Research Round-up: August 2010

Availability and quality of emergency obstetric care in Shanxi Province, China. Gao Y, Barclay L. International Journal of Gynecology and Obstetrics, June 2010.

Objective: To investigate the availability and quality of emergency obstetric care (EmOC) received by women in a rural Chinese province.  Methods: The study was conducted in 7 rural counties and townships in Shanxi Province, China. Data sources included interviews with 7 hospital leaders, 5 maternal and child health workers, and 7 obstetricians; 118 records of complicated delivery were audited, 21 Maternal and Child Health Annual Reports analyzed, and observations conducted of facilities and advanced labor care.  Results: The number of comprehensive EmOC facilities was adequate in all counties. Three counties had fewer basic EmOC facilities than recommended and only 4 counties reached the recommended level. Most of the existing township hospitals did not provide birthing services. All the county hospitals could perform cesarean deliveries with rates from 6.8%-40.8%. The management of complications was not evidence-based. For example, women with pre-eclampsia and eclampsia were given too little magnesium sulfate; women were not closely monitored for hemorrhage after birth and the partograph was used incorrectly with consequences for obstructed labor.  Conclusion:  Basic EmOC facilities are not adequate and township hospitals should be upgraded to provide birthing services. The quality of EmOC is poor and needs improvement.

Birthing Practices of Traditional Birth Attendants in South Asia in the Context of Training Programmes. Saravanan S, Turrell G, Johnson H, et al. Journal of Health Management, June 2010.
Abstract:   Traditional Birth Attendants (TBA) training has been an important component of public health policy interventions to improve maternal and child health in developing countries since the 1970s. More recently, since the 1990s, the TBA training strategy has been increasingly seen as irrelevant, ineffective or, on the whole, a failure due to evidence that the maternal mortality rate (MMR) in developing countries had not reduced. Although, worldwide data show that, by choice or out of necessity, 47 percent of births in the developing world are assisted by TBAs and/or family members, funding for TBA training has been reduced and moved to providing skilled birth attendants for all births. Any shift in policy needs to be supported by appropriate evidence on TBA roles in providing maternal and infant health care service and effectiveness of the training programmes.  This article reviews literature on the characteristics and role of TBAs in South Asia with an emphasis on India. The aim was to assess the contribution of TBAs in providing maternal and infant health care service at different stages of pregnancy and after-delivery and birthing practices adopted in home births. The review of role revealed that apart from TBAs, there are various other people in the community also involved in making decisions about the welfare and health of the birthing mother and new born baby. However, TBAs have changing, localised but nonetheless significant roles in delivery, postnatal and infant care in India. Certain traditional birthing practices such as bathing babies immediately after birth, not weighing babies after birth and not feeding with colostrum are adopted in home births as well as health institutions in India. There is therefore a thin precarious balance between the application of biomedical and traditional knowledge. Customary rituals and perceptions essentially affect practices in home and institutional births and hence training of TBAs need to be implemented in conjunction with community awareness programmes.  

Community and health system factors associated with facility delivery in rural Tanzania: A multilevel analysisKruk ME, Rockers PC, Mbaruku G, et al. Health Policy, June 2010. 
Objectives: Tanzania, a country with high maternal mortality, has many primary health facilities yet has a low rate of facility deliveries. This study estimated the contribution of individual and community factors in explaining variation in the use of health facilities for childbirth in rural Tanzania. Methods: A two-stage cluster population-based survey was conducted in Kasulu District, western Tanzania with women with a recent delivery. Random intercept multilevel logistic regression models were used to assess the association between individual- and village-level factors and likelihood of facility delivery.Results: 1205 women participated in the study. In the fully adjusted two-level model, in addition to several individual factors, positive village perception of doctor and nurse skills (odds ratio (OR) 6.72, 95% confidence interval (CI): 2.47-18.31) and negative perception of traditional birth attendant skills (OR 0.13, 95% CI: 0.04-0.40) were associated with higher odds of facility delivery. Conclusion: This study suggests that community perceptions of the quality of the local health system influence women’s decisions to deliver in a clinic. Improving quality of care at first-level clinics and communicating this to communities may assist efforts to increase facility delivery in sub-Saharan Africa.  

Confronting Maternal Mortality, Controlling Birth in Nepal: The Gendered Politics Of Receiving Biomedical Care At BirthBrunson J, Social Science & Medicine, June 2010. 
Abstract:  One way of reducing maternal mortality in developing countries is to ensure that women have a referral system at the local level that includes access to emergency obstetric care. Using a 13-month ethnographic study from 2003-2005 of women’s social positions and maternal health in a semi-urban community of Hindu-caste women in the Kathmandu Valley, this paper identifies impediments to receiving obstetric care in a context where the infrastructure and services are in place. As birth in Nepal predominantly takes place at home, this paper identifies the following areas for potential improvement in order to avoid the loss of women’s lives during childbirth: the frequency of giving birth unaided, minimal planning for birth or obstetric complications, and delayed responses at the household level to obstetric emergencies. Focusing particularly on the last item, this study concludes that women do not have the power to demand biomedical services or emergency care, and men still viewed birth as the domain of women and remained mostly uninvolved in the process. As the cultural construction of birth shifts from a “natural” phenomenon that did not require human regulation toward one that is located within the domain of biomedical expertise and control, local acceptance of a biomedical model does not necessarily lead to the utilization of services if neither women nor men are in a culturally-defined position to act.  

Countdown to 2015 decade report (2000—10): taking stock of maternal, newborn, and child survival. Bhutta ZA, Chopra M, Axelson H, et al. The Lancet, June 2010. 
Abstract:  The Countdown to 2015 for Maternal, Newborn, and Child Survival monitors coverage of priority interventions to achieve the Millennium Development Goals (MDGs) for child mortality and maternal health. We reviewed progress between 1990 and 2010 in coverage of 26 key interventions in 68 Countdown priority countries accounting for more than 90% of maternal and child deaths worldwide. 19 countries studied were on track to meet MDG 4, in 47 we noted acceleration in the yearly rate of reduction in mortality of children younger than 5 years, and in 12 countries progress had decelerated since 2000. Progress towards reduction of neonatal deaths has been slow, and maternal mortality remains high in most Countdown countries, with little evidence of progress. Wide and persistent disparities exist in the coverage of interventions between and within countries, but some regions have successfully reduced longstanding inequities. Coverage of interventions delivered directly in the community on scheduled occasions was higher than for interventions relying on functional health systems. Although overseas development assistance for maternal, newborn, and child health has increased, funding for this sector accounted for only 31% of all development assistance for health in 2007. We provide evidence from several countries showing that rapid progress is possible and that focused and targeted interventions can reduce inequities related to socioeconomic status and sex. However, much more can and should be done to address maternal and newborn health and improve coverage of interventions related to family planning, care around childbirth, and case management of childhood illnesses.   

Human touch to detect hypothermia in neonates in Indian slum dwellingsAgarwal S, Sethi V, Srivastava K, et al. Urban Health Resource Center.
Objective:  To assess the validity of human touch (HT) method to measure hypothermia compared against axillary digital thermometry (ADT) and study association of hypothermia with poor suckle and underweight status in newborns and environmental temperature in 11 slums of Indore city, India. Methods:  Field supervisors of slum-based health volunteers measured body temperature of 152 newborns by HT and ADT, observed suckling and weighed newborns. Underweight status was determined using WHO growth standards. Results: Hypothermia prevalence (axillary temperature <36.5 degrees C) was 30.9%. Prevalence varied by season but insignificantly. Hypothermia was insignificantly associated with poor suckle (31% vs 19.7%, p=0.21) and undernutrition (33.3% vs 25.3%, p=0.4). HT had moderate diagnostic accuracy when compared with ADT (kappa: 0.38, sensitivity: 74.5%, specificity: 68.5%).  Conclusions:  HT emerged simpler and programmatically feasible. There is a need to examine whether trained and supervised community-based health workers and mothers can use HT accurately to identify and manage hypothermia and other simple signs of newborn illness using minimal algorithm at home and more confidently refer such newborns to proximal facilities linked to the program to ensure prompt management of illness.

India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation. Lim SS, Dandona L, Hoisington JA, James SL, et al. The Lancet, June 2010.
In 2005, with the goal of reducing the numbers of maternal and neonatal deaths, the Government of India launched Janani Suraksha Yojana (JSY), a conditional cash transfer scheme, to incentivise women to give birth in a health facility. We independently assessed the effect of JSY on intervention coverage and health outcomes.  Methods: We used data from the nationwide district-level household surveys done in 2002—04 and 2007—09 to assess receipt of financial assistance from JSY as a function of socioeconomic and demographic characteristics; and used three analytical approaches (matching, with-versus-without comparison, and differences in differences) to assess the effect of JSY on antenatal care, in-facility births, and perinatal, neonatal, and maternal deaths.Findings:  Implementation of JSY in 2007—08 was highly variable by state—from less than 5% to 44% of women giving birth receiving cash payments from JSY. The poorest and least educated women did not always have the highest odds of receiving JSY payments. JSY had a significant effect on increasing antenatal care and in-facility births. In the matching analysis, JSY payment was associated with a reduction of 3•7 (95% CI 2•2—5•2) perinatal deaths per 1000 pregnancies and 2•3 (0•9—3•7) neonatal deaths per 1000 livebirths. In the with-versus-without comparison, the reductions were 4•1 (2•5—5•7) perinatal deaths per 1000 pregnancies and 2•4 (0•7—4•1) neonatal deaths per 1000 livebirths.Interpretation: The findings of this assessment are encouraging, but they also emphasise the need for improved targeting of the poorest women and attention to quality of obstetric care in health facilities. Continued independent monitoring and evaluations are important to measure the effect of JSY as financial and political commitment to the programme intensifies.

Institutional delivery in rural India: the relative importance of accessibility and economic statusKesterton, A., J. Cleland, et al. BMC Pregnancy and Childbirth.
Background: Skilled attendance at delivery is an important indicator in monitoring progress towards Millennium Development Goal 5 to reduce the maternal mortality ratio by three quarters between 1990 and 2015. In addition to professional attention, it is important that mothers deliver their babies in an appropriate setting, where life saving equipment and hygienic conditions can also help reduce the risk of complications that may cause death or illness to mother and child. Over the past decade interest has grown in examining influences on care-seeking behavior and this study investigates the determinants of place of delivery in rural India, with a particular focus on assessing the relative importance of community access and economic status.  Methods: A descriptive analysis of trends in place of delivery using data from two national representative sample surveys in 1992 and 1998 is followed by a two-level (child/mother and community) random-effects logistical regression model using the second survey to investigate the determinants. Results: In this investigation of institutional care seeking for child birth in rural India, economic status emerges as a more crucial determinant than access. Economic status is also the strongest influence on the choice between a private-for-profit or public facility amongst institutional births. Conclusion: Greater availability of obstetric services will not alone solve the problem of low institutional delivery rates. This is particularly true for the use of private-for-profit institutions, in which the distance to services does not have a significant adjusted effect. In the light of these findings a focus on increasing demand for existing services seems the most rational action. In particular, financial constraints need to be addressed, and results support current trials of demand side financing in India.

Issue attention in global health: the case of newborn survivalShiffman, J. The Lancet, June 2010.
Summary:  In many low-income countries newborn babies face difficult odds in living past the first month of life. About 3.8 million deaths occur every year in babies younger than 28 days—of which 99% are in the developing world—and deaths in the first month of life account for 42% of deaths in children younger than 5 years. Before 2000, few organisations paid much attention to neonatal mortality. Since that year, several organisations have come to address the problem, including foundations, UN agencies, bilateral development agencies, governments of low-income countries, and non-governmental organisations (NGOs).  

Maternal, neonatal and child health interventions and services: moving from knowledge of what works to systems that deliver. McCoy D, Storeng K, Filippi V, et al. International Health, June 2010.
Abstract: The last few years have seen a welcome re-emphasis on the need to address the unmet health needs of pregnant women and children worldwide in an integrated manner. Although a number of high profile publications have synthesized the main challenges, scientific evidence and policy recommendations for improving maternal and child health, there are many uncertainties and even disagreements about how maternal, neonatal and child health (MNCH) services and interventions should be scaled up. This paper describes the existence of eight ‘tensions’ which underlie these uncertainties and disagreements. These are competition between maternal and child health needs for scarce resources; demands for investment across the full continuum of care; balancing the provision of community and facility-based services; bridging the selective-comprehensive divide; using evidence but recognizing its limitations; managing both the public and the private; improving both supply and demand; and balancing short-term urgent demands with long-term needs. Based on a review of the literature and the experience of researchers belonging to the UK Department of International Development’s research program consortium on maternal health, this paper discusses the implications of these tensions for MNCH advocates, policy makers and planners, and makes three sets of recommendations. Two key messages are the need for more harmonization between the MNCH and health systems development agendas and greater recognition of the limitations of universal `gold standard’ evidence in informing policy development and implementation.  

Newborn care practices in urban slums: Evidence from central India. Siddharth Agarwal, Vani Sethi, Karishma Srivastava, Prabhat K. Jha, Abdullah H. Baqui. Journal of Neonatal-Perinatal Medicine, Issue Volume 2, Number 4 / 2009
Summary:  One-third of India’s urban population resides in slums and squatters, in extreme poverty conditions. Newborn care is sub-optimal among India’s urban poor, yet scarcely documented. We assessed newborn care practices in 11 urban slums of Indore in Central India. Practices such as clean cord care, thermal care, timely initiation of breastfeeding and exclusive breastfeeding upto neonatal period were enquired from 312 mothers of infants aged 2–4 months. Correlates of these practices were identified using multiple logistic regression. 72.1% births were home births (slum-home: 56.4%, native-village home: 15.7%).  Slum-based traditional birth attendants (sTBAs) conducted 77.3% slum-home births. Skilled assistance during slum-home births was low (7.4%). Clean cord care (22.2%) and thermal care (10.2%) practices were also low. Trained or skilled assistance during slum-home births was positively associated with clean cord care (OR 4.8 CI 1.7–13.6) and thermal care (OR 2.0 CI: 1.1–4.1). Timely initiation of breastfeeding was sub-optimal (50.6%) even in facility births. Exclusive breastfeeding upto neonatal period was higher for mothers counselled on exclusive breastfeeding by a health volunteer during neonatal period (OR 2.3, CI 1.4–3.8).  Following emerge imperative for improving newborn care in urban slums- i) antenatal and postnatal counselling by trained health volunteers, ii) enhancing competence of sTBAs and linking them to affordable facilities and iii) sensitizing and training public health facility staff.  

Sub-Saharan Africa’s Mothers, Newborns, and Children: How Many Lives Could Be Saved with Targeted Health Interventions? Friberg IK, Kinney MV, Lawn JE, et al. PLoS Medicine, June 2010.
Summary:  Sub-Saharan Africa is at a critical point for achieving the Millennium Development Goals for maternal and child survival. Time is short so strategic action is needed now to maximize mortality reduction by 2015.  We estimated mortality reduction for 42 sub-Saharan African countries if high coverage of MNCH interventions was achieved, using the Lives Saved Tool (LiST). Nearly 4 million African women, newborns, and children need not die each year if already well known interventions reached 90% of families.  We also undertook a detailed analysis of nine African countries that estimated mortality reductions and additional cost for feasible increases in coverage of selected high-impact MNCH interventions considering three differing health system contexts. It revealed that a 20% coverage increase for selected community-based/outreach interventions would save an estimated 486,000 lives and cost an additional US$1.21 per capita. Increasing the quality of current facility births would save 105,000 lives and cost an additional US$0.54 per capita.  Functioning health systems require both community-based or outreach services and facility-based care. Maximizing mortality impact for Africa’s mothers, newborns, and children depends on using local data to prioritize the most effective mix of interventions, while building a stronger health system.

Sub-Saharan Africa’s Mothers, Newborns, and Children: Where and Why Do They Die? Kinney MV, Kerber KJ, Black RE, et al. PLoS Medicine, June 2010.
Summary:  Every year 4.4 million children—including 1.2 million newborns—and 265,000 mothers die in sub-Saharan Africa. This amounts to 13,000 deaths per day or almost nine deaths every minute. Sub-Saharan Africa has half of the world’s maternal, newborn, and child deaths.  The five biggest challenges for maternal, newborn, and child health in sub-Saharan Africa are: pregnancy and childbirth complications, newborn illness, childhood infections, malnutrition, and HIV/AIDS.  Many scientifically proven health interventions are available for maternal, newborn, and child health such as medicines, immunizations, insecticide-treated bed nets, and equipment for emergency obstetric care. Yet many African governments are currently underutilizing existing scientific knowledge to save women’s and children’s lives.  A scientific approach based on local epidemiological and coverage data is needed to prioritize the highest impact and most appropriate interventions in a given context. Most countries in sub-Saharan Africa are behind in achieving the Millennium Development Goals (MDGs) for maternal and child health by 2015. However, progress in several low-income countries demonstrates that the MDGs could still be attained through immediate strategic investments in selected evidence-based interventions and targeted health systems strengthening. Many countries are at a tipping point and now is the critical time to use local data to set priorities and accelerate action.

Post a Comment