The SMNH implementation framework for districts

The Safe Motherhood Demonstration Project (SMDP) implementation framework was developed as a result of lessons learned and approaches used during SMDP in Western Province, Kenya, 2000–04. All the components require cooperation and support at the provincial and national level. The six components, as outlined in this brief, are: preparation; safe motherhood (SM) rapid appraisal; analysis; intervention planning; implementation; and evaluation. The development of a Safe Motherhood Rapid Appraisal Tool has been an important outcome of the DFID Western Province SMDP. The intervention in Western Province was based on addressing resource and skills gaps in service provision, which were identified by a situation analysis carried out in each district. Through the introduction of training programs tailored to staff needs, ensuring that basic equipment and drugs were available, and ensuring greater community involvement, safe motherhood services have been improved in Western Province. The situation analysis exercise was refined during the project, resulting in the development of the Safe Motherhood Rapid Appraisal Tool

Repositioning post partum care in Kenya

In Kenya, although 45 percent of maternal deaths occur within the first 24 hours after childbirth and 65 percent of maternal deaths occur during the first week postpartum, health-care providers continue to advise on a first check-up six weeks after childbirth. The early postpartum period is also critical to newborn survival, with 50–70 percent of life-threatening newborn illnesses occurring in the first week. Yet most strategies to reduce maternal and perinatal morbidity and mortality have focused on pregnancy and birth. In addition to the heavy workload of providers who do not assess the mother post-delivery when she may bring her infant for immunization, lack of knowledge, poverty, cultural beliefs and practices perpetuate the problem. The only register that exists for mothers post-delivery is for family planning, thus perpetuating the lack of emphasis on the early postpartum period with no standardized register to record care given. To address this gap in service delivery, the Population Council defined the minimal services a mother and baby should receive from a skilled attendant after birth. As stated in this brief, the development of a standardized postpartum register is one step toward advocating for providing early postpartum care among health-service providers

Introducing magnesium sulphate for the management of pregnancy induced hypertension

Global studies have demonstrated that using magnesium sulphate (MgSO4) to manage hypertensive disease in pregnancy reduces morbidity and mortality due to severe pre-eclampsia/eclampsia, one of the five direct causes of maternal death. Many countries have been slow to introduce MgSO4 to the detriment of women’s health. There are also critical gaps in health-care provider knowledge, skills, and practice in management of eclampsia. Although the use of MgSO4 was introduced successfully to the Maternity Unit at Kenyatta National Hospital, Nairobi, in 2001, there has been no systematic introduction of the drug across the country. Generally, the only facilities utilizing MgSO4 are those supported by development partners and some mission hospitals. In response to requests from health-care managers and providers in Western Province to be trained in the use of MgSO4, a two-day practical training program was developed. As noted in this brief, the main objective of the training was to ensure that participants had specific skills for preventing and managing severe pre-eclampsia and eclampsia

Taking maternal services to pregnant women: The community midwifery model

Evidence from a number of studies globally has shown a reduction in maternal and perinatal mortality when women have a skilled attendant present at birth. In Kenya, a skilled attendant assists at only 42 percent of births. In Central Province, over 70 percent deliver with a skilled attendant compared to 28 percent in Western Province. Results from one district in Western Province where midwives were given the necessary equipment and support to assist women during birth at home, showed a significant increase in home births attended by skilled health workers between 2001 and 2003 and a similar decrease in utilization of traditional birth attendants. As noted in this brief, this an indication that skilled attendance in the community is possible and a good alternative for women who are unable to reach a health facility. Building on these results, a Community Midwifery Model was developed that focuses on empowering midwives living in the community to assist women during pregnancy, childbirth, and the postpartum period in their homes, manage minor complications, and facilitate referral when necessary and transfer to the hospital

Physical activity during pregnancy and its influence on delivery time: a randomized clinical trial

Introduction. During pregnancy, women often change their lifestyle for fear of harmful effects on the child or themselves. In this respect, many women reduce the amount of physical exercise they take, despite its beneficial effects. Objective. To determine the duration of labor in pregnant women who completed a program of moderate physical exercise in water and subsequently presented eutocic birth. Methods.Arandomized trial was performed with 140 healthy pregnant women, divided into an exercise group (EG) (nD70) and a control group (CG) (nD70). The women who composed the study population were recruited at 12 weeks of gestation. The intervention program, termedSWEP(Study of Water Exercise during Pregnancy) began in week 20 of gestation and ended in week 37. Perinatal outcomes were determined by examining the corresponding partographs, recorded by the Maternity Service at the Granada University Hospital Complex. Results. The intervention phase of the study took place from June through October 2016, with the 120 women finally included in EG and CG (60 in each group). At term, 63% of the women in EG and 56% of those in CG had a eutocic birth. The average total duration of labor was 389.33 +/- 216.18 min for the women in EG and 561.30 +/- 199.94 min for those in CG, a difference of approximately three hours (p<0:001). Conclusions. The women who exercised in water during their pregnancy presented a shorter duration of labor than those who did not. The difference was especially marked with respect to the duration of the first and second stages of labor

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

How Mistimed and Unwanted Pregnancies Affect Timing of Antenatal Care Initiation in three Districts in Tanzania

Early antenatal care (ANC) initiation is a doorway to early detection and management of potential complications associated with pregnancy. Although the literature reports various factors associated with ANC initiation such as parity and age, pregnancy intentions is yet to be recognized as a possible predictor of timing of ANC initiation. Data originate from a cross-sectional household survey on health behaviour and service utilization patterns. The survey was conducted in 2011 in Rufiji, Kilombero and Ulanga districts in Tanzania on 910 women of reproductive age who had given birth in the past two years. ANC initiation was considered to be early only if it occurred in the first trimester of pregnancy gestation. A recently completed pregnancy was defined as mistimed if a woman wanted it later, and if she did not want it at all the pregnancy was termed as unwanted. Chisquare was used to test for associations and multinomial logistic regression was conducted to examine how mistimed and unwanted pregnancies affect timing of ANC initiation. Although 49.3% of the women intended to become pregnant, 50.7% (34.9% mistimed and 15.8% unwanted) became pregnant unintentionally. While ANC initiation in the 1st trimester was 18.5%, so was 71.7% and 9.9% in the 2nd and 3rd trimesters respectively. Multivariate analysis revealed that ANC initiation in the 2nd trimester was 1.68 (95% CI 1.10‒2.58) and 2.00 (95% CI 1.05‒3.82) times more likely for mistimed and unwanted pregnancies respectively compared to intended pregnancies. These estimates rose to 2.81 (95% CI 1.41‒5.59) and 4.10 (95% CI 1.68‒10.00) respectively in the 3rd trimester. We controlled for gravidity, age, education, household wealth, marital status, religion, district of residence and travel time to a health facility. Late ANC initiation is a significant maternal and child health consequence of mistimed and unwanted pregnancies in Tanzania. Women should be empowered to delay or avoid pregnancies whenever they need to do so. Appropriate counseling to women, especially those who happen to conceive unintentionally is needed to minimize the possibility of delaying ANC initiation.\u

Use of antenatal services and delivery care among women in rural western Kenya: a community based survey

BACKGROUND: Improving maternal health is one of the UN Millennium Development Goals. We assessed provision and use of antenatal services and delivery care among women in rural Kenya to determine whether women were receiving appropriate care. METHODS: Population-based cross-sectional survey among women who had recently delivered. RESULTS: Of 635 participants, 90% visited the antenatal clinic (ANC) at least once during their last pregnancy (median number of visits 4). Most women (64%) first visited the ANC in the third trimester; a perceived lack of quality in the ANC was associated with a late first ANC visit (Odds ratio [OR] 1.5, 95% confidence interval [CI] 1.0–2.4). Women who did not visit an ANC were more likely to have < 8 years of education (adjusted OR [AOR] 3.0, 95% CI 1.5–6.0), and a low socio-economic status (SES) (AOR 2.8, 95% CI 1.5–5.3). The ANC provision of abdominal palpation, tetanus vaccination and weight measurement were high (>90%), but provision of other services was low, e.g. malaria prevention (21%), iron (53%) and folate (44%) supplementation, syphilis testing (19.4%) and health talks (14.4%). Eighty percent of women delivered outside a health facility; among these, traditional birth attendants assisted 42%, laypersons assisted 36%, while 22% received no assistance. Factors significantly associated with giving birth outside a health facility included: age ≥ 30 years, parity ≥ 5, low SES, < 8 years of education, and > 1 hour walking distance from the health facility. Women who delivered unassisted were more likely to be of parity ≥ 5 (AOR 5.7, 95% CI 2.8–11.6). CONCLUSION: In this rural area, usage of the ANC was high, but this opportunity to deliver important health services was not fully utilized. Use of professional delivery services was low, and almost 1 out of 5 women delivered unassisted. There is an urgent need to improve this dangerous situation