Innovative partnerships for Safe Motherhood::participation and transdisciplinary collaboration as tools towards increasing skilled birth attendance

Motherhood is far from safe in various contexts and settings. Maternal mortality is still unacceptably high, as World Health Organization (WHO) reports indicate. In 2017, around 295 000 women died during pregnancy, childbirth and puerperium. Many initiatives contribute to decreasing the number of maternal deaths, among which those stemming from the Millennium Development Goals and more recently, the Sustainable Development Goals. The new goal is that in 2030, less than 70 women die per 100.000 live births. However, especially in vulnerable populations, the decrease in maternal mortality is too slow to reach this target. Although clear international strategies exist, these are not effective in some contexts. One of the strategies to decrease maternal mortality, is giving birth in the presence of a skilled birth attendant (SBA). Unfortunately, diverse barriers to SBA utilization exist. The underlying causes are often complex and insufficiently researched. In this thesis, underutilization of SBAs is analyzed in two ways. In the first part, is described if interventions can increase skilled birth attendance through using the Birth Preparedness and Complication Readiness model (BPCR). In part two a local context in northern Tanzania is studied, where most women of the mainly Maasai population, give birth in the presence of a traditional birth attendant (TBA) instead of a SBA. This thesis endorses, through analysis of the BPCR model and a local context in northern Tanzania, the importance of: participatory evaluation of contexts in which skilled birth attendance is low, collaboration between all parties involved through co-creating context specific solutions and maternity care. Possibly this facilitates skilled birth attendance, but more certain this increases experiences quality of care and collaboration between maternity care providers, like TBAs and SBAs. The adaptive research approach made the research directly locally relevant. In the discussion I describe that context specific care is often a social innovation and inherently a challenging process. Challenges include: making context specific care measurable, sustainable within health systems, taking power dynamics within communities and health systems into account. It is essential, that those who hold power in (the organization of) maternity care, give way to wishes and needs of women, their families and of those who care for them, both TBAs and SBAs. The research in this thesis fits new definitions of implementation research, in which knowledge is represented in a trans disciplinary way. Insights from this thesis add, modestly, to how we can bridge the “know-do” gap between knowledge and practice. More specifically: how we can understand and counter underutilization of SBA: through participation and collaboration while respecting local expertise. I recommend continuing the co-creation in maternity care and as such contribute to maternity health, wellbeing and the decrease of maternal mortality globally

Innovative partnerships for Safe Motherhood:: participation and transdisciplinary collaboration as tools towards increasing skilled birth attendance

Motherhood is far from safe in various contexts and settings. Maternal mortality is still unacceptably high, as World Health Organization (WHO) reports indicate. In 2017, around 295 000 women died during pregnancy, childbirth and puerperium. Many initiatives contribute to decreasing the number of maternal deaths, among which those stemming from the Millennium Development Goals and more recently, the Sustainable Development Goals. The new goal is that in 2030, less than 70 women die per 100.000 live births. However, especially in vulnerable populations, the decrease in maternal mortality is too slow to reach this target. Although clear international strategies exist, these are not effective in some contexts. One of the strategies to decrease maternal mortality, is giving birth in the presence of a skilled birth attendant (SBA). Unfortunately, diverse barriers to SBA utilization exist. The underlying causes are often complex and insufficiently researched. In this thesis, underutilization of SBAs is analyzed in two ways. In the first part, is described if interventions can increase skilled birth attendance through using the Birth Preparedness and Complication Readiness model (BPCR). In part two a local context in northern Tanzania is studied, where most women of the mainly Maasai population, give birth in the presence of a traditional birth attendant (TBA) instead of a SBA. This thesis endorses, through analysis of the BPCR model and a local context in northern Tanzania, the importance of: participatory evaluation of contexts in which skilled birth attendance is low, collaboration between all parties involved through co-creating context specific solutions and maternity care. Possibly this facilitates skilled birth attendance, but more certain this increases experiences quality of care and collaboration between maternity care providers, like TBAs and SBAs. The adaptive research approach made the research directly locally relevant. In the discussion I describe that context specific care is often a social innovation and inherently a challenging process. Challenges include: making context specific care measurable, sustainable within health systems, taking power dynamics within communities and health systems into account. It is essential, that those who hold power in (the organization of) maternity care, give way to wishes and needs of women, their families and of those who care for them, both TBAs and SBAs. The research in this thesis fits new definitions of implementation research, in which knowledge is represented in a trans disciplinary way. Insights from this thesis add, modestly, to how we can bridge the “know-do” gap between knowledge and practice. More specifically: how we can understand and counter underutilization of SBA: through participation and collaboration while respecting local expertise. I recommend continuing the co-creation in maternity care and as such contribute to maternity health, wellbeing and the decrease of maternal mortality globally

A protocol for a systematic review of birth preparedness and complication readiness programs

BACKGROUND: One of the effective strategies for reducing the number of maternal deaths is delivery by a skilled birth attendant. Low utilization of skilled birth attendants has been attributed to delay in seeking care, delay in reaching a health facility and delay in receiving adequate care. Health workers could play a role in helping women prepare for birth and anticipate complications, in order to reduce delays. There is little evidence to support these birth preparedness and complication readiness (BP/CR) programs; however, BP/CR programs are frequently implemented. The objective of this review is to assess the effect of BP/CR programs on increasing skilled birth attendance in low-resource settings. METHODS: Due to the complexity of BP/CR programs and the need to understand why certain programs are more effective than others, we will combine both quantitative and qualitative studies in this systematic review. Search terms were selected with the assistance of a health information specialist. Three reviewers will independently select and assess studies for quality. Data will be extracted by one reviewer and checked for accuracy and completeness by a second reviewer. Discussion between the reviewers will resolve disagreements. If disagreements remain, a third party will be consulted. Data analysis will be carried out in accordance with the BP/CR matrix, developed by the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO). Study data will be grouped and analyzed by quality and study design and regrouped according to type of intervention strategy. DISCUSSION: This review will provide: 1) an insight into existing BP/CR programs, 2) recommendations on effective elements of the different approaches, 3) proposals for concrete action plans for health professionals in the field of reproductive health in resource-poor settings and 4) an overview of existing knowledge gaps requiring further research. TRIAL REGISTRATION: PROSPERO registration no.: CRD4201200312

Developing a Pictorial Sisterhood Method in collaboration with illiterate Maasai traditional birth attendants in northern Tanzania

Objective To study whether data on maternal mortality can be gathered while maintaining local ownership of data in a pastoralist setting where a scarcity of data sources and a culture of silence around maternal death amplifies limited awareness of the magnitude of maternal mortality. Methods As part of a participatory action research project, investigators and illiterate traditional birth attendants (TBAs) collaboratively developed a quantitative participatory tool—the Pictorial Sisterhood Method—that was pilot-tested between March 12 and May 30, 2011, by researchers and TBAs in a cross-sectional study. Results Fourteen TBAs interviewed 496 women (sample), which led to 2241 sister units of risk and a maternal mortality ratio of 689 deaths per 100 000 live births (95% confidence interval 419–959). Researchers interviewed 474 women (sample), leading to 1487 sister units of risk and a maternal mortality ratio of 484 (95% confidence interval 172–795). Conclusion The Pictorial Sisterhood Method is an innovative application that might increase the participation of illiterate individuals in maternal health research and advocacy. It offers interesting opportunities to increase maternal mortality data ownership and awareness, and warrants further study and validation

Impact of Birth Preparedness and Complication Readiness Interventions on Birth with a Skilled Attendant: A Systematic Review

<div><p>Background</p><p>Increased preparedness for birth and complications is an essential part of antenatal care and has the potential to increase birth with a skilled attendant. We conducted a systematic review of studies to assess the effect of birth preparedness and complication readiness interventions on increasing birth with a skilled attendant.</p><p>Methods</p><p>PubMed, Embase, CINAHL and grey literature were searched for studies from 2000 to 2012 using a broad range of search terms. Studies were included with diverse designs and intervention strategies that contained an element of birth preparedness and complication readiness. Data extracted included population, setting, study design, outcomes, intervention description, type of intervention strategy and funding sources. Quality of the studies was assessed. The studies varied in BP/CR interventions, design, use of control groups, data collection methods, and outcome measures. We therefore deemed meta-analysis was not appropriate and conducted a narrative synthesis of the findings.</p><p>Results</p><p>Thirty-three references encompassing 20 different intervention programmes were included, of which one programmatic element was birth preparedness and complication readiness. Implementation strategies were diverse and included facility-, community-, or home-based services. Thirteen studies resulted in an increase in birth with a skilled attendant or facility birth. The majority of authors reported an increase in knowledge on birth preparedness and complication readiness.</p><p>Conclusions</p><p>Birth Preparedness and Complication Readiness interventions can increase knowledge of preparations for birth and complications; however this does not always correspond to an increase in the use of a skilled attendant at birth.</p></div

Prisma Flow Diagram [22].

<p>Prisma Flow Diagram [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0143382#pone.0143382.ref022" target="_blank">22</a>].</p

BP/CR interventions aiming to increase use of EmOC: Relevant outcomes and characteristics per study.

<p>BP/CR interventions aiming to increase use of EmOC: Relevant outcomes and characteristics per study.</p

Study details for BP/CR interventions aiming to increase SBA in case of an emergency.

<p>Study details for BP/CR interventions aiming to increase SBA in case of an emergency.</p