Occurrence and determinants of postpartum maternal morbidities and disabilities among women in Matlab, Bangladesh.

The burden of maternal ill-health includes not only the levels of maternal mortality and complications during pregnancy and around the time of delivery but also extends to the standard postpartum period of 42 days with consequences of obstetric complications and poor management at delivery. There is a dearth of reliable data on these postpartum maternal morbidities and disabilities in developing countries, and more research is warranted to investigate these and further strengthen the existing safe motherhood programmes to respond to these conditions. This study aims at identifying the consequences of pregnancy and delivery in the postpartum period, their association with acute obstetric complications, the sociodemographic characteristics of women, mode and place of delivery, nutritional status of the mother, and outcomes of birth. From among women who delivered between 2007 and 2008 in the icddr,b service area in Matlab, we prospectively recruited all women identified with complicated births (n=295); a perinatal mortality (n=182); and caesarean-section delivery without any maternal indication (n=147). A random sample of 538 women with uncomplicated births, who delivered at home or in a facility, was taken as the control. All subjects were clinically examined at 6-9 weeks for postpartum morbidities and disabilities. Postpartum women who had suffered obstetric complications during birth and delivered in a hospital were more likely to suffer from hypertension [adjusted odds ratio (AOR)=3.44; 95% confidence interval (CI)=1.14-10.36], haemorrhoids (AOR=1.73; 95% CI=1.11-3.09), and moderate to severe anaemia (AOR=7.11; 95% CI=2.03-4.88) than women with uncomplicated normal deliveries. Yet, women who had complicated births were less likely to have perineal tears (AOR=0.05; 95% CI=0.02-0.14) and genital prolapse (AOR=0.22; 95% CI=0.06-0.76) than those with uncomplicated normal deliveries. Genital infections were more common amongst women experiencing a perinatal death than those with uncomplicated normal births (AOR=1.92; 95% CI=1.18-3.14). Perineal tears were significantly higher (AOR=3.53; 95% CI=2.32-5.37) among those who had delivery at home than those giving birth in a hospital. Any woman may suffer a postpartum morbidity or disability. The increased likelihood of having hypertension, haemorrhoids, or anaemia among women with obstetric complications at birth needs specific intervention. A higher quality of maternal healthcare services generally might alleviate the suffering from perineal tears and prolapse amongst those with a normal uncomplicated delivery.

Obstetric complications and psychological well-being: experiences of Bangladeshi women during pregnancy and childbirth.

Women in developing countries experience postnatal depression at rates that are comparable with or higher than those in developed countries. However, their personal experiences during pregnancy and childbirth have received little attention in relation to postnatal depression. In particular, the contribution of obstetric complications to their emotional well-being during the postpartum period is still not clearly understood. This study aimed to (a) describe the pregnancy and childbirth experiences among women in Bangladesh during normal childbirth or obstetric complications and (b) examine the relationship between these experiences and their psychological well-being during the postpartum period. Two groups of women--one group with obstetric complications (n=173) and the other with no obstetric complications (n=373)--were selected from a sample of women enrolled in a community-based study in Matlab, Bangladesh. The experiences during pregnancy and childbirth were assessed in terms of a five-point rating scale from 'severely uncomfortable=1' to 'not uncomfortable at all=5'. The psychological status of the women was assessed using a validated local version of the Edinburgh Postnatal Depression Scale (EPDS) at six weeks postpartum. Categorical data were analyzed using the chi-square test and continuous data by analysis of variance. Women with obstetric complications reported significantly more negative experiences during their recent childbirth [95% confidence interval (CI) 1.36-1.61, p<0.001] compared to those with normal childbirth. There was a significant main effect on emotional well-being due to experiences of pregnancy [F (4,536)=4.96, p=0.001] and experiences of childbirth [F (4,536)=3.29, p=0.01]. The EPDS mean scores for women reporting severe uncomfortable pregnancy and childbirth experiences were significantly higher than those reporting no such problems. After controlling for the background characteristics, postpartum depression was significantly associated with women reporting a negative childbirth experience. Childbirth experiences of women can provide important information on possible cases of postnatal depression.

Responding to the Maternal Health Care Challenge: the Ethiopian Health Extension Program

Background: Responding to challenges in achieving Millennium Development Goals (MDG); the Ethiopian government initiated the Health Extension Program in 2003 as part of the Health Sector Development Program (HSDP) to improve equitable access to preventive; promotive and select curative health interventions through paid community level health extension workers. Objective: To explore Ethiopia's progress toward achieving MDG 5 that focuses on improved maternal health through the Health Extension Program. Methods: This paper reviews available survey data and literature to determine the feasibility of reaching the targets specified for MDG 5 and for HSDP. Important findings: Achieving the set targets is a daunting task despite reaching the physical targets of two health extension workers per kebele. The 2015 MDG target for the Maternal Mortality Ratio (MMR) is 218 while the 2005 MMR estimate is 673. The HSDP target is 32skilled birth attendant use by 2010 but only about 12use was found in the four most populated regions of the country in 2009. Conclusions: Accelerating progress towards these targets is possible through the Health Extension Program at the worker level through improved promotion of family planning and specific maternal interventions; such as misoprostol for active management of third stage of labor; immediate postpartum visits; and improved coordination from community to referral level

Inequity in maternal health-care services: evidence from home-based skilled-birth-attendant programmes in Bangladesh.

OBJECTIVE: To explore use-inequity in maternal health-care services in home-based skilled-birth-attendant (SBA) programme areas in Bangladesh. METHODS: Data from a community survey, conducted from February to May 2006, were analysed to examine inequities in use of SBAs, caesarean sections for deliveries and postnatal care services according to key socioeconomic factors. FINDINGS: Of 2164 deliveries, 35% had an SBA, 22.8% were in health facilities and 10.8% were by caesarean section. Rates of uptake of antenatal and postnatal care were 93% and 28%, respectively. There were substantial use-inequities in maternal health by asset quintiles, distance, and area of residence, and education of both the woman and her husband. However, not all inequities were the same. After adjusting for other determinants, the differences in the use of maternal health-care services for poor and rich people remained substantial [adjusted odds ratio (OR) 2.51 (95% confidence interval, CI: 1.68-3.76) for skilled attendance; OR 2.58 (95% CI: 1.28-5.19) for use of caesarean sections and OR 1.53 (95% CI: 1.05-2.25) for use of postnatal care services]. Complications during pregnancy influenced use of SBAs, caesarean-section delivery and postnatal care services. The number of antenatal care visits was a significant predictor for use of SBAs and postnatal care, but not for caesarean sections. CONCLUSION: Use of maternity care services was higher in the study areas than national averages, but a tremendous use-inequity persists. Interventions to overcome financial barriers are recommended to address inequity in maternal health. A greater focus is needed on the implementation and evaluation of maternal-health interventions for poor people.

Evaluation of a comprehensive home-based midwifery programme in South Kalimantan, Indonesia.

We report the findings of an evaluation of a programme in three districts in South Kalimantan, Indonesia, which consisted of the training, deployment and supervision of a large number of professional midwives in villages, an information, education and communication (IEC) strategy to increase use of village midwives for birth, and a district-based maternal and perinatal audit (MPA). Before the programme, the midwives had limited ability to manage obstetric complications, and 90% of births took place at home. Only 37% were attended by a skilled attendant. By 1998-99, 510 midwives were posted in the districts and skilled attendance at delivery had increased to 59%. Through in-service training, continuous supervision and participation in the audit system midwives also gained confidence and skills in the management of obstetric complications. Despite this, the proportion admitted to hospital for a caesarean section declined from 1.7 to 1.4% and the proportion admitted to hospital with a complication requiring a life-saving intervention declined from 1.1% to 0.7%. The strategy of a midwife in every village has dramatically increased skilled birth attendance, but does not yet provide specialized obstetric care for all women needing it. The high cost of emergency obstetric interventions may well be the most important obstacle to the use of hospital care.

Organizing delivery care: what works for safe motherhood?

The various means of delivering essential obstetric services are described for settings in which the maternal mortality ratio is relatively low. This review yields four basic models of care, which are best described by organizational characteristics relating to where women give birth and who performs deliveries. In Model 1, deliveries are conducted at home by a community member who has received brief training. In Model 2, delivery takes place at home but is performed by a professional. In Model 3, delivery is performed by a professional in a basic essential obstetric care facility, and in Model 4 all women give birth in a comprehensive essential obstetric care facility with the help of professionals. In each of these models it is assumed that providers do not increase the risk to women, either iatrogenically or through traditional practices. Although there have been some successes with Model 1, there is no evidence that it can provide a maternal mortality ratio under 100 per 100,000 live births. If strong referral mechanisms are in place the introduction of a professional attendant can lead to a marked reduction in the maternal mortality ratio. Countries using Models 2-4, involving the use of professional attendants at delivery, have reduced maternal mortality ratios to 50 or less per 100,000. However, Model 4, although arguably the most advanced, does not necessarily reduce the maternal mortality ratio to less than 100 per 100,000. It appears that not all countries are ready to adopt Model 4, and its affordability by many developing countries is doubtful. There are few data making it possible to determine which configuration with professional attendance is the most cost-effective, and what the constraints are with respect to training, skill maintenance, supervision, regulation, acceptability to women, and other criteria. A successful transition to Models 2-4 requires strong links with the community through either traditional providers or popular demand.

PIP: This study aims to clarify the processes involved in reducing maternal mortality by reviewing national-level data from developing countries. Various processes of delivering essential obstetric services are described in settings where mortality ratio is relatively low. This paper yields four basic models of care, which are best described by organizational characteristics relating to where women give birth and who conducts the deliveries. In Model 1, community members who have received brief training conduct deliveries at home. In Model 2, delivery takes place at home but is performed by a professional. In Model 3, delivery is performed by a professional in a basic essential obstetric care facility. In Model 4, all women give birth in a comprehensive essential obstetric care facility with the help of professionals. Some features of successful models of safe motherhood care are shown. A list of national programs and projects exemplifying each model of care and their respective maternal mortality ratios is also tabulated. In each of these models it is assumed that professional providers of care do not increase risks to women, either by drug procedure or through traditional practices. Results reveal that although Model 1 has achieved some success, there is no evidence that it can produce a maternal mortality ratio under 100/100,00 live births. With the introduction of a professional attendant, as in Model 2-4, the ratio can be reduced to 50 or lower if strong referral mechanisms are in place. It should be noted, however, that Model 4 does not necessarily reduce the ratio to below 100/100,000 live births. Not all countries appear ready to adopt Model 4, and it is doubtful whether it is affordable for many developing countries. A successful transition to Models 2-4 requires strong links to the community through traditional providers or popular demand.

Beyond maternal mortality--magnitude, interrelationship, and consequences of women's health, pregnancy-related complications and nutritional status on pregnancy outcomes.

The magnitude of maternal mortality in developing countries and its disparity with similar statistics from the developed world has touched a responsive chord among policy makers and health services program officials. What is not well appreciated, however, is that maternal mortality is only the tip of the iceberg--for every one maternal death, acute obstetrical complications cause suffering in nearly 100 women, 250 women contract a sexually transmitted disease, and 1000 women suffer stunting and/or anemia. All of these problems impact on the pregnancy outcome, both for the woman as well as for the newborn. Through a review of the literature, the magnitude, interrelationships and consequences of these various problems are described. The woman and the newborn are a dyad, a unit; what affects the woman typically affects the fetus and is manifest in the newborn. Safe motherhood programs need to pay attention to both, realizing that interventions aimed at the women can benefit the next generation.

Off to a rapid start: appraising maternal mortality and services.

Enthusiasm for 'doing something about Safe Motherhood' has been expressed in many developing countries, but priorities for action cannot be identified without adequately assessing a country's maternal mortality situation. It is also important, however, to avoid embarking on time-consuming research measuring indicators which are not essential to developing programs. After presenting an overview of ideal Safe Motherhood program components, the paper lists a series of questions which serve as an assessment tool for collecting useful information and for identifying data sources on maternal mortality and health. The framework for these questions centers around the following steps: (1) gaining an overview of health policy relevant to maternal mortality and morbidities; (2) assessing the magnitude and causes of maternal mortality and morbidity, and the characteristics of groups at particular risk; and (3) assessing the available inputs in terms of services (access, quality, providers, what is provided at various tiers, etc.) and in terms of the culture and existing resources and groups.

An integrated village maternity service to improve referral patterns in a rural area in West-Java.

The Regionalization of Perinatal Care, an intervention study carried out in Tanjungsari, a subdistrict in rural West Java, aimed to develop a comprehensive maternal health program to improve maternal and perinatal health outcomes. The main inputs included training at all levels of the health care system (informal and formal) and the establishment of birthing homes in villages to make services more accessible. Special attention was given to referral, transportation, communication and appropriate case management, A social marketing program was conducted to inform people of the accessible birthing homes for clean delivery, located near the women, and with better transportation and communications to referral facilities should complications arise. The study design was longitudinal, following all pregnant women from early pregnancy until 42 days postpartum in an intervention and a comparison area. The population was +/- 90,000 in the intervention area and 40,000 in the comparison area. Inclusion criteria were all mother and infant units delivered between June 1st, 1992 and May 31st, 1993. Analysis showed the following results: Most women sought antenatal care (> 95%). In Tanjungsari, nearly 90% sought such care from professional providers as versus 75% in the control area of Cisalak. Most women with bleeding or bleeding and edema during pregnancy sought professional assistance in both the study and control areas. However, fever for more than 3 days received more attention in the study area versus control area (93 vs. 69%). Greater than 85% of deliveries in both areas were conducted by TBAs. However, in the study area, nearly one-third of those with intrapartum complications (17%) delivered in a health facility compared to one-tenth in the control area. This meant a hospital delivery, primarily with assistance of a doctor or doctor/midwife combination. Overall referral rates by TBAs were low -13% of women with complications in Tanjungsari and 6% in Cisalak. More women with intrapartum complications were referred in the study area than in the control, and more complied when referred. Women who suffered intrapartum complications were more likely to have a perinatal death. Perinatal deaths declined in Tanjungsari, but not significantly. However, the trend over the period of the intervention shows an improvement in the deliveries managed by TBAs with more deaths resulting in the hands of professionals. Either women were arriving too late or the quality of care could not meet the needs. There was no change in the levels or place of perinatal deaths in Cisalak.

Programming for safe motherhood: a guide to action.

The Safe Motherhood Initiative has successfully stimulated much interest in reducing maternal mortality. To accelerate programme implementation, this paper reviews lessons learned from the experience of industrial countries and from demonstration projects in developing countries, and proposes intervention strategies of policy dialogue, improved services and behavioural change. A typological approach with three hypothetical settings from resource poor to resource rich environments is used to address the variability in health behaviours and infrastructure encountered when programming for safe motherhood.

PIP: Safe Motherhood programs have been expanded over the past six years, but funding and evaluation are still insufficient to meet needs in a cost effective manner. Process indicators may be appropriate qualitative and quantitative indicators of how well programs are functioning and of the underlying mechanisms influencing maternal health outcomes. Three important dimensions of the Safe Motherhood Initiative are policy dialogue, improved services, and behavior change. The World Bank/MotherCare Workshop on Guidelines for Safe Motherhood Programming and the World Bank Discussion Paper on Making Motherhood Safe provide guides to action. Many features of the reports are summarized in this paper (a definition of the problem, the lessons learned, essential features of an effective motherhood program, strategies appropriate for specific settings, policy issues, costs of interventions, and measurement of progress). The problems of maternal mortality stem from septic abortion, postpartum hemorrhage, eclampsia, hypertension, obstructed labor, and sepsis/infection. Community-based family planning has been instrumental in rapidly reducing maternal mortality in Bangladesh. Community-based maternity care programs with trained midwives, medical supplies, and a referral system can reduce the risk of dying by 66%. Trained traditional birth attendants alone do not reduce the risk of maternal mortality. Essential, accessible obstetric care has had an impact in Zaire. Community-based maternity waiting homes, referrals, and prenatal screening prevent maternal mortality in Ethiopia. Safe Motherhood begins with a healthy environment (women's status, political commitment, and socioeconomic development), which is influenced by women's health and nutritional status, reproductive and health behavior, and access to family planning and maternal care services. Immediate determinants of maternal mortality are 1) exposure to pregnancy and 2) complications and their management. Important program elements are services, skilled assistance, referrals, and communication.

Maternal tetanus: magnitude, epidemiology and potential control measures.

Maternal tetanus, defined as tetanus occurring during pregnancy or within 6 weeks after any type of pregnancy termination, is one of the most easily preventable causes of maternal mortality. It includes postpartum or puerperal tetanus resulting from septic procedures during delivery, postabortal tetanus resulting from septic abortion and tetanus incidental to pregnancy, resulting from any type of wound during pregnancy. This review of published and unpublished hospital and community studies concludes that between 15,000 and 30,000 cases of maternal tetanus occur each year. Complete coverage of reproductive-aged women by tetanus toxoid is the most cost-effective way to eliminate this often neglected cause of maternal death.

Helping managers to manage: work schedules of field-workers in rural Bangladesh.

The Maternal-Child Health/Family Planning (MCH/FP) Extension Project in Bangladesh identifies and examines barriers to implementation of the national MCH/FP program, and determines strategies to overcome them. This study analyzes field-workers' ability to carry out more tasks than they do presently, and how their performance might be improved when additional field-workers are hired. In two experimental subdistricts, researchers observed the work of family welfare assistants (FWAs), the female family planning field-workers, to determine the duration and frequency of their home visits with village women and the content of their exchanges. While many factors influence the FWA's work, researchers found that the preplanned monthly work schedules could be manipulated relatively easily to improve duration and frequency of program contact with village women. With more time available to spend with women, the potential to improve the quality of services is enhanced.

Client relations in South Asia: programmatic and societal determinants.

Client relations constitute a neglected area of research in family planning. Findings from studies in northern India and Bangladesh reveal considerable variation in both the quantity and quality of contacts in programs that function under roughly comparable socioeconomic conditions. Client relations are determined by a complex set of forces in which both programmatic factors and conditions pertaining to the societal environment play a key role. Worker-client exchanges have a net, incremental effect on contraceptive use.

PIP: Despite their considerable importance, client relations constitute a neglected area of research in family planning (FP). This paper analyzes research findings on the nature of client relations and their determinants from northern India programs: 1) the Kanpur study, on FP in 1 division of Uttar Pradesh; 2) another from a smaller Uttar Pradesh project, on interactions between male and female workers and villagers; and Bangladesh: 3) a maternal-child health (MCH) and FP project of the International Center for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) in Matlab; and 4) an ICDDR,B study of a MCH-FP extension project in 2 subdistricts. Additional information is reported from an earlier survey of 6 Bangladesh subdistricts. Important aspects of client encounters are initiation, medium, and setting of contact, and degree of dependence. Determinants of client relations are expressed in diagram form. Some survey studies of the quantity of FP contacts with villages reveal variation between villages, and between northern India and Bangladesh. Not only coverage but also degree of follow-up are shown to affect program performance. Worker density and work effort, as well as village accessibility, affect coverage. The managerial context and societal conditions are also important. Female workers are generally more effective because women are more responsive to the FP message and female to female communication is more culturally appropriate. Females are also less likely to be affected by political influences, lacking political connections, and are less likely to have alternative employment. Females with high status and access to patronage are more likely to be successful, and workers' integration into networks of status and influence lends social credibility to program activities. But aside from personnel characteristics, policy formulation and program implementation are constrained by patronage politics, dependence and poverty economics, and bureaucratic structures.

Medidas para el control de las enfermedades diarreicas en niños menores de cinco años: 4. Fomento de la lactancia materna / Interventions for the control of diarrheal disease among children under five years of age: 4. Promotion of breast-feeding

...Se examinaron nueve estudios de cinco países y la mayoría de ellos reveló que la lactancia natural confiere considerable protección contra la mortalidad por diarrea. Si se comparan los niños que no reciben leche materna y los que se alimentan exclusivamente de esta, se observa que el riesgo relativo promedio de mortalidad por diarrea durante los primeros seis meses de vida es de 25. La comparación entre los niños que no reciben leche materna y los que se alimentan exclusiva o parcialmente de esta, reveló que el riesgo relativo promedio de mortalidad por diarrea era de 8,6

La lactancia natural se puede fomentar por medio de cambios en las actividades regulares de los hospitales y proporcionando información y apoyo a las madres. Un examen de 21 estudios de ocho países indica que de esta manera es probable que la prevalencia de la diarrea en los niños que no reciben leche materna disminuya en un 40 por ciento en los niños de 0 a 2 meses, 30 por ciento en los de 3 a 5 meses, y 10 por ciento en los niños de seis meses a un año... (AU)