Incentivizing (and disincentivizing) mothers to utilize maternal health services: A focus group study

@#BACKGROUND: In ensuring access to maternal health services, various strategies toward safer health practices and improved health service delivery are important ingredients to eliminate avoidable maternal deaths. A recent household survey showed that access to antenatal care (ANC) (89%) and facility-based delivery (FBD) (82.4%) in the Eastern Visayas region is significantly high, despite the extensive damage to over 500 health facilities caused by Typhoon Haiyan in November 2013. Postpartum care (PPC), however, was relatively low (37.4%). As these findings needed further elaboration, a qualitative study using focus groups was conducted. METHOD: The focus groups method was utilized to elicit responses from the mothers, BHWs, and midwives to explain what contributed to the high ANC visits, high FBD, and low PPC. Sixteen focus groups were conducted in the local dialect (Waray and Cebuano), and all discussions were audio recorded. Focus groups data were transcribed and subsequently translated to English text, then reviewed and validated by socio-linguistic academics from the region. Other data sources included debriefing session reports and expanded field notes. Nvivo 10 software was used in the coding process and data management. The data analysis referred to the principles of thematic analysis. RESULTS: The findings showed that incentives in the form of free maternal services and cash grants drive mothers to go to the health facility for antenatal care and facility-based deliveries. The free services were provided by PhilHealth (the country's social health insurance), while cash grants were awarded through the government's conditional cash transfer program and other community partners. Mothers were provided with some financial risk protection through these financial incentives. The disincentives came in the form of local ordinances, which prohibited home births. Penalties included fines for both mother and birth attendant when the mother was found to deliver outside the health facility. The unintended stigma, shame, and fear that developed in response to these ordinances also deterred home births. The significantly low use of PPC services in the health facility was attributed to the lack of advices given to mothers regarding the need for follow up care after delivery. It is also noted that there are no incentives for PPC, which may contribute to its low rates. The role of the community health workers and midwives were to inform and educate the mothers on these incentives and disincentives. However, these incentives and disincentives are extrinsic motivators and are deemed insufficient to provide long-term impact. CONCLUSION AND RECOMMENDATIONS. The implementation of the incentives and disincentives in Eastern Visayas has increased rates of ANC and FBD. The presence of these in the current environment has initially facilitated behavior change, shifting home births to facility births. However, we argue that financial incentives, with a lack of intrinsic motivation, may be insufficient to sustain long-term impact. Disincentives, in the form of local ordinances, forced mothers instead to seek care in facilities. Such an approach may eventually become less effective over time. Incentives and disincentives are both demand-side factors, and to sustain change, concurrent improvements in the supply end need to be implemented. The capacity of facilities to absorb the increased demand should be in place to provide positive experiences for mothers in the health facilities.

Extreme Maternal Morbidity: a tracer event to improve the quality of obstetric care in Latin America / Morbilidad Materna Extrema: evento trazador para mejorar la calidad de la atención obstétrica en América Latina

Abstract This article reviews critical aspects that have had an impact on the implementation of epidemiological surveillance of extreme maternal morbidity, as a tracer event of quality maternal care at population and institutional level; taking into account that maternal mortality has been usually monitored, and its analysis allows interventions to avoid maternal death. Until 2015, very few countries had been able to meet the goals established in the Millennium Development Goals (MDGs), especially MDG 5 - improving maternal health. As of today, it is observed that maternal mortality rate is quite heterogeneous, with rates from 1 case per 100,000 live births in developed countries, to more than 100 cases per 100,000 live births in developing countries. Therefore, complementary strategies such as surveillance of the extreme maternal morbidity could offer a more effective alternative to identify and implement interventions that allow us to prevent mortality and strengthen the quality of obstetric care. In addition, the importance of extreme maternal morbidity as a quality tracer event is that, unlike what is observed with maternal mortality, this is an event that occurs more frequently, is anticipatory of death, and the surviving pregnant woman is the primary source of information.

Resumen Este artículo revisa aspectos críticos que han tenido incidencia en la implementación de la vigilancia epidemiológica de la morbilidad materna extrema, como un evento trazador de calidad del cuidado materno a nivel poblacional e institucional, ya que usualmente se ha monitoreado la mortalidad materna y su análisis permite realizar intervenciones para evitar la muerte materna. Para el año 2015, muy pocos países lograron cumplir las metas establecidas en los Objetivos de Desarrollo del Milenio (ODM), especialmente el ODM 5- mejorar la salud materna. Al día de hoy se observa que la tasa de mortalidad materna es bastante heterogénea con tasas desde 1 caso por 100,000 nacidos vivos en países desarrollados, hasta más de 100 casos por cada 100,000 nacidos vivos en países en vía de desarrollo. Por lo tanto, estrategias complementarias como la vigilancia de la mortalidad materna extrema podrían ofrecer una alternativa más eficaz para identificar e implementar intervenciones que nos permitan prevenir la mortalidad y fortalecer la calidad de atención obstétrica, a partir de información más confiable y sin esperar que ocurra una muerte materna.

Ropivacaine use in transnasal sphenopalatine ganglion block for post dural puncture headache in obstetric patients - case series / Uso de ropivacaína em bloqueio do gânglio esfenopalatino via transnasal para cefaleia pós-punção dural em pacientes obstétricas - série de casos

Abstract Purpose Sphenopalatine ganglion block is widely accepted in chronic pain; however it has been underestimated in post dural puncture headache treatment. The ganglion block does not restore normal cerebrospinal fluid dynamics but effectively reduces symptoms associated with resultant hypotension. When correctly applied it may avoid performance of epidural blood patch. The transnasal approach is a simple and minimally invasive technique. In the cases presented, we attempted to perform and report the ganglion block effectiveness and duration, using ropivacaine. Clinical features We present four obstetrics patients with post dural puncture headache, after epidural or combined techniques, with Tuohy needle 18G that underwent a safe and successful sphenopalatine ganglion block. We performed the block 24-48 h after dural puncture, with 4 mL of ropivacaine 0.75% in each nostril. In three cases pain recurred within 12-48 h, although less intense. In one patient a second block was performed with complete relief and without further recurrence. In the other two patients a blood patch was performed without success. All patients were asymptomatic within 7 days. Conclusion The average duration of analgesic effect of the block remains poorly defined. In the cases reported, blocking with ropivacaine was a simple, safe and effective technique, with immediate and sustained pain relief for at least 12-24 h.

Resumo Justificativa e objetivo O bloqueio do gânglio esfenopalatino é amplamente aceito em dor crônica; porém, esse bloqueio tem sido subestimado no tratamento de cefaleia pós-punção dural. O bloqueio do gânglio não restaura a dinâmica normal do líquido cefalorraquidiano, mas reduz de modo eficaz os sintomas associados à hipotensão resultante. Quando aplicado corretamente, pode evitar a realização de tampão sanguíneo epidural. A abordagem transnasal é uma técnica simples e minimamente invasiva. Nos casos apresentados, tentamos realizar o bloqueio do gânglio e relatar sua eficácia e duração usando ropivacaína. Características clínicas Apresentamos quatro pacientes de obstetrícia com cefaleia pós-punção dural, após técnica epidural ou técnicas combinadas, com agulha Tuohy (18 G), que foram submetidas ao bloqueio do gânglio esfenopalatino de forma segura e bem-sucedida. Realizamos o bloqueio após 24 a 48 horas da punção dural, com 4 mL de ropivacaína a 0,75% em cada narina. Em três casos, a dor voltou em 1-48 horas, embora menos intensa. Em uma paciente, um segundo bloqueio foi realizado com alívio completo e sem recorrência. Nas outras duas pacientes, um tampão sanguíneo foi feito sem sucesso. Todas as pacientes estavam assintomáticas dentro de sete dias. Conclusão A duração média do efeito analgésico do bloqueio continua mal definida. Nos casos relatados, o bloqueio com ropivacaína foi uma técnica simples, segura e eficaz, com alívio imediato e prolongado da dor durante pelo menos 12-24 horas.

Postpartum and Newborn Care - A Qualitative study

Community-based postpartum care of mothers and newborns is vital to achieve mortality reduction. This qualitative study explored cultural beliefs and practices regarding postpartum care of mothers and newborns in rural Karnataka. Focus group discussions with newly delivered mothers and their caregivers in a rural maternity hospital, and in-depth interviews with community level health workers revealed cessation of the practice of withholding colostrum and the barbaric practice of branding, but found persisting harmful cultural beliefs and practices like withholding nutritious foods considered “hot” or “cold”, inadequate postpartum ambulation, separating husband and wife for up to a year or more after the birth, application of various substances to the umbilical stump and eyes of the newborn and giving pre-lacteal feeds. Antenatal and postpartum mothers, their caregivers, including elders in the family should be targeted by community level health workers for counseling and behavior change.

Factors Influencing Health Promoting Behavior in Postpartum Women at Sanhujoriwon

PURPOSE: The purpose of this study was to identify degrees of mood states, perceived health status, social support, and health promoting behavior, and to explore factors influencing health promoting behavior in postpartum women who were at Sanhujoriwon. METHODS: A cross-sectional survey design was used. Data were collected using questionnaires from 197 postpartum women who were at Sanhujoriwon from May 28 to June 18, 2015. Data were analyzed using descriptive statistics, Pearson's correlation analyses, and a multiple linear regression. RESULTS: The mean age of the participants was 31.8 years. About a half (47.2%) participants had a plan to receive 2 weeks of Sanhujoriwon care service. The mean health promoting behavior score was 123.5 ranged from 72 to 171. The health promoting behavior was explained by perceived health status (β=.25) and social support (β=.24). These factors accounted for 14% of the health promoting behavior. CONCLUSION: The findings of this study reveal an important role of perceived health status, social support in health promoting behavior of postpartum women at Sanhujoriwon.

An Analysis on the Determinants and Equity of the Postpartum Care Service Utilization / 보건행정학회지

BACKGROUND: This study aimed to analyze effects of postpartum care services to women after birth, identify the factors affecting their use, and examine the extent of income-related inequality in the postpartum care services utilization and expenditures using Korean Health Panel data between 2010 and 2013. METHODS: The panel data of the year 2010–2013 of the 247 women after birth were used. First, EuroQoL-5D was used to evaluate the effects of postpartum care service to women's quality of life. Second, multinominal logistic regression analysis was used to identify determinants of the use of the postpartum care services. Finally, concentration index and HIwv (horizontal equity) index were used to find that the concentration index for the inequality in the use of postpartum care services showed negative sign, which implied pro-rich. RESULTS: The estimation results showed that utilization of the postpartum services has a positive effect on women after birth. Also age, area of residence, and number of household members turn out to be the factors of using postpartum services. And there are inequality in the use of postpartum care services whose HIwv index showed positive sign, which implied pro-rich. CONCLUSION: Therefore, the government's policy of the postpartum care service is necessary to be expanded and diversified considering the personal characteristics and equity of the women after birth.

Study on service demands towards Institute of Postpartum Care / 中国实用护理杂志

Objective To investigate the maternal attitude and demands for Institute of Postpartum Care in order to provide targeted services.Methods 285 women were a investigated about maternal attitude and demands towards Institute of Postpartum Care with self-designed questionnaire.Results 97.9％ (279/285) women thought sitting the month (puerperal period) was very important,50.2％ (143/285)women were interested in Institute of Postpartum Care.They thought the main three advantages were energy saving,medical expertise and technology and avoidance of family conflicts;The three major issues were high price,lack of monitoring mechanism and unfamiliar environment and less family company;33 items of services demands over four points accounted for 78.6％,the three modules with highest scores were cleaning services scored 4.64±0.47,newborn services scored 4.45±0.41,consultation service scored 4.41:±0.53.Conclusions Professional postnatal care services have been a trend and social need,and a large proportion of women have great interest and demand on Institute of Postpartum Care which should make full use of its concentrate resources,and provide specific services according to maternal demands for services.It is urgent to build unified service standards and evaluation indicators to improve service quality.

Postnatal Urinary Incontinence: Prevalence and Factors Associated with It in a Malaysian Population

The aim of this study was to investigate the prevalence of postnatal urinary incontinence (PNUI), the risk factors associated with it and postnatal women’s (PN) level of engagement in practicing traditional Malay confinement care (TMCC) in Kelantan, Malaysia. A cross-sectional survey was conducted among 362 postnatal women aged between 18 – 45 years and who were between three to five months post-delivery. Participants were selected through convenience sampling at six Maternal and Child Health Clinics located in comparatively similar districts. Descriptive and inferential analyses including, factor analysis, Pearson chi-square, Mann-Whitney U test and logistic regressions analysis were used for data analysis. Overall, PNUI was reported by 80 women (22.1%). Vaginal delivery was associated with PNUI. All PN women within the study context practiced TMCC. The findings revealed that women who had PNUI were more likely to engage in a higher level of the ‘Body care’ component of TMCC. UI is prevalent among PN women in Kelantan, Malaysia. Further research into the impact of the ‘body care’ component of TMCC on PNUI is required.

Development of Infection Control Guideline for Postpartum Care Centers / 병원감염관리

BACKGROUND: This study aimed to develop feasible and detailed infection control guidelines (ICG) and audit protocols for health care workers and auditors in postpartum care centers (PCC). METHODS: PCC ICG and audit protocols were developed in several steps: 1) review of previous ICG for PCCs; 2) establishment of frameworks for updating guidelines and audit protocols; 3) review of new ICG, regulations, etc.; 4) drafting of PCC ICG and audit protocols and revision based on feedback from the research committee; 5) Delphi survey to solicit opinions from infection control, infant care, and maternal care professionals as well as PCC health care workers; 6) re-revision after discussion with the research committee; and 7) finalization of PCC ICG and audit protocols. RESULTS: We developed ICG with 4 categories and 26 sub-categories, and internal and external audit protocols with 163 and 85 items, respectively. CONCLUSION: The ICG and audit protocols are valid and feasible; we recommend their utilization as auditing tools, baseline data for the development of national infection control policies, and as educational materials for PCC healthcare workers.

Early Postpartum Maternal Morbidity among Rural Women of Rajasthan, India: A Community-based Study.

The first postpartum week is a high-risk period for mothers and newborns. Very few community-based studies have been conducted on patterns of maternal morbidity in resource-poor countries in that first week. An intervention on postpartum care for women within the first week after delivery was initiated in a rural area of Rajasthan, India. The intervention included a rigorous system of receiving reports of all deliveries in a defined population and providing home-level postpartum care to all women, irrespective of the place of delivery. Trained nurse-midwives used a structured checklist for detecting and managing maternal and neonatal conditions during postpartum-care visits. A total of 4,975 women, representing 87.1% of all expected deliveries in a population of 58,000, were examined in their first postpartum week during January 2007– December 2010. Haemoglobin was tested for 77.1% of women (n=3,836) who had a postnatal visit. The most common morbidity was postpartum anaemia—7.4% of women suffered from severe anaemia and 46% from moderate anaemia. Other common morbidities were fever (4%), breast conditions (4.9%), and perineal conditions (4.5%). Life-threatening postpartum morbidities were detected in 7.6% of women— 9.7% among those who had deliveries at home and 6.6% among those who had institutional deliveries. None had a fistula. Severe anaemia had a strong correlation with perinatal death [p<0.000, adjusted odds ratio (AOR)=1.99, 95% confidence interval (CI) 1.32-2.99], delivery at home [p<0.000, AOR=1.64 (95% CI 1.27-2.15)], socioeconomically-underprivileged scheduled caste or tribe [p<0.000, AOR=2.47 (95% CI 1.83-3.33)], and parity of three or more [p<0.000, AOR=1.52 (95% CI 1.18-1.97)]. The correlation with antenatal care was not significant. Perineal conditions were more frequent among women who had institutional deliveries while breast conditions were more common among those who had a perinatal death. This study adds valuable knowledge on postpartum morbidity affecting women in the first few days after delivery in a low-resource setting. Health programmes should invest to ensure that all women receive early postpartum visits after delivery at home and after discharge from institution to detect and manage maternal morbidity. Further, health programmes should also ensure that women are properly screened for complications before their discharge from hospitals after delivery.

Interfering Factors of Breastfeeding in the Postpartum Care Centers / 대한주산의학회잡지

PURPOSE: Recently, mothers stay in postpartum care centers (PPCCs) instead of their home for a few weeks after child birth in Korea. The policies of breastfeeding in those facilities can affect the success of breastfeeding. We studied the breastfeeding practice of mothers who stayed in PPCCs and the policies of these facilities. METHODS: We conducted a survey using questionnaires about breastfeeding practice on mothers who visited the Departments of Pediatrics of Cheil General Hospital, Yeungnam University Hospital, Dongsan Medical Center and Chonnam University Hospital, from February 2010 to July 2010. We also conducted another survey on the PPCCs. RESULTS: We collected 349 replies from mothers and 151 responses from PPCCs. 97.4% of mothers had been encouraged breastfeeding, but only 60.3% of mothers practiced rooming-in care, and only 15.2% of them performed it for 24 hours. Milk bottle was used in 92.6% to supply formula instead of cup or spoon. 54.8% of mothers used breast pump unnecessarily to collect breast milk to feed their babies using bottle. 77.3% of mothers withheld breastfeeding in case of cracked nipples, mild jaundice or loose stool. Only 18% of personnels in PPCCs was educated about breastfeeding. Educational materials were provided in only 67.1% of PPCCs. Regional difference was noted in rooming-in care, lecture, feeding device for supplementation and breastfeeding in case of mild jaundice, loose stool or cracked nipples. CONCLUSION: Insufficiently trained people in PPCC may make mothers difficult to breastfeed. It is necessary for the people in PPCCs to be educated for breastfeeding appropriately.

Knowledge, attitude and practice on postpartum care of mothers in Chi Linh district, Hai Duong province

There are some problems in the postpartum requiring knowledge, attitude and practice of the mothers to take care themselves. Objectives: to describe knowledge, attitude and practice of mothers on postpartum care at Chi Linh district, Hai Duong province in 2003. Subjects: 195 mothers in postpartum period. Method: crossectional study of the knowledge, attitude and practice on postpatum care. Result: 40% of mothers have good knowledge on postpartum care and 57.4% lack of knowledge on FP in the postpartum period. 50.7% and 59.5% of mothers declaired that it is necessary to use iron and vitamin A in the postpartum period. In fact the percentage of mothers who using vitamin A was 57.4%. The percentage of mothers were using contraceptives was 42.1%. The 72.6% out of 113 mothers had not applied any contraceptive methods because they think pregnancy can not be occurned during postpartum period. Conclusion: It is needed to strengthen the communication and counseling to mothers in order to improve their knowledge, attitude and practice for postpartum care.

Studying of actual situations of postpartum care for mothers at Chi Linh district, Hai Duong province

A cross-section study of actual situations to postpartum care of 195 cases at Chi Linh district, Hai Duong province. There were 52.3% cases had been examined by Community Health Workers and among them 51.1% was good quality. The rate of postpartum care of the first week was low. 77.4% cases had provided the Home based mother and child record but it was used 15.6% only in the postpartum care. The occupations and mothers culture level influenced to knowledge and practice of postpartum care. The postpartum care by Community Health Workers for mothers was low not only in quality but also in quantity. There were 47.7% of mothers who have never been cared. It was necessary to improve postpartum care for mothers