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

“We have been working overnight without sleeping”: traditional birth attendants’ practices and perceptions of post-partum care services in rural Tanzania

Background: In many low-income countries, formal post-partum care utilization is much lower than that of skilled delivery and antenatal care. While Traditional Birth Attendants (TBAs) might play a role in post-partum care, research exploring their attitudes and practices during this period is scarce. Therefore, the aim of this study was to explore TBAs’ practices and perceptions in post-partum care in rural Tanzania. Methods: Qualitative in-depth interview data were collected from eight untrained and three trained TBAs. Additionally, five multiparous women who were clients of untrained TBAs were also interviewed. Interviews were conducted in February 2013. Data were digitally recorded and transcribed verbatim. Qualitative content analysis was used to analyze data. Results: Our study found that TBAs take care of women during post-partum with rituals appreciated by women. They report lacking formal post-partum care training, which makes them ill-equipped to detect and handle post-partum complications. Despite their lack of preparation, they try to provide care for some post-partum complications which could put the health of the woman at risk. TBAs perceive that utilization of hospital-based post-partum services among women was only important for the baby and for managing complications which they cannot handle. They are poorly linked with the health system. Conclusions: This study found that the TBAs conducted close follow-ups and some of their practices were appreciated by women. However, the fact that they were trying to manage certain post-partum complications can put women at risk. These findings point out the need to enhance the communication between TBAs and the formal health system and to increase the quality of the TBA services, especially in terms of prompt referral, through provision of training, mentoring, monitoring and supervision of the TBA servic

Photosynthetic acclimation within individual Typha latifolia leaf segments

Growing Typha latifolia leaf segments traverse a wide range of light environments as they are pushed upward from basal meristems through sediment, water, and dense litter and leaf layers. We used light transfer experiments in a greenhouse to investigate the photosynthetic acclimation of individual Typha leaf segments. Fully expanded leaf segments exhibited strong and symmetrical acclimation to increases or decreases in light. The photosynthetic light response curves of shade grown segments that were transferred to high light acclimated within 10-15 days to match those of segments that grew and remained in high light. Acclimation was highly localized; the light response curves of shade grown segments that remained shaded did not change, even as adjacent segments acclimated to high light. Leaf segments exposed to various treatments did not differ significantly in leaf mass per area; Typha leaves are apparently morphologically preformed to function in high light and allow high photosynthetic capacity, regardless of the growth environment. Likewise, nitrogen content did not differ significantly between treatments, and photosynthetic acclimation may involve a reallocation or activation of nitrogen within a leaf segment, rather than a net nitrogen translocation into or out of a segment. We interpret these patterns as an adaptive strategy that maximizes carbon gain by monocot leaves growing in a vertically heterogeneous light environment. © 2013 Elsevier B.V

Microenvironmental heterogeneity and space utilization by desert vines within their host trees

The three-dimensional biomass distribution and the microenvironments experienced by several desert vine species growing within the canopy of host trees were studied at the Centro Ecológico de Sonora in México. The light environment within the crown of the host tree Cercidium microphyllum showed a horizontal and vertical gradient from the base of the trunk to the edges of the canopy. Within this gradient total daily photosynthetically active radiation (PAR) varied from 47.8 mol m-2outside the crown to 4.6 mol m-2at the centre of the crown and close to the ground. Maximum air temperature was 3 °C lower beneath the crown than outside. Within the canopy, most vines experienced less than 50% of the daily available PAR outside the canopy. For most of the day, leaves of vines received 15% or less of the maximum available PAR. Our study shows that vines do not grow towards full sunlight but rather they exploit different habitat possibilities within their host tree crown. Leaves along the stems of vines experienced a wide range of light environments, showing coefficients of variation (CV) in total daily PAR from 36.4 to 94.6%. Daily courses of PAR also showed that leaves within the canopy experienced short-term temporal variation in the light environment. Differences in CV of daily PAR values and preferences in heterogeneous light microenvironments among species suggested that different vine species might be spatially separated in the canopy. We suggest that in desert habitats, conditions within the crown of host trees result in an important microhabitat that vines can exploit, allowing them to avoid the high light, temperature and water deficits found in the surrounding environment