Too poor to live? A case study of vulnerability and maternal mortality in Burkina Faso.

This paper examines the concept of vulnerability in the context of maternal morbidity and mortality in Burkina Faso, an impoverished country in West Africa. Drawing on a longitudinal cohort study into the consequences of life-threatening or 'near miss' obstetric complications, we provide an in-depth case study of one woman's experience of such morbidity and its aftermath. We follow Kalizeta's trajectory from her near miss and the stillbirth of her child to her death from pregnancy-related hypertension after a subsequent delivery less than two years later, in order to examine the impact of severe and persistent illness and catastrophic health expenditure on her health and on her family's everyday life. Kalizeta's case illustrates how vulnerability in health emerges and is maintained or exacerbated over time. Even where social arrangements are supportive, structural impediments, including unaffordable and inadequate healthcare, can severely limit individual resilience to mitigate the negative social and economic consequences of ill health

Quality of routine essential care during childbirth: clinical observations of uncomplicated births in Uttar Pradesh, India.

OBJECTIVE: To evaluate the quality of essential care during normal labour and childbirth in maternity facilities in Uttar Pradesh, India. METHODS: Between 26 May and 8 July 2015, we used clinical observations to assess care provision for 275 mother-neonate pairs at 26 hospitals. Data on 42 items of care were collected, summarized into 17 clinical practices and three aggregate scores and then weighted to obtain population-based estimates. We examined unadjusted differences in quality between the public and private facilities. Multilevel linear mixed-effects models were used to adjust for birth attendant, facility and maternal characteristics. FINDINGS: The quality of care we observed was generally poor in both private and public facilities; the mean percentage of essential clinical care practices completed for each woman was 35.7%. Weighted estimates indicate that unqualified personnel provided care for 73.0% and 27.0% of the mother-neonate pairs in public and private facilities, respectively. Obstetric, neonatal and overall care at birth appeared better in the private facilities than in the public ones. In the adjusted analysis, the score for overall quality of care in private facilities was found to be six percentage points higher than the corresponding score for public facilities. CONCLUSION: In 2015, the personnel providing labour and childbirth care in maternity facilities were often unqualified and adherence to care protocols was generally poor. Initiatives to measure and improve the quality of care during labour and childbirth need to be developed in the private and public facilities in Uttar Pradesh

Consequences of maternal morbidity on health-related functioning: a systematic scoping review.

OBJECTIVES: To assess the scope of the published literature on the consequences of maternal morbidity on health-related functioning at the global level and identify key substantive findings as well as research and methodological gaps. METHODS: We searched for articles published between 2005 and 2014 using Medline, Embase, Popline, CINAHL Plus and three regional bibliographic databases in January 2015. DESIGN: Systematic scoping review PRIMARY OUTCOME: Health-related functioning RESULTS: After screening 17 706 studies, 136 articles were identified for inclusion. While a substantial number of papers have documented mostly negative effects of morbidity on health-related functioning and well-being, the body of evidence is not spread evenly across conditions, domains or geographical regions. Over 60% of the studies focus on indirect conditions such as depression, diabetes and incontinence. Health-related functioning is often assessed by instruments designed for the general population including the 36-item Short Form or disease-specific tools. The functioning domains most frequently documented are physical and mental; studies that examined physical, mental, social, economic and specifically focused on marital, maternal and sexual functioning are rare. Only 16 studies were conducted in Africa. CONCLUSIONS: Many assessments have not been comprehensive and have paid little attention to important functioning domains for pregnant and postpartum women. The development of a comprehensive instrument specific to maternal health would greatly advance our understanding of burden of ill health associated with maternal morbidity and help set priorities. The lack of attention to consequences on functioning associated with the main direct obstetric complications is of particular concern. REVIEW REGISTRATION: CRD42015017774

Prevalence of symptoms of vaginal fi stula in 19 sub-Saharan Africa countries: a meta-analysis of national household survey data

Background Vaginal fi stula is a serious medical disorder characterised by an abnormal opening between the vagina and the bladder or rectum, which results in continuous leakage of urine or stool. The burden of this disorder in sub- Saharan Africa is uncertain. We estimated the lifetime and point prevalence of symptoms of vaginal fi stula in this region using national household surveys based on self-report of symptoms. Methods We considered all Demographic and Health Surveys (DHS) and Multiple Indicators Cluster Surveys (MICS) from sub-Saharan Africa and included data for women of reproductive age (15–49 years). We estimated lifetime prevalence and point prevalence of vaginal fi stula with use of Bayesian hierarchical meta-analysis. Findings We included 19 surveys in our analysis, including 262 100 respondents. Lifetime prevalence was 3·0 cases (95% credible interval 1·3–5·5) per 1000 women of reproductive age. After imputation of missing data, point prevalence was 1·0 case (0·3–2·4) per 1000 women of reproductive age. Ethiopia had the largest number of women who presently have symptoms of vaginal fi stula. Interpretation This study is the fi rst to estimate the burden of vaginal fi stula in 19 sub-Saharan Africa countries using nationally representative survey data. Point prevalence was slightly lower than previously estimated but these earlier estimates are within the prevalence’s credible intervals. Although vaginal fi stula is relatively rare, it is still too common in sub-Saharan Africa

An investigation into mistreatment of women during labour and childbirth in maternity care facilities in Uttar Pradesh, India: a mixed methods study.

OBJECTIVES: To investigate the nature and context of mistreatment during labour and childbirth at public and private sector maternity facilities in Uttar Pradesh, India. METHODS: This study analyses mixed-methods data obtained through systematic clinical observations and open-ended comments recorded by the observers to describe care provision for 275 mothers and their newborns at 26 hospitals in three districts of Uttar Pradesh from 26 May to 8 July 2015. We conducted a bivariate descriptive analysis of the quantitative data and used a thematic approach to analyse qualitative data. FINDINGS: All women in the study encountered at least one indicator of mistreatment. There was a high prevalence of not offering birthing position choice (92%) and routine manual exploration of the uterus (80%) in facilities in both sectors. Private sector facilities performed worse than the public sector for not allowing birth companions (p = 0.02) and for perineal shaving (p = < 0.001), whereas the public sector performed worse for not ensuring adequate privacy (p = < 0.001), not informing women prior to a vaginal examination (p = 0.01) and for physical violence (p = 0.04). Prepared comments by observers provide further contextual insights into the quantitative data, and additional themes of mistreatment, such as deficiencies in infection prevention, lack of analgesia for episiotomy, informal payments and poor hygiene standards at maternity facilities were identified. CONCLUSIONS: Mistreatment of women frequently occurs in both private and public sector facilities. This paper contributes to the literature on mistreatment of women during labour and childbirth at maternity facilities in India by articulating new constructs of overtreatment and under-treatment. There are five key implications of this study. First, a systematic and context-specific effort to measure mistreatment in public and private sector facilities in high burden states in India is required. Second, a training initiative to orient all maternity care personnel to the principles of respectful maternity care would be useful. Third, innovative mechanisms to improve accountability towards respectful maternity care are required. Fourth, participatory community and health system interventions to support respectful maternity care would be useful. Lastly, we note that there needs to be a long-term, sustained investment in health systems so that supportive and enabling work-environments are available to front- line health workers

Health of women after severe obstetric complications in Burkina Faso: a longitudinal study.

BACKGROUND: Little is known about the health of women who survive obstetric complications in poor countries. Our aim was to determine how severe obstetric complications in Burkina Faso affect a range of health, social, and economic indicators in the first year post partum. METHODS: We did a prospective cohort study of women with severe obstetric complications recruited in hospitals when their pregnancy ended with a livebirth (n=199), perinatal death (74), or a lost pregnancy (64). For every woman with severe obstetric complications, two unmatched control women with uncomplicated delivery were sampled in the same hospital (677). All women were followed up for 1 year. FINDINGS: Women with severe obstetric complications were poorer and less educated at baseline than were women with uncomplicated delivery. Women with severe obstetric complications, and their babies, were significantly more likely to die after discharge: six (2%) of the 337 women with severe obstetric complications died within 1 year, compared with none of the women with uncomplicated delivery (unadjusted p=0.001); 17 babies of women with severe obstetric complications died within 1 year, compared with 18 of those born by uncomplicated delivery (hazard ratio for mortality 4.67, 95% CI 1.68-13.04, adjusted for loss to follow-up and confounders; p=0.003). Women with severe obstetric complications were significantly more likely to have experienced depression and anxiety at 3 months (odds ratio 1.82, 95% CI 1.18-2.80), to have experienced suicidal thoughts within the past year at all time points (2.27, 1.33-3.89 at 3 months; 2.30, 1.17-4.50 at 6 months; 2.26, 1.30-3.95 at 12 months), and to report the pregnancy having had a negative effect on their lives at all time points (1.54, 1.04-2.30 at 3 months; 2.30, 1.56-3.39 at 6 months; 2.44, 1.63-3.65 at 12 months) than were women with uncomplicated delivery. INTERPRETATION: Women who give birth with severe obstetric complications are at greater risk of death and mental-health problems than are women with uncomplicated delivery. Greater resources are needed to ensure that these women receive adequate care before and after discharge from hospital

Experiences of women seeking care for abortion complications in health facilities: Secondary analysis of the WHO Multi-Country Survey on Abortion in 11 African countries.

OBJECTIVE: Despite evidence of acute and long-term consequences of suboptimal experiences of care, standardized measurements across countries remain limited, particularly for postabortion care. We aimed to determine the proportion of women reporting negative experiences of care for abortion complications, identify risk factors, and assess the potential association with complication severity. METHODS: Data were sourced from the WHO Multi-Country Survey on Abortion for women who received facility-based care for abortion complications in 11 African countries. We measured women\u27s experiences of care with eight questions from an audio computer-assisted self-interview related to respect, communication, and support. Multivariable generalized estimating equations were used for analysis. RESULTS: There were 2918 women in the study sample and 1821 (62%) reported at least one negative experience of postabortion care. Participants who were aged under 30 years, single, of low socioeconomic status, and economically dependent had higher odds of negative experiences. Living in West or Central Africa, rather than East Africa, was also associated with reportedly worse care. The influence of complication severity on experience of care appeared significant, such that women with moderate and severe complications had 12% and 40% higher odds of reporting negative experiences, respectively. CONCLUSION: There were widespread reports of negative experiences of care among women receiving treatment for abortion complications in health facilities. Our findings contribute to the scant understanding of the risk factors for negative experiences of postabortion care and highlight the need to address harmful provider biases and behaviors, alleviate health system constraints, and empower women in demanding better care

Ambient temperature during pregnancy and risk of maternal hypertensive disorders: A time-to-event study in Johannesburg, South Africa

Hypertensive disorders in pregnancy are a leading cause of maternal and perinatal mortality and morbidity. We evaluate the effects of ambient temperature on risk of maternal hypertensive disorders throughout pregnancy. We used birth register data for all singleton births (22–43 weeks\u27 gestation) recorded at a tertiary-level hospital in Johannesburg, South Africa, between July 2017–June 2018. Time-to-event analysis was combined with distributed lag non-linear models to examine the effects of mean weekly temperature, from conception to birth, on risk of (i) high blood pressure, hypertension, or gestational hypertension, and (ii) pre-eclampsia, eclampsia, or HELLP (hemolysis, elevated liver enzymes, low platelets). Low and high temperatures were defined as the 5th and 95th percentiles of daily mean temperature, respectively. Of 7986 women included, 844 (10.6%) had a hypertensive disorder of which 432 (51.2%) had high blood pressure/hypertension/gestational hypertension and 412 (48.8%) had pre-eclampsia/eclampsia/HELLP. High temperature in early pregnancy was associated with an increased risk of pre-eclampsia/eclampsia/HELLP. High temperature (23 °C vs 18 °C) in the third and fourth weeks of pregnancy posed the greatest risk, with hazard ratios of 1.76 (95% CI 1.12–2.78) and 1.79 (95% CI 1.19–2.71), respectively. Whereas, high temperatures in mid-late pregnancy tended to protect against pre-eclampsia/eclampsia/HELLP. Low temperature (11°) during the third trimester (from 29 weeks’ gestation) was associated with an increased risk of high blood pressure/hypertension/gestational hypertension, however the strength and statistical significance of low temperature effects were reduced with model adjustments. Our findings support the hypothesis that high temperatures in early pregnancy increase risk of severe hypertensive disorders, likely through an effect on placental development. This highlights the need for greater awareness around the impacts of moderately high temperatures in early pregnancy through targeted advice, and for increased monitoring of pregnant women who conceive during periods of hot weather

Fistula in sub-Saharan Africa – Authors' reply

info:eu-repo/semantics/publishe