Preventing and reducing violence against women: innovation in community-level studies

Intimate partner violence is a serious global problem that damages the health and prosperity of individuals, their families, community, and society. WHO endorses an ‘ecological model,’ which states that there are multi-level intersecting factors enabling perpetration and victimization of violence. Intervention science to prevent or reduce the problem is in its infancy, and the few existing intervention studies have been targeted at the individual level. In a recent study published in BMC Medicine, Abramsky et al. bring innovation to the field, targeting their intervention trial “SASA!” in Kampala Uganda at all ecological levels, but particularly at the community level. Recruiting and training both male and female community leaders and activists who enabled group and media discussions, the authors focused on the beneficial and abusive detrimental uses of power rather than commencing with the central issue of gender inequality. SASA! successfully reduced community attitudes to tolerance of violence and inequality, men’s sexual risk behaviors, and women’s experience of physical violence. The study also improved the communities’ response to victimized women. SASA! has promise for adaptation and replication in low, middle and high income countries. Please see related article: http://www.biomedcentral.com/1741-7015/12/122

The power of social connection and support in improving health: lessons from social support interventions with childbearing women

<p>Abstract</p> <p>Background and objective</p> <p>Social support interventions have a somewhat chequered history. Despite evidence that social connection is associated with good health, efforts to implement interventions designed to increase social support have produced mixed results. The aim of this paper is to reflect on the relationship between social connectedness and good health, by examining social support interventions with mothers of young children and analysing how support was conceptualised, enacted and valued, in order to advance what we know about providing support to improve health.</p> <p>Context and approach</p> <p>First, we provide a brief recent history of social support interventions for mothers with young children and we critically examine what was intended by ‘social support’, who provided it and for which groups of mothers, how support was enacted and what was valued by women. Second, we examine the challenges and promise of lay social support approaches focused explicitly on companionship, and draw on experiences in two cluster randomised trials which aimed to improve the wellbeing of mothers. One trial involved a universal approach, providing befriending opportunities for all mothers in the first year after birth, and the other a targeted approach offering support from a ‘mentor mother’ to childbearing women experiencing intimate partner violence.</p> <p>Results</p> <p>Interventions providing social support to mothers have most often been directed to women seen as disadvantaged, or ‘at risk’. They have also most often been enacted by health professionals and have included strong elements of health education and/or information, almost always with a focus on improving parenting skills for better child health outcomes. Fewer have involved non-professional ‘supporters’, and only some have aimed explicitly to provide companionship or a listening ear, despite these aspects being what mothers receiving support have said they valued most. Our trial experiences have demonstrated that non-professional support interventions raise myriad challenges. These include achieving adequate reach in a universal approach, identification of those in need of support in any targeted approach; how much training and support to offer befrienders/mentors without ‘professionalising’ the support provided; questions about the length of time support is offered, how ‘closure’ is managed and whether interventions impact on social connectedness into the future. In our two trials what women described as helpful was not feeling so alone, being understood, not being judged, and feeling an increased sense of their own worth.</p> <p>Conclusion and implications</p> <p>Examination of how social support has been conceptualised and enacted in interventions to date can be instructive in refining our thinking about the directions to be taken in future research. Despite implementation challenges, further development and evaluation of non-professional models of providing support to improve health is warranted.</p

Recovery after caesarean birth: a qualitative study of women's accounts in Victoria, Australia

<p>Abstract</p> <p>Background</p> <p>The caesarean section rate is increasing globally, especially in high income countries. The reasons for this continue to create wide debate. There is good epidemiological evidence on the maternal morbidity associated with caesarean section. Few studies have used women's personal accounts of their experiences of recovery after caesarean. The aim of this paper is to describe women's accounts of recovery after caesarean birth, from shortly after hospital discharge to between five months and seven years after surgery.</p> <p>Method</p> <p>Women who had at least one caesarean birth in a tertiary hospital in Victoria, Australia, participated in an interview study. Women were selected to ensure diversity in experiences (type of caesarean, recency), caesarean and vaginal birth, and maternal request caesarean section. Interviews were audiotaped and transcribed verbatim. A theoretical framework was developed (three Zones of clinical practice) and thematic analysis informed the findings.</p> <p>Results</p> <p>Thirty-two women were interviewed who between them had 68 births; seven women had experienced both caesarean and vaginal births. Three zones of clinical practice were identified in women's descriptions of the reasons for their first caesareans. Twelve women described how, at the time of their first caesarean section, the operation was performed for potentially life-saving reasons (Central Zone), 11 described situations of clinical uncertainty (Grey Zone), and nine stated they actively sought surgical intervention (Peripheral Zone).</p> <p>Thirty of the 32 women described difficulties following the postoperative advice they received prior to hospital discharge and their physical recovery after caesarean was hindered by a range of health issues, including pain and reduced mobility, abdominal wound problems, infection, vaginal bleeding and urinary incontinence. These problems were experienced across the three zones of clinical practice, regardless of the reasons women gave for their caesarean.</p> <p>Conclusion</p> <p>The women in this study reported a range of unanticipated and unwanted negative physical health outcomes following caesarean birth. This qualitative study adds to the existing epidemiological evidence of significant maternal morbidity after caesarean section and underlines the need for caesarean section to be reserved for circumstances where the benefit is known to outweigh the harms.</p

‘Essential but not always available when needed’ – an interview study of physicians’ experiences and views regarding use of obstetric ultrasound in Tanzania

Background The value of obstetric ultrasound in high-income countries has been extensively explored but evidence is still lacking regarding the role of obstetric ultrasound in low-income countries. Objective We aimed to explore experiences and views among physicians working in obstetric care in Tanzania, on the role of obstetric ultrasound in relation to clinical management. Design A qualitative study design was applied. Data were collected in 2015, through 16 individual interviews with physicians practicing in obstetric care at hospitals in an urban setting in Tanzania. Data were analyzed using qualitative content analysis. Results Use of obstetric ultrasound in the management of complicated pregnancy was much appreciated by participating physicians, although they expressed considerable concern about the lack of ultrasound equipment and staff able to conduct the examinations. These limitations were recognized as restricting physicians’ ability to manage complications adequately during pregnancy and birth. Better availability of ultrasound was requested to improve obstetric management. Concerns were also raised regarding pregnant women\u27s lack of knowledge and understanding of medical issues which could make counseling in relation to obstetric ultrasound difficult. Although the physicians perceived a positive attitude toward ultrasound among most pregnant women, occasionally they came across women who feared that ultrasound might harm the fetus. Conclusions There seems to be a need to provide more physicians in antenatal care in Tanzania with ultrasound training to enable them to conduct obstetric ultrasound examinations and interpret the results themselves. Physicians also need to acquire adequate counseling skills as counseling can be especially challenging in this setting where many expectant parents have low levels of education. Providers of obstetric care and policy makers in Tanzania will need to take measures to ensure appropriate use of the scarce resources in the Tanzanian health care system and prevent the potential risk of overuse of ultrasound in pregnancy

Exploring the views and experiences of callers to the PANDA Post and Antenatal Depression Association Australian National Perinatal Depression Helpline: A cross-sectional survey

Background Anxiety and depression are common in the perinatal period. Telephone interventions, including telephone peer support and counselling, have been developed to support those experiencing perinatal mental illness. PANDA Post and Antenatal Depression Association provides support to women and men experiencing perinatal mental illness via the Australian National Perinatal Depression Helpline, encompassing both volunteer peer support and professional counselling. This study aimed to explore the experiences of callers to the Helpline. Methods A cross-sectional survey design was used. All new callers from 1st May to 30th September 2013 were invited to participate. The survey, adapted from a previous survey of PANDA callers, included 23 questions using Likert-type scales, demographic and open-ended questions. Thematic network analysis was undertaken for responses to open-ended questions. Results 124 responses were received (124/405; 30 % response). The majority of callers had called the Helpline regarding themselves (90 %), with over one third (33 %) of all callers seeking crisis support and help. Ninety-nine per cent of respondents ‘agreed’ or ‘strongly agreed’ that staff and/or volunteers understood their concerns, and 97 % ‘agreed’ or ‘strongly agreed’ that overall PANDA had helped them. Callers described the PANDA service as uniquely tailored to the perinatal period, providing accessible, non-judgemental understanding and support, with a global theme from open-ended comments describing PANDA as ‘a safe space to be heard and receive support without judgement’. Recommendations for service changes included increased hours of availability. Conclusions Callers reported positive experiences of accessing support from the PANDA National Perinatal Depression Helpline. The Helpline was described as an accessible and acceptable telephone support for individuals experiencing perinatal mental illness. Recommendations for changes to the service included an increase in hours of operation to enable greater responsiveness at times of need, reduced waiting times, and access to continuity with the same volunteer and/or telephone counsellor. The findings of the study will be useful in informing future service provision, review, and implementation

Midwife-led debriefing after operative birth: four to six year follow-up of a randomised trial [ISRCTN24648614]

BACKGROUND: There is little evidence that single-session debriefing is effective in reducing adverse mental health outcomes after trauma. Few trials have included long-term follow-up, but two also suggest possible negative effects of debriefing. We aimed to assess longer-term maternal health outcomes in a trial of midwife-led debriefing following an operative birth, given that findings at six months could not rule out a possible adverse effect of debriefing. METHODS: Four to six years after participating in a midwife-led trial of debriefing following an operative birth, 1039/1041 women were mailed a questionnaire containing the Edinburgh Postnatal Depression Scale (EPDS) and the SF-36 health status measure. RESULTS: Responses were obtained from 534 women (51.4%). Responders from the two trial groups remained comparable 4–6 years postpartum. No significant differences on maternal health outcomes were found between the trial groups. CONCLUSION: In the longer term, maternal health status was neither positively nor adversely affected by the experience of debriefing, despite a hint of adverse effects at six months postpartum. Short debriefing interventions have not proven effective in improving mental health outcomes for women following childbirth

Health professionals\u27 experiences and views on obstetric ultrasound in Vietnam: a regional, cross-sectional study

Objectives: Obstetric ultrasound is an important part of antenatal care in Vietnam, although there are great differences in access to antenatal care and ultrasound services across the country. The aim of this study was to explore Vietnamese health professionals\u27 experiences and views of obstetric ultrasound in relation to clinical management, resources and skills. Design: A cross-sectional questionnaire study was performed as part of the CROss Country UltraSound study. Setting: Health facilities (n=29) in urban, semiurban and rural areas of Hanoi region in Vietnam. Participants: Participants were 289 obstetricians/gynaecologists and 535 midwives. Results: A majority (88%) of participants agreed that \u27every woman should undergo ultrasound examination\u27 during pregnancy to determine gestational age. Participants reported an average of six ultrasound examinations as medically indicated during an uncomplicated pregnancy. Access to ultrasound at participants\u27 workplaces was reported as always available regardless of health facility level. Most participants performing ultrasound reported high-level skills for fetal heart rate examination (70%), whereas few (23%) reported being skilled in examination of the anatomy of the fetal heart. Insufficient ultrasound training leading to suboptimal pregnancy management was reported by 37% of all participants. \u27Better quality of ultrasound machines\u27, \u27more physicians trained in ultrasound\u27 and \u27more training for health professionals currently performing ultrasound\u27 were reported as ways to improve the utilisation of ultrasound. Conclusions: Obstetric ultrasound is used as an integral part of antenatal care at all selected health facility levels in the region of Hanoi, and access was reported as high. However, reports of insufficient ultrasound training resulting in suboptimal pregnancy management indicate a need for additional training of ultrasound operators to improve utilisation of ultrasound

Maternal health care professionals’ experiences and views on the use of obstetric ultrasound in Rwanda: A cross-sectional study

Background This study, undertaken in Rwanda, aimed to investigate health professionals’ experiences and views on the following topics: current clinical guidelines for ultrasound from second trimester at the clinic, regional and national levels, and adherence to clinical guidelines; medically indicated ultrasound examinations; non-medical use of ultrasound including ultrasounds on maternal request; commercialisation of ultrasound; the value of ultrasound in relation to other clinical examinations in pregnancy; and ultrasound and medicalisation of pregnancy. Methods A cross-sectional design was adopted. Health professionals providing antenatal care and delivery services to pregnant women in 108 health facilities were invited to complete a survey, which was developed based on the results of earlier qualitative studies undertaken as part of the CROss Country Ultrasound Study (CROCUS). Results Nine hundred and seven health professionals participated: obstetricians/gynecologists (3.2%,) other physicians (24.5%), midwives (29.7%) and nurses (42.7%). Few physicians reported the existence of clinical guidelines at clinic, regional or national levels in Rwanda, and guidelines were moderately adhered to. Three obstetric ultrasound examinations were considered medically indicated in an uncomplicated pregnancy. Most participants (73.0%) were positive about obstetric ultrasound examinations on maternal request. Commercialisation was not considered a problem, and the majority (88.5%) agreed that ultrasound had contributed to medicalisation of pregnancy. Conclusions Findings indicate that clinical guidelines for the use of obstetric ultrasound are limited in Rwanda. Non-medically indicated obstetric ultrasound was not considered a current problem at any level of the healthcare system. The positive attitude to obstetric ultrasound examinations on maternal request may contribute to further burden on a maternal health care system with limited resources. It is essential that limited obstetric ultrasound resources are allocated where they are most beneficial, and clearly stated medical indications would likely facilitate this

Ringing up about breastfeeding: a randomised controlled trial exploring early telephone peer support for breastfeeding (RUBY) - trial protocol

BACKGROUND: The risks of not breastfeeding for mother and infant are well established, yet in Australia, although most women initiate breastfeeding many discontinue breastfeeding altogether and few women exclusively breastfeed to six months as recommended by the World Health Organization and Australian health authorities. We aim to determine whether proactive telephone peer support during the postnatal period increases the proportion of infants who are breastfed at six months, replicating a trial previously found to be effective in Canada. DESIGN/METHODS: A two arm randomised controlled trial will be conducted, recruiting primiparous women who have recently given birth to a live baby, are proficient in English and are breastfeeding or intending to breastfeed. Women will be recruited in the postnatal wards of three hospitals in Melbourne, Australia and will be randomised to peer support or to 'usual' care. All women recruited to the trial will receive usual hospital postnatal care and infant feeding support. For the intervention group, peers will make two telephone calls within the first ten days postpartum, then weekly telephone calls until week twelve, with continued contact until six months postpartum. Primary aim: to determine whether postnatal telephone peer support increases the proportion of infants who are breastfed for at least six months. HYPOTHESIS: that telephone peer support in the postnatal period will increase the proportion of infants receiving any breast milk at six months by 10% compared with usual care (from 46% to 56%).Outcome data will be analysed by intention to treat. A supplementary multivariate analysis will be undertaken if there are any baseline differences in the characteristics of women in the two groups which might be associated with the primary outcomes. DISCUSSION: The costs and health burdens of not breastfeeding fall disproportionately and increasingly on disadvantaged groups. We have therefore deliberately chosen trial sites which have a high proportion of women from disadvantaged backgrounds. This will be the first Australian randomised controlled trial to test the effectiveness and cost effectiveness of proactive peer telephone support for breastfeeding. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12612001024831

Supporting breastfeeding In Local Communities (SILC) in Victoria, Australia : A cluster randomised controlled trial

Objectives: Breastfeeding has significant health benefits for mothers and infants. Despite recommendations from the WHO, by 6 months of age 40% of Australian infants are receiving no breast milk. Increased early postpartum breastfeeding support may improve breastfeeding maintenance. 2 community-based interventions to increase breastfeeding duration in local government areas (LGAs) in Victoria, Australia, were implemented and evaluated. Design: 3-arm cluster randomised trial. Setting: LGAs in Victoria, Australia. Participants: LGAs across Victoria with breastfeeding initiation rates below the state average and > 450 births/year were eligible for inclusion. The LGA was the unit of randomisation, and maternal and child health centres in the LGAs comprised the clusters. Interventions: Early home-based breastfeeding support by a maternal and child health nurse (home visit, HV) with or without access to a community-based breastfeeding drop-in centre (HV+drop-in). Main outcome measures: The proportion of infants receiving 'any' breast milk at 3, 4 and 6 months (women's self-report). Findings: 4 LGAs were randomised to the comparison arm and provided usual care (n=41 clusters; n=2414 women); 3 to HV (n=32 clusters; n=2281 women); and 3 to HV+drop-in (n=26 clusters; 2344 women). There was no difference in breastfeeding at 4 months in either HV (adjusted OR 1.04; 95% CI 0.84 to 1.29) or HV+drop-in (adjusted OR 0.92; 95% CI 0.78 to 1.08) compared with the comparison arm, no difference at 3 or 6 months, nor in any LGA in breastfeeding before and after the intervention. Some issues were experienced with intervention protocol fidelity. Conclusions: Early home-based and community-based support proved difficult to implement. Interventions to increase breastfeeding in complex community settings require sufficient time and partnership building for successful implementation. We cannot conclude that additional community-based support is ineffective in improving breastfeeding maintenance given the level of adherence to the planned protocol. Trial registration number: ACTRN12611000898954; Results