Safe Motherhood Programs Research Articles

Healthy mothers, healthy children: does maternal demand for antenatal care matter for child health in Nepal?

Nepal's Safe Motherhood Programme has failed to deliver expected gains in maternal and child health. Nepalese mothers and their children continue to dispense with (or be denied) antenatal care, experience high maternal mortality rates and suffer chronic malnutrition. We address the correlates and consequences of antenatal care utilization in Nepal by applying two-stage least squares, binomial logit and Heckman selection bias estimates to data drawn from the Nepal Health and Demographic Surveys of 1996 and 2001. Results indicate that maternal education, even at low levels, significantly increases the use of antenatal care; paternal education plays a more important role in the use of routine antenatal care than the conventional wisdom suggests; and when mothers use routine professional antenatal care and maintain good health their children tend to stay healthy through infancy and early childhood. Since health-seeking behaviour is circumscribed by patriarchal gender norms in Nepal, health policies should not only focus on female education and women's status, but also involve husbands in the process of maternal care utilization.

Strengthening HIV services for pregnant women: an opportunity to reduce maternal mortality rates in Southern Africa/sub‐Saharan Africa

Reliable data from South Africa emanating from WHO recommendations for the Safe Motherhood programme underscores HIV/AIDS as the most common cause of maternal deaths. The strengthening of HIV services for pregnant women especially in countries with a high burden of HIV infection will reduce HIV-related and un-related maternal mortality rates. High-quality and complete data on maternal deaths is a critical foundation for reliably monitoring temporal trends in maternal deaths, and causes thereof, but needs substantial strengthening in many resource-constrained settings. HIV/AIDS is an increasing contributor to direct and indirect causes of maternal deaths in sub-Saharan Africa. A review of published data on maternal deaths and its association with HIV shows that reliable data come from the Confidential Enquiries into Maternal Deaths from South Africa, population-based surveys in sentinel populations, and facility-based data. Despite an increase in knowledge of the HIV status of pregnant women and the initiation of antiretroviral treatment, reversals in trends towards increased maternal deaths are not being observed. The strengthening of HIV services provides an opportunity to alter HIV epidemic trajectories and reduce maternal deaths.

An impact evaluation of the Safe Motherhood Program in China

Using 11 years of county-level panel data, fixed effect models are estimated to evaluate the impact of the Safe Motherhood (SM) Program in China. Propensity score matching is used to select comparable factual and counterfactual counties. Out of 2013 counties in China, 283 are selected for the treatment group and 1051 for the control group. The results support the causal relationship between the program and its targeted outcomes and the partial effects increases as years of exposure in the program: 7 years' treatment of the program increases hospital delivery rate by 3.992 per 100 live births and decreases Maternal mortality ratio (MMR) due to hemorrhage by 10.229 per 100,000 live births. Further modeling supports the conclusion that the program reduces MMR by enhancing MCH care. With an average annual incremental unit cost for the program of about 318.0 thousand RMB (39.8 thousand USD) per county, we conclude that the SM Program is effective in reducing MMR through the enhancement of hospital delivery.

Community perceptions of the causes and prevention of maternal mortality

The objective was to identify community members' perceptions of the causes and prevention of maternal mortality in Ibadan, North East Local Government Area of Oyo State, Nigeria. Reported in this article are the results from a pilot study, carried out in 2005, of the views of 418 community men and women aged 15–49 years in Idi ape, Iwo Road and Okeadu areas of Ibadan North East. Data were collected over a two-week period using interviews with a structured questionnaire consisting of open-ended questions. People's perceptions of the causes and prevention of maternal death varied widely. Both medical and non-medical factors were reported as being responsible. The perceived causes of maternal mortality ranged from medical/obstetrical to individual, health personnel, governmental and supernatural causes. Participants stated that to prevent maternal mortality in this setting, awareness creation of the causes of maternal mortality is crucial and that a lot of political will is needed from the government of Oyo State and Nigeria as a whole. The government should improve the provision of well-equipped health facilities staffed by qualified health professionals providing a free or subsidised service. For a fuller understanding of maternal morbidity and mortality, it is important to consider factors outside the hospital and formal medical practice. These findings have important implications for the design and implementation of safe motherhood programmes and in formulation of safe motherhood policy in Nigeria.

Nyfødtmedisin i India

ENGLISH SUMMARYSaugstad OD. Newborn medicine in India. Nor J Epidemiol 1997; 7 (1): 99-102.India has the largest newborn population in the world with approximately 25 million deliveries annually.Of these 1.3 million die in the newborn period and 4 million before the age of five. The last yearsnewborn medicine has become a high priority area in India. The goals by the year 2000 are to reduceperinatal mortality from 60 to 30-35/1000 and infant mortality from 74 to < 60/1000. The number oflow birth weigth infants is today approximately 30% and the goal is to reduce this to 10% at the turn ofthe century. A number of efficient strategies have been developed in order to reduce perinatal andneonatal mortality. Since 1992 the socalled Child Survival and Safe Motherhood (CSSM) program hascontributed significantly to reduce mortality and improve newborn care. The Indian approach is verysystematic summing up in a few key points the necessary care which should be provided at each level.Developing countries could certainly learn from the Indian experience in solving their own healthproblems. The strategy for improving the skills in newborn resuscitation has for instance been verysuccessfull by implementing the program: ‘Give a breath, save a life’. In the course of only 3 yearsmore than 10 000 health care workers were trained in resuscitation procedures.

Causes of Maternal Mortality Decline in Matlab, Bangladesh

Bangladesh is distinct among developing countries in achieving a low maternal mortality ratio (MMR) of 322 per 100,000 livebirths despite the very low use of skilled care at delivery (13% nationally). This variation has also been observed in Matlab, a rural area in Bangladesh, where longitudinal data on maternal mortality are available since the mid-1970s. The current study investigated the possible causes of the maternal mortality decline in Matlab. The study analyzed 769 maternal deaths and 215,779 pregnancy records from the Health and Demographic Surveillance System (HDSS) and other sources of safe motherhood data in the ICDDR,B and government service areas in Matlab during 1976-2005. The major interventions that took place in both the areas since the early 1980s were the family-planning programme plus safe menstrual regulation services and safe motherhood interventions (midwives for normal delivery in the ICDDR,B service area from the late 1980s and equal access to comprehensive emergency obstetric care [EmOC] in public facilities for women from both the areas). National programmes for social development and empowerment of women through education and microcredit programmes were implemented in both the areas. The quantitative findings were supplemented by a qualitative study by interviewing local community care providers for their change in practices for maternal healthcare over time. After the introduction of the safe motherhood programme, reduction in maternal mortality was higher in the ICDDR,B service area (68.6%) than in the government service area (50.4%) during 1986-1989 and 2001-2005. Reduction in the number of maternal deaths due to the fertility decline was higher in the government service area (30%) than in the ICDDR,B service area (23%) during 1979-2005. In each area, there has been substantial reduction in abortion-related mortality--86.7% and 78.3%--in the ICDDR,B and government service areas respectively. Education of women was a strong predictor of the maternal mortality decline in both the areas. Possible explanations for the maternal mortality decline in Matlab are: better access to comprehensive EmOC services, reduction in the total fertility rate, and improved education of women. To achieve the Millenium Development Goal 5 targets, policies that bring further improved comprehensive EmOC, strengthened family-planning services, and expanded education of females are essential.

Joining the dots: a plea for precise estimates of the maternal mortality ratio in sub‐Saharan Africa

Monitoring of maternal mortality levels in sub-Saharan Africa (SSA) to assess the achievements of safe motherhood programmes and for MDG-5 has been made difficult because of the lack of precise estimates of the maternal mortality ratio (MMR). Projections based on the slow rate of decline of the MMR indicate that MDG-5 may not be reached before the end of this century in this region. Measurements done using demographical and health surveys, statistical modelling and censuses are imprecise and do not allow trends in individual countries to be established. SSA countries should be encouraged to measure mortality levels from their own resources, using methods that produce precise estimates such as population-based surveys. Establishment of the trends will lead to country-specific program targets. The less frequent but more precise measurements can be afforded by SSA countries, as a case study from Zimbabwe shows.

National neonatology forum (NNF): Role in mainstreaming newborn health in India

In the late seventies, a group of concerned and motivated pediatricians founded the National Neonatology Forum of India. This proactive group highlighted the plight of non-existent neonatal care to the government. The group got together to define the tasks and priorities of the forum. In addition, they formulated the norms for newborn care including the need for space, equipment and the nursing and medical manpower. Realizing the acute shortage of trained professionals along with the other inadequacies, the forum's committed members put up a strong case of advocacy for newborn care at the government, non-government and the community level. The sustained efforts resulted in formulation of “Minimum Perinatal Care Task Force” by the Ministry of Health & FW, Government of India in 1982. The forum then laid guidelines for health care, education and research. The sustained highly motivated and aggressive advocacy with well defined task oriented objectives and efforts began to bear fruits in the decade of nineties. This was first reflected by inclusion of the newborn care albeit at a low key in the Government of India, Ministry of Health & FW, “Child Survival and Safe motherhood Program”. The legacy has continued and more recently the forum has been actively pursuing neonatal care program with the government and non-government national and international agencies. These are the Integrated Management of Neonatal & Childhood Illnesses (IMNCI) and Facility Based Newborn Care program under RCH II, the flagship program of the National Rural Health Mission.

Severe acute maternal morbidity in low-income countries

Although obstetric complications are sometimes presented as a relatively easy alternative to maternal deaths, difficulties remain in their definition and identification, and there is limited experience with the use of severe obstetric complications as a starting point for audits or case reviews or as an indicator for monitoring the success of safe motherhood programmes in low-income countries. In this paper we review published studies reporting on the measurement of severe acute maternal morbidity in low-income countries. We found 37 studies from 24 countries. We describe the definition and ascertainment of cases of severe acute maternal morbidity and we give examples of how information on severe acute maternal morbidity has been used to inform safe motherhood programmes in low-income countries.

Cultural Humility is the First Step to Becoming Global Care Providers

Correspondence Suellen Miller, CNM, CNM, PhD, Safe Motherhood Programs, University of California, San Francisco, 50 Beale Street, San Francisco, CA. smiller@globalhealth.ucsf. edu, suellenmiller@gmail.com Within the past two decades there has been an exponential growth of interest in and participation of U.S. health clinicians and students in global health. Schools of Nursing, Midwifery, Medicine, and Public Health have developed courses, programs, divisions, and specialty areas that focus on global health. As a result, many students, faculty, and clinicians spend time in low resource countries where the disease burdens are greatest. Attention to the 90/10 gap in health (in which only 10% of the world’s health research budget is spent on diseases that aiect 90% of the world’s population) (Resnik, 2004) has also engendered more research on the diseases and disorders of low resource countries. Further, the United Nations Millennium Development Goals, a set of global mandates for health and development, address diseases of poverty and demand greater global equity in health (United Nations Development Programme, 2008). Goal 4, Reducing Child Mortality and Goal 5, Reducing Maternal Mortality are particularly relevant for JOGNN readers. Finally, during this 20-year time period, the United States has become far more culturally and ethnically diverse. Now most nurses care for people from a wide range of cultural backgrounds.

How important are individual, household and commune characteristics in explaining utilization of maternal health services in Vietnam?

Using Vietnam's latest National Household Survey data for 2001–2002 this paper assesses the influence of individual, household and commune-level characteristics on a woman's decision to seek prenatal care, on the number of prenatal visits, and on the choice between giving birth at a health facility or at home. The decision to use any care and the number of prenatal visits is modeled using a two-part model. A random intercept logistic model is used to capture the influence of unobserved commune-specific factors found in the data regarding a woman's decision to give birth at a health facility rather than at home. The results show that access to prenatal care and delivery assistance is limited by observed barriers such as low income, low education, ethnicity, geographical isolation and a high poverty rate in the community. More specifically, more prenatal visits increase the likelihood of giving birth at a health facility. Having compulsory health insurance increases the odds of giving birth at a health facility for middle and high income women. In contrast, health insurance for the poor increases the likelihood of having more prenatal visits but has little effect on the place of delivery. These results suggest that the existing safe motherhood programs should be linked with the objectives of social development programs such as poverty reduction, and that policy makers need to view both the individual and the commune as appropriate units for policy targeting.

From evaluating a Skilled Care Initiative in rural Burkina Faso to policy implications for safe motherhood in Africa

Evaluation findings from a particular setting need to be generalized into policy implications if they are to find widespread use. Skilled attendance at delivery is widely regarded as one of the most important intervention strategies for safe motherhood in low-resource settings, particularly in Africa, but implementations of such strategies are often not rigorously evaluated or interpreted into future policy. Initiative for Maternal Mortality Programme Assessment (Immpact) has applied a package of research-based monitoring and evaluation tools to assess the Family Care International Skilled Care Initiative in Ouargaye District, Burkina Faso. This evaluation research aimed to generate reliable, evidence-based policies for accelerating safe motherhood programmes in Burkina Faso and elsewhere in Africa. Five policy priorities were identified as representing real chances of improving the safety of motherhood: (1) enhancing national coverage of delivery by professionally skilled attendants; (2) to provide a network of 24-h basic emergency obstetric care within 5 km; (3) to have an effective referral system, equipped and resourced to undertake a reasonable number of Caesarean sections; (4) to promote community mobilization activities as a lever to increasing delivery care utilization; and (5) to implement strategies to remove financial barriers to delivery care. To meet Millennium Development Goal five by 2015, both supply and demand side constraints on the provision of quality maternity care have to be addressed, which in turn need greater political commitment and funding.

Skilled or Traditional Birth Attendant? Choices of Communities in Lukulu District, Rural Zambia

To analyse factors that contribute to the choice of either traditional birth attendants (TBAs) or skilled birth attendants (SBAs) by inhabitants of Zambia's Lukulu District. Cross-sectional descriptive survey. Lukulu District, Western Province, Zambia. 1413 participants: parous women, their husbands, village headmen and elderly women. Preferred and actual place of birth. Questionnaires, structured interviews and focus group discussions. 42% of women gave birth in a health facility, assisted by SBAs; 75: prefer to give birth in a health facility; many barriers are to be passed for women to reach a skilled attendant in time. Skilled birth attendants are preferred to assist at childbirth in Lukulu District. Transportation problems, sociocultural reasons and unpreparedness still cause the majority of women to turn to traditional birth attendants. Traditional birth attendants should not yet be excluded from safe motherhood programs.

Perception of Bleeding as a Danger Sign During Pregnancy, Delivery, and the Postpartum Period in Rural Nepal

Many developing countries implement safe motherhood programs to tackle high maternal mortality rates. The approach requires recognition of the signs of emergency obstetric cases in order to facilitate immediate care seeking, followed by immediate medical care. Whether such signs are recognized in a timely manner at the community level is determined by how the community perceives health problems. We explore the local understanding of one danger sign--bleeding during pregnancy and at delivery--and the meaning attached to it. The study was conducted in the Kavrepalanchowk district of Nepal. Different qualitative methods were applied. The findings indicate that the community's perception of bleeding might be quite different from that of health professionals and that perceptions and meanings attached to bleeding vary depending on the actors in the family. They all have significant implications for what should be the focus of health education and who should be involved in promoting maternal health.

Delivery practices of traditional birth attendants in Dhaka slums, Bangladesh.

This paper describes associations among delivery-location, training of birth attendants, birthing practices, and early postpartum morbidity in women in slum areas of Dhaka, Bangladesh. During November 1993-May 1995, data on delivery-location, training of birth attendants, birthing practices, delivery-related complications, and postpartum morbidity were collected through interviews with 1,506 women, 489 home-based birth attendants, and audits in 20 facilities where the women from this study gave birth. Associations among maternal characteristics, birth practices, delivery-location, and early postpartum morbidity were specifically explored. Self-reported postpartum morbidity was associated with maternal characteristics, delivery-related complications, and some birthing practices. Dais with more experience were more likely to use potentially-harmful birthing practices which increased the risk of postpartum morbidity among women with births at home. Postpartum morbidity did not differ by birth-location. Safe motherhood programmes must develop effective strategies to discourage potentially-harmful home-based delivery practices demonstrated to contribute to morbidity.

Safe motherhood in Ghana: Still on the agenda?

Objective This paper is an exploration of health sector and programming issues that resulted from a description of safe motherhood activities in Ghana. Methods Descriptions of safe motherhood programmes were collected from various stakeholders through structured interviews. The characteristics of the programmes were compared to national safe motherhood aims and in the context of the reproductive health and sector-wide environment in Ghana. Results Thirteen safe motherhood programmes were described. Their goals were wide ranging and did not necessarily target pregnant and postpartum women only. Community based interventions were slightly less dominant than service provision activities. A broad funding base was identified, strongly represented by external donors. Many funding contributions were not part of the Ghana government's Sector-Wide Approach (SWAp) to health. Conclusions Although reduction in maternal mortality ratio is a priority in Ghana's policy, many funding agencies supporting what are known as “safe motherhood” programmes are actually pursuing a somewhat broader reproductive health agenda. The evidence that this situation has actually led to a dilution of the maternal mortality reduction agenda is inconclusive, although our analysis has resulted in lessons which could be used to avert any risk to achieving this key millennium development goal. Government can use the SWAp to keep interests focused on the need for maternal mortality reduction, without detriment to other priorities. Strengthening partnerships will allow civil society and community focused interests to have a voice in influencing SWAp agendas. Good programme design with clear understanding of the link between programme components and objectives will help in making sure that maternal mortality targets are indeed achieved.

Strengthening emergency obstetric care in Nepal: The Women's Right to Life and Health Project (WRLHP)

Introduction The Women's Right to Life and Health Project contributes to Nepal's National Safe Motherhood Program and maternal mortality reduction efforts by working to improve the availability, quality and utilization of emergency obstetric care services in public health facilities. Methods The project upgraded 8 existing public health facilities through infrastructure, equipment, training, data collection, policy advocacy, and community information activities. The total cost of the project was approximately US$1.6 million. Results In 5 years, 3 comprehensive and 4 basic emergency obstetric care (EmOC) facilities were established in an area where adequate EmOC services were previously lacking. From 2000 to 2004, met need for EmOC improved from 1.9 to 16.9%; the proportion of births in EmOC project facilities increased from 3.8 to 8.3%; and the case fatality rate declined from 2.7 to 0.3%. Discussion While the use of maternity services is still low in Nepal, improving availability and quality of EmOC together with community empowerment can increase utilization by women with complications, even in low-resource settings. Partnerships with government and donors were key to the project's success. Similar efforts should be replicated throughout Nepal to expand the availability of essential life-saving services for pregnant women.

Patterns of maternal care seeking behaviours in rural Bangladesh

Seeking care from a basic or comprehensive facility in response to obstetric complications is a key behaviour promoted in safe motherhood programmes. This study examined definitions of care seeking for maternal health complications used by families in rural Bangladesh, and the frequency and determinants of locally-defined care seeking practices. We conducted 24 semi-structured qualitative interviews with women who had recently given birth to characterize care seeking behaviours in response to perceived complications. Based on these findings, a quantitative household questionnaire was developed and administered to 1490 women, half of whom reported a 'serious or very serious' complication during their last pregnancy and/or delivery (n=769; 52%), and were included in the quantitative analysis. Informants described three care seeking patterns in qualitative interviews: (i) sending a family member to purchase treatment to administer in the home; (ii) sending for a provider to treat the woman in the home and (iii) taking the woman outside the home to a facility or provider's office. The quantitative survey revealed that most women sought care for 'serious' complications (86%), with 42% seeking multiple sources of care. The majority of women purchased a treatment to administer at home (68%), while 20% brought a provider to the home. Thirty per cent of women were taken to a provider or facility. Families generally seek care for complications, but care seeking does not correspond to definitions used by maternal health programmes. Local definitions of care seeking must be considered in intervention design so that promotion of care seeking increases for facility-based care for life-threatening emergencies rather than unintentionally increasing the use of home-based treatments of little medical value for prevention of mortality.

ACCESS TO HEALTH: WOMEN’S STATUS AND UTILIZATION OF MATERNAL HEALTH SERVICES IN NEPAL

With the objective of reducing maternal and neonatal mortality, the Safe Motherhood Program was implemented in Nepal in 1997. It was launched as a priority programme during the ninth five-year plan period, 1997-2002, with the aim of increasing women's access to health care and raising their status. This paper examines the association of access to health services and women's status with utilization of prenatal, delivery, and postnatal care during the plan period. The 1996 Nepal Family Health Survey and the 2001 Nepal Demographic and Health Survey data were pooled and the likelihood of women's using maternal health care was examined in 2001 in comparison with 1996. Multiple logistic regression analysis indicates that the utilization of maternal health services increased over the period. Programme interventions such as outreach worker's visits, radio programmes on maternal health, maternal health information disseminated through various mass media sources and raising women's status through education were able to explain the observed change in utilization. Health worker visits and educational status of women showed a large association, but radio programmes and other mass media information were only partially successful in increasing use of maternal health services. Socioeconomic and demographic variables such as household economic status, number of living children and place of residence showed stronger association with use of maternal health services then did intervention programmes.

Setting priorities for safe motherhood programme evaluation: A participatory process in three developing countries

A participatory approach to priority setting in programme evaluation may help improve the allocation and more efficient use of scarce resources especially in low-income countries. Research agendas that are the result of collaboration between researchers, programme managers, policy makers and other stakeholders have the potential to ensure rigorous studies are conducted on matters of local priority, based on local, expert knowledge. This paper describes a process involving key stakeholders to elicit and prioritise evaluation needs for safe motherhood in three developing countries. A series of reiterative consultations with safe motherhood stakeholders from each country was conducted over a period of 36 months. In each country, the consultation process consisted of a series of participatory workshops; firstly, stakeholder's views on evaluation were elicited with parallel descriptive work on the contexts. Secondly, priorities for evaluation were identified from stakeholders; thirdly, the evaluation-priorities were refined; and finally, the evaluation research questions, reflecting the identified priorities, were agreed and finalised. Three evaluation-questions were identified in each country, and one selected, on which a full scale evaluation was undertaken. While there is a great deal written about the importance of transparent and participatory priority setting in evaluation; few examples of how such processes could be implemented exist, particularly for maternal health programmes. Our experience demonstrates that the investment in a participatory priority-setting effort is high but the process undertaken resulted in both globally and contextually-relevant priorities for evaluation. This experience provides useful lessons for public health practitioners committed to bridging the research–policy interface.