"It's complicated ": Exploring second stage caesarean sections and reasons for non-performance of assisted vaginal births in Kenya: A mixed methods study.

Unnecessary Caesarean Section (CS) can have adverse effects on women and their newborns. Assisted vaginal birth/delivery (AVB/AVD) using a suction device or obstetric forceps is a potential alternative when delays or complications occur in the second stage of labour. Unlike CS, AVB using a suction device does not require regional or general anaesthesia, can often be performed by midwives, and does not scar the uterus, lowering the risk of maternal mortality and morbidity, in this and subsequent pregnancies. This study examined the appropriateness and outcomes of second stage CS (SSCS), and reasons for low levels of AVB use, in Kenya. Using a mixed methods study design, we reviewed case notes from women having SSCS births and AVB, and conducted key informant interviews with healthcare providers, from 8 purposively selected hospitals in Kenya. Randomly selected SSCS and all AVB case notes were reviewed by a panel of four experienced obstetricians, and appropriateness of the procedure assessed. Semi-structured interviews were conducted with obstetricians, medical officers and midwives, and analysed using a thematic approach. Review of 67 SSCS case notes showed 10% might have been conducted as AVBs, with a further 58% unable to be classified due to inadequate/inconsistent record keeping or excessive delay following initial CS decision. Outcomes following SSCS showed perinatal mortality rate of 89.6/1,000 births, with 11% of infants and 9% of mothers experiencing complications. Non-referred cases of AVB showed good outcomes. The findings of the 20 interviews explored the experience and confidence of healthcare providers in performing AVBs, and adequacy of the training they received. Key reasons for non-performance included lack of functioning equipment, lack of trained staff or their rotation to other departments. Reasons for non-performance of AVB were complex and often multiple. Any solutions to these problems will need to address various local, regional and national issues.

Assessing quality of care in maternity services in low and middle-income countries: Development of a Maternity Patient Reported Outcome Measure.

Globally, low and middle-income countries bear the greatest burden of maternal and newborn mortality. To reduce these high levels, the quality of care provided needs to be improved. This study aimed to develop a patient reported outcome measure for use in maternity services in low and middle-income countries, to facilitate improvements in quality of care. Semi-structured interviews and focus groups discussions were conducted with women who had recently given birth in selected healthcare facilities in Malawi and Kenya. Transcripts of these were analysed using a thematic approach and analytic codes applied. Draft outcomes were identified from the data, which were reviewed by a group of clinical experts and developed into a working copy of the Maternity Patient Reported Outcome Measure (MPROM). A further sample of new mothers were asked to evaluate the draft MPROM during cognitive debriefing interviews, and their views used to revise it to produce the final proposed measure. Eighty-three women were interviewed, and 44 women took part in 10 focus group discussions. An array of outcomes was identified from the data which were categorised under the domains of physical and psychological symptoms, social issues, and baby-related health outcomes. The draft outcomes were configured into 79 questions with answers provided using a five-point Likert scale. Minor revisions were made following cognitive debriefing interviews with nine women, to produce the final proposed MPROM. In conjunction with women from the target population and clinical experts, this study has developed what is believed to be the first condition-specific PROM suitable for assessing care quality in maternity services in low and middle-income countries. Following further validation studies, it is anticipated that this will be a useful tool in facilitating improvements in the quality of care provided to women giving birth in healthcare facilities in these settings.

Using electronic tablets for data collection for healthcare service and maternal health assessments in low resource settings: lessons learnt.

BACKGROUND: Health service and health outcome data collection across many low- and middle-income countries (LMICs) is, to date largely paper-based. With the development and increased availability of reliable technology, electronic tablets could be used for electronic data collection in such settings. This paper describes our experiences with implementing electronic data collection methods, using electronic tablets, across different settings in four LMICs. METHODS: Within our research centre, the use of electronic data collection using electronic tablets was piloted during a healthcare facility assessment study in Ghana. After further development, we then used electronic data collection in a multi-country, cross-sectional study to measure ill-health in women during and after pregnancy, in India, Kenya and Pakistan. All data was transferred electronically to a central research team in the UK where it was processed, cleaned, analysed and stored. RESULTS: The healthcare facility assessment study in Ghana demonstrated the feasibility and acceptability to healthcare providers of using electronic tablets to collect data from seven healthcare facilities. In the maternal morbidity study, electronic data collection proved to be an effective way for healthcare providers to document over 400 maternal health variables, in 8530 women during and after pregnancy in India, Kenya and Pakistan. CONCLUSIONS: Electronic data collection provides an effective platform which can be used successfully to collect data from healthcare facility registers and from patients during health consultations; and to transfer large quantities of data. To ensure successful electronic data collection and transfer between settings, we recommend that close attention is paid to study design, data collection, tool design, local internet access and device security.

Experiences from the field: maternal, reproductive and child health data collection in humanitarian and emergency situations.

BACKGROUND: Humanitarian emergencies can disproportionately affect women of reproductive age, and children. Good data on reproductive maternal, newborn and child health (RMNCH) are vital to plan and deliver programmes to address RMNCH needs. There is currently a lack of information regarding the availability, use and applicability of data collection tools. METHODS: Key informant interviews (KII) were conducted with participants with experience of data collection in humanitarian settings, identified from relevant publications. Data were analysed using the thematic framework approach. RESULTS: All participants reported challenges, especially in the acute phase of an emergency and when there is insufficient security. Four common themes were identified: the importance of a mixed methods approach, language both with regard to development of data collection tools and data collection, the need to modify existing tools and build local capacity for data collection. Qualitative data collection was noted to be time consuming but considered to be important to understand the local context. Both those who have experienced trauma (including sexual violence) and data collectors require debriefing after documenting these experiences. CONCLUSIONS: There were numerous challenges associated with data collection assessing the health status of, and services available, to women and children in humanitarian settings, and researchers should be well prepared.

Breast feeding practices and views among diabetic women: a retrospective cohort study.

OBJECTIVE: to explore the pattern and experiences of breast-feeding practices among diabetic women. DESIGN: retrospective cohort study using maternal records and postal questionnaires in a Baby-Friendly hospital. PARTICIPANTS: diabetic mothers including women with gestational diabetes, and type 1 and 2 diabetes mellitus. FINDINGS: from the total group of respondents, 81.9% intended to breast feed. The actual breast feeding rates were 81.9% at birth, 68.1% at 2 weeks and 28.7% at 6 months postpartum. Major themes that were identified from women's experiences included information and advice, support vs. pressure, classification and labelling, and expectations. CONCLUSIONS: more than two-thirds of the diabetic women intended to breast feed and actually did breast feed in this study. For both the total study population and the type 1 and 2 diabetics alone, more than half were still breast feeding at 2 weeks postpartum, and approximately one-third were still breast feeding at 6 months postpartum. IMPLICATIONS FOR PRACTICE: structured support, provided for women through Baby-Friendly initiatives, was appreciated by the diabetic women in this study. The extent to which this support influenced the highly successful breast feeding practices in this group of women needs focused investigation. The need for a delicate balancing act between pressure and advice in order to prevent coercion was noted.