Health System Support for Childbirth care in Southern Tanzania: Results from a Health Facility Census.

Progress towards reaching Millennium Development Goals four (child health) and five (maternal health) is lagging behind, particularly in sub-Saharan Africa, despite increasing efforts to scale up high impact interventions. Increasing the proportion of birth attended by a skilled attendant is a main indicator of progress, but not much is known about the quality of childbirth care delivered by these skilled attendants. With a view to reducing maternal mortality through health systems improvement we describe the care routinely offered in childbirth offered at dispensaries, health centres and hospitals in five districts in rural Southern Tanzania. We use data from a health facility census assessing 159 facilities in five districts in early 2009. A structural and operational assessment was undertaken based on staff reports using a modular questionnaire assessing staffing, work load, equipment and supplies as well as interventions routinely implemented during childbirth. Health centres and dispensaries attended a median of eight and four deliveries every month respectively. Dispensaries had a median of 2.5 (IQR 2--3) health workers including auxiliary staff instead of the recommended four clinical officer and certified nurses. Only 28% of first-line facilities (dispensaries and health centres) reported offering active management in the third stage of labour (AMTSL). Essential childbirth care comprising eight interventions including AMTSL, infection prevention, partograph use including foetal monitoring and newborn care including early breastfeeding, thermal care at birth and prevention of ophthalmia neonatorum was offered by 5% of dispensaries, 38% of health centres and 50% of hospitals consistently. No first-line facility had provided all signal functions for emergency obstetric complications in the previous six months. Essential interventions for childbirth care are not routinely implemented in first-line facilities or hospitals. Dispensaries have both low staffing and low caseload which constraints the ability to provide high-quality childbirth care. Improvements in quality of care are essential so that women delivering in facility receive "skilled attendance" and adequate care for common obstetric complications such as post-partum haemorrhage

Policy Barriers Preventing Access to Emergency Obstetric are in Rural India

India with its one billion people contributes to about 20% of all maternal deaths in the world. Even though infant mortality has declined in India maternal mortality has remained high at about 540 per 100,000 live births. Recent scientific evidence shows that access and use of high quality emergency obstetric care is the key to reducing maternal mortality and that high risk approach in ante natal care do not help in reducing maternal mortality significantly. This paper analyzes the policy level barriers, which restrict access of rural women to life saving emergency obstetric care in rural India. The paper is based on study of policies, research reports and experience of working in the area of maternal health over last several years. The paper describes how policies restrict basic doctors from performing obstetric surgical procedures including cesarean section even in remote areas where there is no specialist obstetrician available. The para-medical staff such as the Auxiliary Nurse Midwife is also not allowed to manage obstetric emergencies in rural areas. The policy also does not allow nurses or basic doctors to give anesthesia. As there is limited number of anesthetists in rural areas, this further reduces access to life saving emergency surgery. New blood banking rules are very utopian, requiring many unnecessary things for licensing of a blood bank. Due to this, already limited access to blood transfusion in rural area has further reduced. Thus many restrictive polices of the government have made emergency obstetric care inaccessible in rural areas leading to continued higher maternal mortality in India.

Why Do Mothers Die? The Silent Tragedy of Maternal Mortality

More than two decades after the launch of the Safe Motherhood Initiative, maternal health in many developing countries has shown little or no improvement. Year after year, more than half a million mothers continue to die in silence. The specificities of the complex cross-cutting issue only partly explain why tireless efforts have led to insufficient progress so far. While some success stories prove that results can be obtained quickly, the dissensions and deficiencies the Initiative has encountered have strongly weakened its impact. However, recent developments over the past 3 years allow us to foresee the silence will soon be broken. While advocacy begins to subsequently raise awareness, more financial means are mobilized. As a consensus on the priority interventions has finally been reached (Women Deliver conference, London, October 2007), more coordinated actions and initiatives are being developed. The strive for the achievement of the Millennium Development Goals helps to create the political momentum the cause strongly needs to generate new leadership, develop and implement the adequate strategies. Sensible focus on resources and structure as well as innovative management will be crucial in that process

ESTIMATING MATERNAL OBSTETRIC RISK; THE APPLICATION OF SURVIVAL ANALYSIS TECHNIQUES

Studies on Maternal Survival and its converse mortality are of much recent origins with basic statistics, including data, in this area still a major challenge particularly for developing countries. While there are several estimators of maternal mortality and hence survival, the development of an appropriate measure of obstetric risk has been a challenge. In this study, the application of survival analysis techniques in developing appropriate estimates for maternal mortality and its usefulness have been proposed. Results of its application to data from Ghana showed that while about 92 % of pregnant women made it alive to delivery, only 83% of them survived to the end of the postpartum period. There were significant differentials by location, Obstetric history and Maternal Age: The Weibull distribution described maternal survival well

Incidence of early pregnancy complications, management protocols and its outcome in patients at Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat, India

Background: Early Pregnancy Complications can cause significant morbidity and mortality. Pregnant women an present with h/o amenorrhea, abdominal pain, vaginal bleeding or incidental scan finding of missed abortion, ectopic pregnancy and vesicular mole, features of hypermesis gravidorum like fatigue, nausea, vomiting, dryness and diminished urine output. The objective of present study was to analyze the incidence of various early pregnancy complications, assess the protocols for diagnosing these complications and their management.Methods: Present study was conducted at the Department of Obstetrics and Gynecology, Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat. All the women with first trimester pregnancy with different complications were included in this study while those women with uneventful first trimester were excluded. The inducted women were registered on pre-designed proforma. Studied variables including demographic details, gestational period, type of complications, risk factors, treatment and outcome.Results: Out of 740 total admissions 439 abortions of which incomplete abortion was 262, missed abortions were 132, threatened abortion 42 and 3 cases of septic abortion, ectopic pregnancy 154, molar pregnancy33, hyperemesis 31. There were about 63 cases of non-pregnancy related complication reported during early pregnancy like 31 with UTI, 9 with renal colic, 2 cases of appendicitis, four cases of asymptomatic cholelithiasis, 2 cases of hepatitis, 5 cases of ovarian cyst complicating pregnancy, 2 cases of ovarian torsion. Their mean age was 30.8+6.8 years.Conclusions: Study was successful in creating a confidence among trainees when following the recommended protocols as well as delivering clinical benefits to the hospital, patients and staff. Early gynecological consultation and bedside ultrasound scanning within the emergency department were key requirements for any emergency concerns

Travel of pregnant women in emergency situations to hospital and maternal mortality in Lagos, Nigeria: a retrospective cohort study

Introduction: Prompt access to emergency obstetric care (EmOC) reduces the risk of maternal mortality. We assessed institutional maternal mortality by distance and travel time for pregnant women with obstetric emergencies in Lagos State, Nigeria. Methods: We conducted a facility-based retrospective cohort study across 24 public hospitals in Lagos. Reviewing case notes of the pregnant women presenting between 1st November 2018 and 30th October 2019, we extracted socio-demographic, travel, and obstetric data. The extracted travel data was exported to Google Maps, where driving distance and travel time data were extracted. Multivariable logistic regression was conducted to determine the relative influence of distance and travel time on maternal death. Findings: Of 4,181 pregnant women with obstetric emergencies, 182 (4·4%) resulted in maternal deaths. Among those who died, 60.3% travelled ≤10km directly from home, and 61·9% arrived at the hospital ≤30mins. The median distance and travel time to EmOC was 7·6km (IQR 3·4-18·0) and 26mins (IQR 12- 50). For all women, travelling 10-15km (2·53, 95%CI 1·27-5·03) was significantly associated with maternal death. Stratified by referral, odds remained statistically significant for those travelling 10-15km in the non-referred group (2·48, 95%CI 1·18-5·23) and for travel ≥120min (7.05, 95%CI 1.10-45.32). For those referred, odds became statistically significant at 25-35km (21·40, 95%CI 1·24-36·72) and for journeys requiring travel time from as little as 10-29min (184.23, 95%CI 5.14-608.51). Odds were also significantly higher for women travelling to hospitals in suburban (3·60, 95%CI 1·59–8·18) or rural (2·51, 95%CI 1·01–6·29) areas. Conclusion: Our evidence shows that distance and travel time influence maternal mortality differently for referred women and those who are not. Larger scale research that uses closer-to-reality travel time and distance estimates as we have done, rethinking of global guidelines, and bold actions addressing access gaps, including within the suburbs, will be critical in reducing maternal mortality by 2030

Effects of Peer Group Counselling and Sex on the self-concept of Secondary School Adolescents: Implications for Counselling.

The study investigated the efficacy of peer group counselling in enhancing the self-concept of secondary school adolescents in Benin City, Edo State, Nigeria. The influence of sex on the self-concept of these adolescents was also investigated. A pre-test, post test, control group design was employed in the study. Sixty-eight senior secondary school II students, randomly selected from three randomly selected public secondary schools (a boys’ school, a girls’ school and a coeducational school) participated in the study. A 40-item adolescent self concept scale (ASCS) adapted from Akinboye (1977) Adolescent Personal Data Inventory (APDI) was validated and used to measure the self- concept of the participants. A correlation coefficient r = 0.76 was obtained using the test-retest reliability method to establish the stability of the instrument. Three hypotheses were formulated for the study and tested at .05 level of significance. Data collected were analysed using the Students’ t-statistic and analysis of variance (ANOVA).The results of the study revealed that peer group counselling had a significant positive effect on the self-concept of the adolescents. There was no significant effect of sex on the self concept of the adolescents. Further analysis also revealed no interactive effect of treatment and sex on the self concept of the adolescents. The implications of these results for school counselling are exhaustively discussed and recommendations made. Key words: peer group counselling, sex, self-concept, counsellin

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

Perceived Benefits of Prenatal Exercise Among Pregnant Women Attending Antenatal Clinic at Federal Teaching Hospital, Abakaliki, Nigeria

This paper investigated the perceived benefits of prenatal exercise among pregnant women attending antenatal clinic at Federal Teaching Hospital Abakaliki, Ebonyi State. One research question and two hypotheses guided the study. Descriptive survey design was used, the population of the study was 7200 pregnant women while the sample for the study was 720 pregnant women attending antenatal clinic at Federal Hospital Abakaliki, Ebonyi State. A self-developed structured questionnaire was used as instrument for data collection. Mean and standard deviation was used to answer research question while ANOVA statistics were used to test the hypotheses at 0.05 level of significant. The study found that pregnant women attending antenatal clinic at Federal Teaching Hospital Abakaliki, Ebonyi State had positive perception on the benefit of prenatal exercise and that there are significant differences on the perception of benefit of prenatal exercise among pregnant women attending antenatal clinic at Federal Teaching Hospital Abakaliki, Ebonyi State based on age and level of education. It was recommended that Government, health educators and hospital management should organize continuing education programmes, seminars and workshop to promote prenatal exercise among pregnant women to actualize the perceived benefits of prenatal exercise in pregnancy. Keywords: Exercise, prenatal exercise, pregnant woman, perceived benefit