Lessons learned in Liberia: preliminary examination of the psychometric properties of trust and teamwork among maternal healthcare workers

Abstract Background Post-conflict Liberia has one of the fastest growing populations on the continent and one of the highest maternal mortality rates among the world. However, in the rural regions, less than half of all births are attended by a skilled birth attendant. There is a need to evaluate the relationship between trained traditional healthcare providers and skilled birth attendants to improve maternal health outcomes. This evaluation must also take into consideration the needs and desires of the patients. The purpose of this pilot study was to establish the validity and reliability of a survey tool to evaluate trust and teamwork in the working relationships between trained traditional midwives and certified midwives in a post-conflict country. Methods A previously established scale, the Trust and Teambuilding Scale, was used with non- and low-literate trained traditional midwives (n=48) in rural Liberia to evaluate trust and teamwork with certified midwives in their communities. Initial results indicated that the scale and response keys were culturally inadequate for this population. A revised version of the scale, the Trust and Teamwork Scale – Liberia, was created and administered to an additional group of non- and low-literate, trained traditional midwives (n=42). Exploratory factor analysis using Mplus for dichotomous variables was used to determine the psychometric properties of the revised scale and was then confirmed with the full sample (n=90). Additional analyses included contrast validity, convergent validity, and Kuder-Richardson reliability. Results Exploratory factor analysis revealed two factors in the revised Trust and Teamwork Scale – Liberia. These two factors, labeled trust and teamwork, included eleven of the original eighteen items used in the Trust and Teamwork Scale and demonstrated contrast and convergent validity and adequate reliability. Conclusions The revised scale is suitable for use with non- and low-literate, trained traditional midwives in rural Liberia. Continued cross-cultural validation of tools is essential to ensure scale adequacy across populations. Future work should continue to evaluate the use of the Trust and Teamwork Scale – Liberia across cultures and additional work is needed to confirm the factor structure.http://deepblue.lib.umich.edu/bitstream/2027.42/112398/1/12913_2012_Article_2549.pd

Factors that influence midwifery students in Ghana when deciding where to practice: a discrete choice experiment

Abstract Background Mal-distribution of the health workforce with a strong bias for urban living is a major constraint to expanding midwifery services in Ghana. According to the UN Millennium Development Goals (MDG) report, the high risk of dying in pregnancy or childbirth continues in Africa. Maternal death is currently estimated at 350 per 100,000, partially a reflection of the low rates of professional support during birth. Many women in rural areas of Ghana give birth alone or with a non-skilled attendant. Midwives are key healthcare providers in achieving the MDGs, specifically in reducing maternal mortality by three-quarters and reducing by two-thirds the under 5 child mortality rate by 2015. Methods This quantitative research study used a computerized structured survey containing a discrete choice experiment (DCE) to quantify the importance of different incentives and policies to encourage service to deprived, rural and remote areas by upper-year midwifery students following graduation. Using a hierarchical Bayes procedure we estimated individual and mean utility parameters for two hundred and ninety eight third year midwifery students from two of the largest midwifery training schools in Ghana. Results Midwifery students in our sample identified: 1) study leave after two years of rural service; 2) an advanced work environment with reliable electricity, appropriate technology and a constant drug supply; and 3) superior housing (2 bedroom, 1 bathroom, kitchen, living room, not shared) as the top three motivating factors to accept a rural posting. Conclusion Addressing the motivating factors for rural postings among midwifery students who are about to graduate and enter the workforce could significantly contribute to the current mal-distribution of the health workforce.http://deepblue.lib.umich.edu/bitstream/2027.42/112340/1/12909_2012_Article_752.pd

Examining Antenatal Health Literacy in Ghana

Purpose To explore Ghanaian pregnant women's understanding and recognition of danger signs in pregnancy, birth preparedness and complication readiness, and their understanding of newborn care. Design An exploratory, qualitative study design was used. Methods Data were gathered through six focus group discussions with 68 pregnant women attending antenatal care at a busy urban hospital in Ghana. Qualitative and descriptive data were analyzed using SPSS version 21. Health literacy was used as the guiding framework to analyze the qualitative data. Data were analyzed in the content domains of (a) understanding and recognition of danger signs in pregnancy, (b) preparedness for childbirth, (c) understanding and recognition of danger signs in the newborn, and (d) appropriate and timely referral. Findings Women in this study identified danger signs of pregnancy and in the newborn, but had difficulty interpreting and operationalizing information they received during antenatal care visits, indicating that health education did not translate to appropriate health behaviors. Cultural beliefs in alternative medicine, lack of understanding, and prior negative encounters with healthcare professionals may have led to underutilization of professional midwives for delivery and health services. Conclusions Women in this study exhibited low health literacy by incorrectly interpreting and operationalizing health education received during antenatal care. With limited health literacy, pregnant women cannot fully comprehend the scope of services that a health system can provide for them and their families. Clinical Relevance Achieving the greatest impact with limited time in antenatal care is a challenge. Since antenatal care is widely available to pregnant women in Ghana, it is vital to reexamine the way antenatal education is delivered. Pregnant women must receive health information that is accurate and easy to understand in order to make informed health choices that will improve maternal and child health.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/109308/1/jnu12094.pd

Increasing postpartum family planning uptake through group antenatal care: a longitudinal prospective cohort design

Abstract Background Despite significant improvements, postpartum family planning uptake remains low for women in sub-Saharan Africa. Transmitting family planning education in a comprehensible way during antenatal care (ANC) has the potential for long-term positive impact on contraceptive use. We followed women for one-year postpartum to examine the uptake and continuation of family planning following enrollment in group versus individual ANC. Methods A longitudinal, prospective cohort design was used. Two hundred forty women were assigned to group ANC (n = 120) or standard, individual care (n = 120) at their first ANC visit. Principal outcome measures included intent to use family planning immediately postpartum and use of a modern family planning method at one-year postpartum. Additionally, data were collected on intended and actual length of exclusive breastfeeding at one-year postpartum. Pearson chi-square tests were used to test for statistically significant differences between group and individual ANC groups. Odds ratios and adjusted odds ratios were calculated using logistic regression. Results Women who participated in group ANC were more likely to use modern and non-modern contraception than those in individual care (59.1% vs. 19%, p < .001). This relationship improved when controlled for intention, age, religion, gravida, and education (AOR = 6.690, 95% CI: 2.724, 16,420). Women who participated in group ANC had higher odds of using a modern family planning method than those in individual care (AOR = 8.063, p < .001). Those who participated in group ANC were more likely to exclusively breastfeed for more than 6 months than those in individual care (75.5% vs. 50%, p < .001). This relationship remained statistically significant when adjusted for age, religion, gravida, and education (AOR = 3.796, 95% CI: 1.558, 9.247). Conclusions Group ANC has the potential to be an effective model for improving the uptake and continuation of post-partum family planning up to one-year. Antenatal care presents a unique opportunity to influence the adoption of postpartum family planning. This is the first study to examine the impact of group ANC on family planning intent and use in a low-resource setting. Group ANC holds the potential to increase postpartum family planning uptake and long-term continuation. Trial registration Not applicable. No health related outcomes reported.https://deepblue.lib.umich.edu/bitstream/2027.42/146750/1/12978_2018_Article_644.pd

Husbands' involvement in delivery care utilization in rural Bangladesh: A qualitative study

Abstract Background A primary cause of high maternal mortality in Bangladesh is lack of access to professional delivery care. Examining the role of the family, particularly the husband, during pregnancy and childbirth is important to understanding women's access to and utilization of professional maternal health services that can prevent maternal mortality. This qualitative study examines husbands' involvement during childbirth and professional delivery care utilization in a rural sub-district of Netrokona district, Bangladesh. Methods Using purposive sampling, ten households utilizing a skilled attendant during the birth of the youngest child were selected and matched with ten households utilizing an untrained traditional birth attendant, or dhatri. Households were selected based on a set of inclusion criteria, such as approximate household income, ethnicity, and distance to the nearest hospital. Twenty semi-structured interviews were conducted in Bangla with husbands in these households in June 2010. Interviews were transcribed, translated into English, and analyzed using NVivo 9.0. Results By purposefully selecting households that differed on the type of provider utilized during delivery, common themes--high costs, poor transportation, and long distances to health facilities--were eliminated as sufficient barriers to the utilization of professional delivery care. Divergent themes, namely husbands' social support and perceived social norms, were identified as underlying factors associated with delivery care utilization. We found that husbands whose wives utilized professional delivery care provided emotional, instrumental and informational support to their wives during delivery and believed that medical intervention was necessary. By contrast, husbands whose wives utilized an untrained dhatri at home were uninvolved during delivery and believed childbirth should take place at home according to local traditions. Conclusions This study provides novel evidence about male involvement during childbirth in rural Bangladesh. These findings have important implications for program planners, who should pursue culturally sensitive ways to involve husbands in maternal health interventions and assess the effectiveness of education strategies targeted at husbands.http://deepblue.lib.umich.edu/bitstream/2027.42/112942/1/12884_2011_Article_487.pd

Maternity waiting homes as an intervention to increase facility delivery in rural Zambia

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/150534/1/ijgo12864_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/150534/2/ijgo12864.pd

Acceptability and feasibility of insect consumption among pregnant women in Liberia

Maternity waiting homes (MWHs) in Liberia promote facility‐based delivery to reduce maternal mortality. However, women often must bring their own food and supplies to MWHs, which makes food insecurity a barrier to the utilisation of MWHs. Consumption of edible indigenous insects is a common practice and has notable nutritional benefits but has not been studied in Liberia as a potential solution to food insecurity at MWHs. The purpose of this study is to (a) examine the acceptability of insect consumption in the context of Liberian beliefs, (b) identify species commonly consumed by pregnant women in Liberia, and (c) examine the feasibility of harvesting insects as food and income generation for women staying at MWHs. Focus groups were conducted at 18 healthcare facilities in Liberia. Participants included chiefs, community leaders, women of reproductive age, traditional birth attendants, women staying at MWHs, and male partners. Focus group participants identified many different species of insects consumed by pregnant women in the community as well as the perceived health impacts of insect consumption. They also described their own experiences with insect hunting and consumption and the perceived marketability of insects, particularly palm weevil larvae. The results of these discussions demonstrate that insect consumption is an acceptable practice for pregnant women in rural Liberia. These findings suggest that it is feasible to further explore the use of palm weevil larvae as dietary supplementation and income generation for women staying at MWHs in Liberia.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/155915/1/mcn12990_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/155915/2/mcn12990.pd

Postpartum physical intimate partner violence among women in rural Zambia

ObjectiveTo examine the demographic characteristics and mental health of women in rural Zambia who experienced physical intimate partner violence (IPV) postpartum.MethodsThe present secondary analysis was conducted using baseline data from an impact evaluation of a maternity waiting home intervention in rural Zambia. A quantitative household survey was conducted over 6 weeks, from midâ April to late May, 2016, at 40 rural health facility catchment areas among 2381 postpartum women (13 months after delivery; age â ¥15 years).ResultsA total of 192 (8.1%) women reported experiencing any type of physical IPV in the preceding 2 weeks; 126 had experienced severe physical IPV (had been kicked, dragged, beat, and/or choked by a husband or partner). High levels of depression were recorded for 174 (7.3%) women in the preceding 2 weeks. Being a female head of household was associated with an increased likelihood of experiencing severe physical IPV (aOR 2.64, 95% CI 1.70â 4.10). Women with high depression scores were also at an increased risk of experiencing any physical IPV (aOR 17.1, 95% CI 8.44â 34.9) and severe physical IPV (aOR 15.4, 95% CI 5.17â 45.9).ConclusionFuture work should consider the implications of government and educational policies that could impact the screening and treatment of pregnant women affected by all forms of physical IPV and depression in rural Zambia.Postpartum physical intimate partner violence among women in rural Zambia was associated with being a female head of household and high levels of depression.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146407/1/ijgo12654.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/146407/2/ijgo12654_am.pd

Maternity waiting homes and traditional midwives in rural Liberia

ObjectiveMaternity waiting homes (MWHs) can reduce maternal morbidity and mortality by increasing access to skilled birth attendants (SBAs). The present analysis was conducted to determine whether MWHs increase the use of SBAs at rural primary health clinics in Liberia; to determine whether traditional midwives (TMs) are able to work with SBAs as a team and to describe the perceptions of TMs as they engage with SBAs; and to determine whether MWHs decrease maternal and child morbidity and mortality.MethodsThe present analysis was conducted halfway through a large cohort study in which 5 Liberian communities received the intervention (establishment of an MWH) and 5 Liberian communities did not (control group). Focus groups were conducted to examine the views of TMs on their integration into health teams.ResultsCommunities with MWHs experienced a significant increase in team births from baseline to post‐intervention (10.8% versus 95.2%, P < 0.001), with greater TM engagement. Lower rates of maternal and perinatal death were reported from communities with MWHs.ConclusionThe reduction in morbidity and mortality indicates that the establishment of MWHs is an effective strategy to increase the use of SBAs, improve the collaboration between SBAs and TMs, and improve maternal and neonatal health.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135181/1/ijgo114.pd