity of services were important. Our findings indicate that women expect humane, professional and courteous treatment from health professionals and a reasonable standard of physical environment. Women will consciously change their place of delivery and recommendations to others if they experience degrading and unacceptable behaviour. CONCLUSION: The findings suggest that inter-personal aspects of care are key to women's expectations, which in turn govern satisfaction. Service improvements which address this aspect of care are likely to have an impact on health seeking behaviour and utilisation. Our findings suggest that user-views are important and warrant further investigation. The views of providers should also be investigated to identify channels by which service improvements, taking into account women's views, could be operationalised. We also recommend that interventions to improve delivery care should not only be directed to the health professional, but also to general health system improvements