Safe Motherhood Initiative Research Articles

Reaching vulnerable women through maternity waiting homes in Malawi.

To determine whether two maternity waiting homes (MWHs) supported by the Safe Motherhood Initiative are reaching vulnerable women during the early phase of their implementation. A cross-sectional interview-based study was conducted among women who attended two centers in Malawi with attached MWHs (Area 25 Health Centre, Lilongwe; and Kasungu District Hospital, Kasungu). Between April and June 2015, exit interviews were conducted among MWH users and non-users. Compared with non-users, MWH users at Area 25 were significantly more likely to report a prior spontaneous abortion (10/46 [21.7%] vs 5/95 [5.3%]; P=0.006) and to be in the lowest wealth quintile (4/87 [4.6%] vs 0/150; P=0.029). Although not significant, a greater percentage of MWH users at Kasungu District Hospital than non-users had a prior stillbirth (6/84 [7.1%] vs 0/77) or spontaneous abortion (3/84 [3.6%] vs 2/77 [2.6%]), and were in the lowest wealth quintile (15/175 [8.6%] vs 5/141 [3.5%]). MWH users at Kasungu lived further from the hospital than did non-MWH users, although the difference was not significant (mean 6.81±9.1km vs 4.05±7.42km; P=0.067). MWHs offer a promising strategy to reduce maternal mortality in Malawi and other low-income countries.

Maternal health: time for a radical reappraisal

Maternal health: time for a radical reappraisal

Validating Obstetric Emergency Checklists using Simulation: A Randomized Controlled Trial.

Background The World Health Organization's Surgical Safety Checklist has demonstrated significant reduction in surgical morbidity. The American Congress of Obstetricians and Gynecologists District II Safe Motherhood Initiative (SMI) safety bundles include eclampsia and postpartum hemorrhage (PPH) checklists. Objective To determine whether use of the SMI checklists during simulated obstetric emergencies improved completion of critical actions and to elicit feedback to facilitate checklist revision. Study Design During this randomized controlled trial, teams were assigned to use a checklist during one of two emergencies: eclampsia and PPH. Raters scored teams on critical step completion. Feedback was elicited through structured debriefing. Results In total, 30 teams completed 60 scenarios. For eclampsia, trends toward higher completion were noted for blood pressure and airway management. For PPH, trends toward higher completion rates were noted for PPH stage assessment and fundal massage. Feedback resulted in substantial checklist revision. Participants were enthusiastic about using checklists in a clinical emergency. Conclusion Despite trends toward higher rates of completion of critical tasks, teams using checklists did not approach 100% task completion. Teams were interested in the application of checklists and provided feedback necessary to substantially revise the checklists. Intensive implementation planning and training in use of the revised checklists will result in improved patient outcomes.

"Lives in the balance": The politics of integration in the Partnership for Maternal, Newborn and Child Health.

A decade ago, the Partnership for Maternal, Newborn and Child Health (PMNCH) was established to combat the growing fragmentation of global health action into uncoordinated, issue-specific efforts. Inspired by dominant global public-private partnerships for health, the PMNCH brought together previously competing advocacy coalitions for safe motherhood and child survival and attracted support from major donors, foundations and professional bodies. Today, its founders highlight its achievements in generating priority for ‘MNCH’, encouraging integrated health systems thinking and demonstrating the value of collaboration in global health endeavours. Against this dominant discourse on the success of the PMNCH, this article shows that rhetoric in support of partnership and integration often masks continued structural drivers and political dynamics that bias the global health field towards vertical goals. Drawing on ethnographic research, this article examines the Safe Motherhood Initiative’s evolution into the PMNCH as a response to the competitive forces shaping the current global health field. Despite many successes, the PMNCH has struggled to resolve historically entrenched programmatic and ideological divisions between the maternal and child health advocacy coalitions. For the Safe Motherhood Initiative, the cost of operating within an extremely competitive policy arena has involved a partial renouncement of ambitions to broader social transformations in favour of narrower, but feasible and ‘sellable’ interventions. A widespread perception that maternal health remains subordinated to child health even within the Partnership has elicited self-protective responses from the safe motherhood contingent. Ironically, however, such responses may accentuate the kind of fragmentation to global health governance, financing and policy solutions that the Partnership was intended to challenge. The article contributes to the emerging critical ethnographic literature on global health initiatives by highlighting how integration may only be possible with a more radical conceptualization of global health governance.

Traditional birth attendants (TBAs) as potential agents in promoting male involvement in maternity preparedness: insights from a rural community in Uganda.

BackgroundSince the 1994 International Conference on Population and Development, male involvement in reproductive health issues has been advocated as a means to improve maternal and child health outcomes, but to date, health providers have failed to achieve successful male involvement in pregnancy care especially in rural and remote areas where majority of the underserved populations live. In an effort to enhance community participation in maternity care, TBAs were trained and equipped to ensure better care and quick referral. In 1997, after the advent of the World Health Organization’s Safe Motherhood initiative, the enthusiasm turned away from traditional birth attendants (TBAs). However, in many developing countries, and especially in rural areas, TBAs continue to play a significant role. This study explored the interaction between men and TBAs in shaping maternal healthcare in a rural Ugandan context.MethodsThis study employed ethnographic methods including participant observation, which took place in the process of everyday life activities of the respondents within the community; 12 focus group discussions, and 12 in-depth interviews with community members and key informants. Participants in this study were purposively selected to include TBAs, men, opinion leaders like village chairmen, and other key informants who had knowledge about the configuration of maternity services in the community. Data analysis was done inductively through an iterative process in which transcribed data was read to identify themes and codes were assigned to those themes.ResultsContrary to the thinking that TBA services are utilized by women only, we found that men actively seek the services of TBAs and utilize them for their wives’ healthcare within the community. TBAs in turn sensitize men using both cultural and biomedical health knowledge, and become allies with women in influencing men to provide resources needed for maternity care.ConclusionIn this study area, men trust and have confidence in TBAs; closer collaboration with TBAs may provide a suitable platform through which communities can be sensitized and men actively brought on board in promoting maternal health services for women in rural communities.

Abortion Practices in Nepal: What does Evidence Show?

Twenty-five years have passed since the global community agreed in Nairobi to address the high maternal mortality by implementing the Safe Motherhood Initiative. However, every year around 22 million women seek unsafe abortion in developing countries. Globally, the unsafe abortion accounts for 13% maternal deaths. Out of the total aborted women, around five million women were admitted to hospitals as a result of unsafe abortion. Similarly, more than three million women suffer from severe complications from unsafe abortion every year. In 2002, responding to the public voices and high attribution of unsafe abortion on maternal mortality, Nepal granted legal access to safe abortion introducing safe abortion act. Women can seek abortion up to 12 weeks of gestation for any indication. However, sex selective pregnancy termination is prohibited in Nepal. This study aimed to assess the results of various studies on abortion practices in Nepal. Literature published in PubMed, Lancet, Medline, WHO and Google Scholar web pages from 1990 to 2014 were used to prepare this paper. From 2004 to 2014, more than half a million women sought safe abortion care in Nepal. Despite the considerable progress, unsafe abortion is still a major issue in Nepal as it has been estimated that it constitutes half of all abortions undertaken every year. Published literature further showed that still an unmet need of safe abortion services exists in Nepal. However, the overall awareness of legal abortion was found to be high among Nepalese women. We found negative attitude of most people towards women who sought abortion care. Similarly, a large number of unmarried women were found at risk for seeking abortion care due to socio-cultural norms, values and stigmas in Nepal.

Introducción: Los cuidados obstétricos de emergencia como estrategia para la reducción de la muerte materna.

Desde el lanzamiento en Nairobi de la Iniciativa Maternidad Segura, en el año 1987, se puso énfasis en el mundo a una serie de intervenciones, con el propósito de reducir las muertes maternas. Han pasado poco más de 20 años y aún estas muertes no han declinado, particularmente en los países del tercer mundo. Dentro de la multicausalidad que se admite para la mortalidad materna, al final la defunción ocurre porque en el embarazo de una mujer se inserta una complicación, que de ser severa puede terminar en muerte. De allí entonces que si la mujer es atendida en esta situación por personal calificado y en un ambiente adecuado, se puede superar la ocurrencia de esa complicación y asistir a un resultado exitoso.

Utilization of maternal health services and determinants of skilled care during delivery in slums of Gujarat, India

Background: In India one in three women is delivering without skilled care. This is happening even after the Safe Motherhood Initiative began two decades ago. Aim & Objective: The aim of the present paper is to assess utilization of maternal health services and factors affecting skilled delivery care among urban slum women. Method: We selected 562 women delivered two year prior to survey using two stage clusters sampling for a community based cross sectional study. Using a pre-tested structured interview schedule, information was collected on demographics, socioeconomic status, use of maternal health services, and reasons for non-utilization of health services. Univariate and multivariate analysis were performed. Result: Majority (92%) of women received at least one antenatal care during pregnancy, while only 4 out of five women sought skilled care during the last delivery. Women of educationally and socially backward classes (OR=0.46, 95% CI 0.230.94), women live in a distance more than two kilometers from maternity health facility (OR=0.38, 95% CI 0.22-0.65), and women been on their second pregnancy (OR=0.44, 95% CI 0.21-0.94) utilized less of skilled care during delivery compared to their counterparts. Increase in education level of women and number of Antenatal care received were tending more utilization of skilled care during delivery. Minimal sense of need, cost, social barriers and perceptions about care were found to be the reasons for not seeking care. P oor attitude of providers, poor quality of services and long waiting time were found to be the reasons for non-utilization of public health facilities. Conclusion: The factors determine skilled delivery care were caste affiliation, education, service availability, parity, perceived utility of services and health seeking behaviors. Government institutions were lying underutilized as women do not prefer them for delivery.

Maternal health care in Nigeria: Do community factors moderate the effects of individual-level Education and Ethnic origin?

Maternal mortality ratio in Nigeria is still high despite the initiation of the safe motherhood initiative. The poor maternal health situation has been attributed to inadequate use of maternal health care services. This study examines whether community factors moderated the association between individual factors and the use of skilled ANC. Data on 17560 women aged 15-49 years drawn from 2008 Nigeria Demographic and Health Survey were used. Multilevel logistic regression models were used for analysis. Results reveal variations in the use of skilled ANC across the Northern and Southern regions. Residence in communities with a high proportion of women that delivered in a health facility increased the odds of skilled ANC utilization. Community education and poverty moderated the association between individual factors and the utilization of skilled ANC. To improve the use of ANC and increase the pace towards achieving the sustainable Development Goal-improved maternal health in the post 2015 era, increasing health facility delivery, women’s education and targeting poverty alleviation programs in disadvantaged communities should be taken into consideration.

Achieving Safe Motherhood Addressing the Healthcare and Education Needs of the Mothers with Comorbidities; Reenvisioning Prenatal Care and Education

The health and wellness of mothers has been identified as the cornerstone of public health, and it is well documented in the literature that mothers define the health of the family [1-3]. Safe Motherhood has been described as practices, and guidelines that ensure all women receive the care they need for a safe and healthy pregnancy and childbirth (World Health Organization [4]. The safe motherhood initiative begun with discussions in the 1980s in order to address the growing need for women to progress through pregnancy and childbirth ensuring with little health risks and little to no short-term and long-term morbidities [5,6]. Historically safe motherhood was thought to be a public health concern in developing nations, however the United States ranks well below many developed nations [3]. The current rate of maternal and infant mortality is abysmal, with national rates greater than 27 other developed nations. The latest 2014 data reported that the infant mortality rates stood at 6.1 per 1,000 live births. An infant born in Hungary, Poland, Slovakia, and Cuba has a greater chance of surviving past the first year of life than an infant born in the United States. More disconcerting is the fact that an infant born in Mississippi has the same chance of survival as an infant born in Bahrain or Botswana [7,8].

Commentary: Sustaining progress towards comprehensive reproductive health services in Bangladesh

Commentary: Sustaining progress towards comprehensive reproductive health services in Bangladesh

Impact of Training Programme on Knowledge and Perception of Primary Health Care (PHC) Workers on Nutrition Component of Safe Motherhood Initiative in South-West Nigeria

Introduction The global campaign to reduce maternal mortality was launched in 1987, when three United Nations agencies— United Nations Population Fund (UNFPA), the World Bank, and World Health Organization (WHO) —sponsored the international Safe Motherhood Conference in Nairobi, Kenya. The event aimed to raise awareness about the numbers of women dying each year from complications of pregnancy and childbirth, and to challenge the world to intervene [1]. At that time the number of maternal deaths worldwide was estimated to be at least 600,000 each year with 99% of deaths occurring in the developing world. In spite of the promises and good expectations associated with SMI when founded, the programme is yet to witness a quantum leap in progress to reduce maternal challenges. This may be related to neglect of some vital components in the planning of which nutrition is fundamental [15]. In Nigeria, maternal mortality ratio is put at 545 maternal deaths per 100,000 live births [2]. Safe Motherhood refers to a situation in which no woman going through the physiological processes of pregnancy and childbirth suffers any injury or loses her life or that of the baby [3]. One of the core components of Safe Motherhood Initiatives (SMI) is nutrition, yet only few studies have considered this adequately. The goal of this intervention study was to evaluate the effect of training programme on knowledge and perception of PHC health workers on nutrition components of SMIs. The study was quasi-experimental involving two groups of 30 PHC health workers each purposively selected from Egbeda Local Government Area (LGA) (experimental group-EG) and Ido LGA (control group-CG). The two groups completed validated questionnaire at baseline. Knowledge and perception of nutrition components of SMIs were assessed using 42-point and 28-point scales respectively. Knowledge and perception gaps identified during the baseline survey were used to design module for training programme for the EG. Post-intervention assessment was conducted immediately and one month after the training among the two groups. These showed that knowledge scores at baseline, immediate post-intervention and one month postintervention were 12.6±2.9, 36.9±3.6 and 39.9±1.7 respectively (p 0.05). Difference in knowledge scores between the EG and CG groups at the different stages of assessment was significant (p 0.05). Training improved knowledge of health workers’ but had insignificant effect on perception of nutrition components of SMIs. The PHC health workers have right perception of nutrition components of SMIs but lack adequate knowledge. There is need for continuous training of health workers’ on nutrition components of SMI to enhance maternal and child care, especially at the PHC level. Citation: Oyewole OE, Ahmadu AA (2014) Impact of Training Programme on Knowledge and Perception of Primary Health Care (Phc) Workers on Nutrition Component of Safe Motherhood Initiative in SouthWest Nigeria. J Nutr Health Sci 1(3): 304. doi: 10.15744/2393-9060.1.304 Most maternal deaths occur in the developing world; making maternal mortality the health statistics with the largest disparity between developed and developing countries [4]. The consequences of malnutrition, in all its forms (both macronutrients and micronutrients) can be seen in poor birth outcomes and poor breast-feeding and other infant feeding and care practices.

Emergency Obstetric Care: Strategy for Reducing Maternal Mortality in Developing Countries

Twenty-five years have passed since the global community agreed in Nairobi to address the high maternal mortality by implementing the Safe Motherhood Initiative. However, every year nearly three million women die due to pregnancy related causes. This tragedy is avoidable if women have timely access to required emergency obstetric care. Emergency obstetric care refers to life-saving services for maternal and neonatal complications provided by skilled health workers. Since the beginning of the 1980’s, several efforts have been intensified to improve maternal and child health status and reducing the high morbidity and mortality. There was built on a worldwide consensus to provide improved maternal and child health care for addressing the high morbidity and mortality. All participant countries agreed to integrate emergency obstetric care services in their national health care system. Emergency obstetric care is one of the strategies for reducing the maternal mortality as pregnancy related complications are unpredictable. However, many women in developing countries do not have access to essential health care services including emergency obstetric care. Basic emergency obstetric care by skilled birth attendants or timely referral for further comprehensive emergency obstetric care can reduce maternal deaths and disabilities significantly. This paper is based on the results published in PubMed, Medline, Lancet, WHO and Google Scholar web pages from 1990 to 2013. DOI: http://dx.doi.org/10.3126/njog.v9i1.11179 NJOG 2014 Jan-Jun; 2(1):8-16

Development of the community midwifery education initiative and its influence on women's health and empowerment in Afghanistan: a case study.

BackgroundPolitical transition in Afghanistan enabled reconstruction of the destroyed health system. Maternal health was prioritised due to political will and historically high mortality. However, severe shortages of skilled birth attendants - particularly in rural areas - hampered safe motherhood initiatives. The Community Midwifery Education (CME) programme began training rural midwives in 2002, scaling-up nationally in 2005.MethodsThis case study analyses CME development and implementation to help determine successes and challenges. Data were collected through documentary review and key informant interviews. Content analysis was informed by Walt and Gilson’s policy triangle framework.ResultsThe CME programme has contributed to consistently positive indicators, including up to a 1273/100,000 reduction in maternal mortality ratios, up to a 28% increase in skilled deliveries, and a six-fold increase in qualified midwives since 2002. Begun as a small pilot, CME has gained support of international donors, the Afghan government, and civil society.ConclusionCME is considered by stakeholders to be a positive model for promoting women’s education, employment, and health. However, its future is threatened by insecurity, corruption, lack of regulation, and funding uncertainties. Strategic planning and resource mobilisation are required for it to achieve its potential of transforming maternal healthcare in Afghanistan.

Increasing health equity and access to skilled birth delivery services for the poor through community-based health-care interventions: evidence from northern Nigeria

Background The Partnership for Transforming Health Systems Phase 2 (PATHS2) project introduced and supports community based interventions such as safe motherhood initiative demand side (SMID) and an emergency transport scheme within northern Nigeria. This study evaluates the effect of PATHS2’s community based interventions in addressing transportation as a barrier to accessing skilled birth delivery services in health facilities.

"Playing the numbers game": evidence-based advocacy and the technocratic narrowing of the Safe Motherhood Initiative.

Based on an ethnography of the international Safe Motherhood Initiative (SMI), this article charts the rise of evidence-based advocacy (EBA), a term global-level maternal health advocates have used to indicate the use of scientific evidence to bolster the SMI's authority in the global health arena. EBA represents a shift in the SMI's priorities and tactics over the past two decades, from a call to promote poor women's health on the grounds of feminism and social justice (entailing broad-scale action) to the enumeration of much more narrowly defined practices to avert maternal deaths whose outcomes and cost effectiveness can be measured and evaluated. Though linked to the growth of an audit- and business-oriented ethos, we draw from anthropological theory of global forms to argue that EBA—or “playing the numbers game”—profoundly affects nearly every facet of evidence production, bringing about ambivalent reactions and a contested technocratic narrowing of the SMI's policy agenda.

Challenges in delivery of skilled maternal care – experiences of community midwives in Pakistan

BackgroundMaternal mortality ratio in Pakistan remains high at 276 per 100000 live births (175 in the urban areas and 319 in rural) with a mother dying as a result of giving birth every 20 minutes. Despite the intervening years since the Safe Motherhood Initiative launch and the Millennium Development Goals (MDGs), there have been few improvements in MDGs 4 and 5 in Pakistan. A key underlying reason is that only 39% of the births are attended by skilled birth attendants. Pakistan, like many other developing countries has been struggling to make improvements in maternal and neonatal health, amongst other measures, which include a nationwide health infrastructure network. Recently, government of Pakistan revised its maternal and newborn health program and introduced a new cadre of community based birth attendants, called community midwives (CMW), trained to conduct home-based deliveries. There is limited research available on field experiences of community midwives as maternal health care providers. Formative research was designed and conducted in a rural district of Pakistan with the objective of exploring role of CMWs as home based skilled service providers and the challenges they face in provision of skilled maternal care.MethodsA qualitative research using content analysis was conducted in one rural district (Attock) of Pakistan. Focus group discussions were conducted with CMWs and other community based health workers as LHWs and LHSs, focusing on the role of CMWs in the existing primary health care infrastructure.ResultsResults of this study reveal that the community midwives are struggling for survival in rural areas as maternal care providers as they are inadequately trained, lack sufficient resources to deliver services in their catchment areas and lack facilitation for integration in district health system.ConclusionsCMWs face many challenges in the field related to the communities' attitude and the health system. With adequate training and facilitation by health department, CMWs have potential to play a vital role in reducing burden of maternal morbidity and in achieving significant gains in improving maternal and child health.

Educational Standard of Pregnant Women and Their Response to Safe Motherhood Initiative in Orlu Urban, Imo State

It is widely expected and indeed believed that when a pregnant mother has attained a certain level of education, her attitude to issues relating to the pregnancy will be factually informed. It is based on this belief that this work sets out to find out if educated pregnant woman have significantly different attitude to SafeMotherhood Initiative (SMI) than the less educated pregnant women in Orlu Urban, Imo State. The Exploratory and Descriptive cross sectional survey design was adopted. Questionnaire was designed to elicit the required information based on the research questions and objectives using a 4 point Likert-Scale. Our ANOVA test was a return of NO statistical significance at 0.05 level. The implication of this study in general is that greater room still exists for advocacy and enlightenment by the various related Ministries and NGOS to ensure that the lives of pregnant women are secured and guaranteed in Imo State.

Inequality of the Use of Skilled Birth Assistance Among Rural Women in Bangladesh

This study examines the inequality of the use of skilled delivery assistance by the rural women of Bangladesh using the 2007 Bangladesh Demographic and Health Survey data. Simple cross-tabulation and univariate and multivariate statistical analyses were employed in the study. Overall, 56.1% of the women received at least one antenatal care visit, whereas only 13.2% births were assisted by skilled personnel. Findings revealed apparent inequality in using skilled delivery assistance by socioeconomic strata. Birth order, women's education, religion, wealth index, region and antenatal care are important determinants of seeking skilled assistance. To ensure safe motherhood initiative, government should pay special attention to reduce inequality in seeking skilled delivery assistance. A strong focus on community-based and regional interventions is important in order to increase the utilization of safe maternal health care services in rural Bangladesh.

THE IMPORTANCE OF PUBLIC SECTOR HEALTH FACILITY-LEVEL DATA FOR MONITORING CHANGES IN MATERNAL MORTALITY RISKS AMONG COMMUNITIES: THE CASE OF PAKISTAN

This paper illustrates the importance of monitoring health facility-level information to monitor changes in maternal mortality risks. The annual facility-level maternal mortality ratios (MMRs), complications to live births ratios and case fatality ratios (CFRs) were computed from data recorded during 2007 and 2009 in 31 upgraded public sector health facilities across Pakistan. The facility-level MMR declined by about 18%; both the number of Caesarean sections and the episodes of complications as a percentage of live births increased; and CFR based on Caesarean sections and episodes of complications declined by 29% and 37%, respectively. The observed increases in the proportion of women with complications among those who come to these facilities point to a reduction in the delay in reaching facilities (first and second delays; Thaddeus & Maine, 1994); the decrease in CFRs points to improvements in treating obstetric complications and a reduction in the delay in receiving treatment once at facilities (the third delay). These findings point to a decline in maternal mortality risks among communities served by these facilities. A system of woman-level data collection instituted at health facilities with comprehensive emergency obstetric care is essential to monitor changes in the effects of any reduction in the three delays and any improvement in quality of care or the effectiveness of treating pregnancy-related complications among women reaching these facilities. Such a system of information gathering at these health facilities would also help policymakers and programme mangers to measure and improve the effectiveness of safe-motherhood initiatives and to monitor progress being made toward achieving the fifth Millennium Development Goal.