Health Extension Workers' and Mothers' Attitudes to Maternal Health Service Utilization and Acceptance in Adwa Woreda,Tigray Region,Ethiopia

Background

The maternal health system in Ethiopia links health posts in rural communities (kebeles) with district (woreda) health centres, and health centres with primary hospitals. At each health post two Health Extension Workers (HEWs) assist women with birth preparedness, complication readiness, and mobilize communities to facilitate timely referral to mid-level service providers. This study explored HEWs’ and mother’s attitudes to maternal health services in Adwa Woreda, Tigray Region.

Methods

In this qualitative study, we trained 16 HEWs to interview 45 women to gain a better understanding of the social context of maternal health related behaviours. Themes included barriers to health services; women’s social status and mobility; and women’s perceptions of skilled birth attendant’s care. All data were analyzed thematically.

Findings

There have been substantial efforts to improve maternal health and reduce maternal mortality in Adwa Woreda. Women identified barriers to healthcare including distance and lack of transportation due to geographical factors; the absence of many husbands due to off-woreda farming; traditional factors such as zwar (some pregnant women are afraid of meeting other pregnant women), and discouragement from mothers and mothers-in-law who delivered their children at home. Some women experienced disrespectful care at the hospital. Facilitators to skilled birth attendance included: identification of pregnant women through Women’s Development Groups (WDGs), and referral by ambulance to health facilities either before a woman’s Expected Due Date (EDD) or if labour started at home.

Conclusion

With the support of WDGs, HEWs have increased the rate of skilled birth attendance by calling ambulances to transfer women to health centres either before their EDD or when labour starts at home. These findings add to the growing body of evidence that health workers at the community level can work with women’s groups to improve maternal health, thus reducing the need for emergency obstetric care in low-income countries.     

HIV/AIDS in rural India: context and health care needs

Primary research on HIV/AIDS in India has predominantly focused on known risk groups such as sex workers, STI clinic attendees and long-distance truck drivers, and has largely been undertaken in urban areas. There is evidence of HIV spreading to rural areas but very little is known about the context of the infection or about issues relating to health and social impact on people living with HIV/AIDS. In-depth interviews with nineteen men and women infected with HIV who live in rural areas were used to collect experiences of testing and treatment, the social impacts of living with HIV and differential impacts on women and men. Eight focus group discussions with groups drawn from the general population in the four villages were used to provide an analysis of community level views about HIV/AIDS. While men reported contracting HIV from sex workers in the cities, women considered their husbands to be the source of their infection. Correct knowledge about HIV transmission co-existed with misconceptions. Men and women tested for HIV reported inadequate counselling and sought treatment from traditional healers as well as professionals. Owing to the general pattern of husbands being the first to contract HIV women faced a substantial burden, with few resources remaining for their own or their children's care after meeting the needs of sick husbands. Stigma and social isolation following widowhood were common, with an enforced return to the natal home. Implications for potential educational and service interventions are discussed within the context of gender and social relations.     

Reproductive health knowledge and use of services among young adults in Dakar, Senegal

A study was conducted in Dakar, Senegal, to measure reproductive health knowledge and contraceptive use among young adults, and access to family planning services. A household survey was conducted with 1973 single and married women aged 15-24 and 936 single men aged 15-19. Two focus groups and a simulated client study were also conducted. The survey and focus groups noted gaps in knowledge of family planning methods and reproductive health. There were misconceptions about methods and only one-third of men and women aged 15-19 correctly identified the time of the menstrual cycle when a women is most likely to get pregnant. Contraceptive use at time of first premarital sexual experience was less than 30%. The simulated client study noted many barriers to services. 'Clients' felt uncomfortable in the clinics and felt that providers were reluctant to take care of them. None of the 'clients' who requested contraception received it.     

Knowledge,Attitudes, and Practices Related to Uterotonic Drugs during Childbirth in Karnataka,India: A Qualitative Research Study

Background and Objectives

India has the highest annual number of maternal deaths of any country. As obstetric hemorrhage is the leading cause of maternal death in India, numerous efforts are under way to promote access to skilled attendance at birth and emergency obstetric care. Current initiatives also seek to increase access to active management of the third stage of labor for postpartum hemorrhage prevention, particularly through administration of an uterotonic after delivery. However, prior research suggests widespread inappropriate use of uterotonics at facilities and in communities–for example, without adequate monitoring or referral support for complications. This qualitative study aimed to document health providers’ and community members’ current knowledge, attitudes, and practices regarding uterotonic use during labor and delivery in India’s Karnataka state.

Methods

140 in-depth interviews were conducted from June to August 2011 in Bagalkot and Hassan districts with physicians, nurses, recently delivered women, mothers-in-law, traditional birth attendants (dais), unlicensed village doctors, and chemists (pharmacists).

Results

Many respondents reported use of uterotonics, particularly oxytocin, for labor augmentation in both facility-based and home-based deliveries. The study also identified contextual factors that promote inappropriate uterotonic use, including high value placed on pain during labor; perceived pressure to provide or receive uterotonics early in labor and delivery, perhaps leading to administration of uterotonics despite awareness of risks; and lack of consistent and correct knowledge regarding safe storage, dosing, and administration of oxytocin.

Conclusions

These findings have significant implications for public health programs in a context of widespread and potentially increasing availability of uterotonics. Among other responses, efforts are needed to improve communication between community members and providers regarding uterotonic use during labor and delivery and to target training and other interventions to address identified gaps in knowledge and ensure that providers and pharmacists have up-to-date information regarding proper usage of uterotonic drugs.     

Birth rights and rituals in rural south India: care seeking in the intrapartum period

Maternal morbidity and mortality are high in the Indian context, but the majority of maternal deaths could be avoided by prompt and effective access to intrapartum care (WHO, 1999). Understanding the care seeking responses to intrapartum morbidities is crucial if maternal health is to be effectively improved, and maternal mortality reduced. This paper presents the results of a prospective study of 388 women followed through delivery and traditional postpartum in rural Karnataka in southern India. In this setting, few women use the existing health facilities and most deliveries occur at home. The analysis uses quantitative data, collected via questionnaires administered to women both during pregnancy and immediately after delivery. By virtue of its prospective design, the study gives a unique insight into intentions for intrapartum care during pregnancy as well as events following morbidities during labour. Routine care in the intrapartum period, both within institutions and at home, and impediments to appropriate care are also examined. The study was designed to collect information about health seeking decisions made by women and their families as pregnancies unfolded, rather than trying to capture women's experience from a retrospective instrument. The data set is therefore a rich source of quantitative information, which incorporates details of event sequences and health service utilization not previously collected in a Safe Motherhood study. Additional qualitative information was also available from concurrent in-depth interviews with pregnant women, their families, health care providers and other key informants in the area. The level of unplanned institutional care seeking during the intrapartum period within the study area was very high, increasing from 11% planning deliveries at a facility to an eventual 35% actually delivering in hospitals. In addition there was a significant move away from planned deliveries with the auxiliary nurse midwive (ANM), to births with a lay attendant or dai. The proportion of women who planned for an ANM to assist was 49%, as compared with the actual occurrence, which was less than half of this proportion. Perceived quality of care was found to be an important factor in health seeking behaviour, as was wealth, caste, education and experience of previous problems in pregnancy. Actual care given by a range of practitioners was found to contain both beneficial and undesirable elements. As a response to serious morbidities experienced within the study period, many women were able to seek care although sometimes after a long delay. Those women who experienced inadequate progression of labour pains were most likely to proceed unexpectedly to a hospital delivery.     

Do mothers-in-law matter? Family dynamics and fertility decision-making in urban squatter settlements of Karachi, Pakistan

The perspectives of mothers-in-law about intra-household decision-making, family size and family planning are investigated, and their views compared with those of their sons and daughters-in-law. Women (717 daughters-in-law), their husbands (717 sons) and their 522 mothers-in-law were interviewed in eight squatter settlements in Karachi, Pakistan. Decisions about the schooling and health care of children, and the purchase of jewellery, are perceived to lie within the nuclear family domain (i.e. husband and wife). There was a difference in mothers-in-law's, daughters-in-law's and sons' desire to have more children. Twenty-eight per cent of mothers-in-law versus 58%, of daughters-in-law did not want more grandsons/sons and 36%, of mothers-in-law versus 66% of daughters-in-law did not want more granddaughters/daughters. The difference was markedly greater among the mother-in-law/daughter-in-law pairs than in the mother/son pairs. Overall, the mother-in-law's role seems to be somewhat overshadowed by that of her son (family male member), except for limiting family size. It is suggested that mothers-in-law should be included in Information-Education-Communication (IEC) campaigns about family planning.     

A Systematic Review of Individual and Contextual Factors Affecting ART Initiation,Adherence, and Retention for HIV-Infected Pregnant and Postpartum Women

Background

Despite progress reducing maternal mortality, HIV-related maternal deaths remain high, accounting, for example, for up to 24 percent of all pregnancy-related deaths in sub-Saharan Africa. Antiretroviral therapy (ART) is effective in improving outcomes among HIV-infected pregnant and postpartum women, yet rates of initiation, adherence, and retention remain low. This systematic literature review synthesized evidence about individual and contextual factors affecting ART use among HIV-infected pregnant and postpartum women.

Methods

Searches were conducted for studies addressing the population (HIV-infected pregnant and postpartum women), intervention (ART), and outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. Individual and contextual enablers and barriers to ART use were extracted and organized thematically within a framework of individual, interpersonal, community, and structural categories.

Results

Thirty-four studies were included in the review. Individual-level factors included both those within and outside a woman’s awareness and control (e.g., commitment to child’s health or age). Individual-level barriers included poor understanding of HIV, ART, and prevention of mother-to-child transmission, and difficulty managing practical demands of ART. At an interpersonal level, disclosure to a spouse and spousal involvement in treatment were associated with improved initiation, adherence, and retention. Fear of negative consequences was a barrier to disclosure. At a community level, stigma was a major barrier. Key structural barriers and enablers were related to health system use and engagement, including access to services and health worker attitudes.

Conclusions

To be successful, programs seeking to expand access to and continued use of ART by integrating maternal health and HIV services must identify and address the relevant barriers and enablers in their own context that are described in this review. Further research on this population, including those who drop out of or never access health services, is needed to inform effective implementation.     

PROVIDER‐INITIATED HIV TESTING AND COUNSELING IN HEALTH FACILITIES – WHAT DOES THIS MEAN FOR THE HEALTH AND HUMAN RIGHTS OF PREGNANT WOMEN?

Since the introduction of drugs to prevent vertical transmission of HIV, the purpose of and approach to HIV testing of pregnant women has increasingly become an area of major controversy. In recent years, many strategies to increase the uptake of HIV testing have focused on offering HIV tests to women in pregnancy-related services. New global guidance issued by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) specifically notes these services as an entry point for provider-initiated HIV testing and counseling (PITC). The guidance constitutes a useful first step towards a framework within which PITC sensitive to health, human rights and ethical concerns can be provided to pregnant women in health facilities. However, a number of issues will require further attention as implementation moves forward. It is incumbent on all those involved in the scale up of PITC to ensure that it promotes long-term connection with relevant health services and does not result simply in increased testing with no concrete benefits being accrued by the women being tested. Within health services, this will require significant attention to informed consent, pre- and post-test counseling, patient confidentiality, referrals and access to appropriate services, as well as reduction of stigma and discrimination. Beyond health services, efforts will be needed to address larger societal, legal, policy and contextual issues. The health and human rights of pregnant women must be a primary consideration in how HIV testing is implemented; they can benefit greatly from PITC but only if it is carried out appropriately.     

Global Health Care Justice,Delivery Doctors and Assisted Reproduction: Taking a Note From Catholic Social Teachings

This article will examine the Catholic concept of global justice within a health care framework as it relates to women's needs for delivery doctors in the developing world and women's demands for assisted reproduction in the developed world. I will first discuss justice as a theory, situating it within Catholic social teachings. The Catholic perspective on global justice in health care demands that everyone have access to basic needs before elective treatments are offered to the wealthy. After exploring specific discrepancies in global health care justice, I will point to the need for delivery doctors in the developing world to provide basic assistance to women who hazard many pregnancies as a priority before offering assisted reproduction to women in the developed world. The wide disparities between maternal health in the developing world and elective fertility treatments in the developed world are clearly unjust within Catholic social teachings. I conclude this article by offering policy suggestions for moving closer to health care justice via doctor distribution.     

Web-based consumer health information: public access, digital division, and remainders

Public access Internet portals and decreasing costs of personal computers have created a growing consensus that unequal access to information, or a "digital divide," has largely disappeared for US consumers. A series of technology initiatives in the late 1990s were believed to have largely eliminated the divide. For healthcare patients, access to information is an essential part of the consumer-centric framework outlined in the recently proposed national health information initiative. Data from a recent study of health information-seeking behaviors on the Internet suggest that a "digitally underserved group" persists, effectively limiting the planned national health information infrastructure to wealthier Americans.     

Analysis of pregnancy-related calls to an occupational hazard hot line.

Since 1980 the Hazard Evaluation System and Information Service has responded to over 11,000 inquiries regarding workplace health hazards. Of 2,424 inquiries in 1986, 593 (24%) concerned hazards to pregnancy. This represents a 17-fold increase since 1981. Most pregnancy-related inquiries were from employees (70%) and health care providers (23%). Referral sources for the employees calls were almost exclusively individual health care providers or institutions that provide health care or health counseling, or both. These data suggest that pregnant employees seek information on their own or from health care providers instead of from employers. Of the inquiries, 80% were for general pregnancy hazard information; 20% involved symptomatic pregnant employees. Most inquiries concerned employment in the services (58%) and manufacturing (26%) sectors. Organic solvents, pesticides, acrylic nail-grooming products, lead, and video display terminals were among the agents about which callers inquired most frequently.     

Women's understanding of abnormal cervical smear test results: a qualitative interview study.

OBJECTIVE: To describe how women interpret their experiences of diagnosis and treatment of a cervical abnormality and how healthcare services for such women can be improved. DESIGN: Qualitative study using detailed individual interviews. SETTING: Australian gynaecology clinics. SUBJECTS: 29 Women who had a cervical cytological abnormality and who attended a gynaecologist. MAIN OUTCOME MEASURES: Women''s views on their diagnosis and their information needs. RESULTS: Most women wanted to participate in decisions about their care but found it difficult to get the information they required from doctors because they were confused by what their doctors told them and felt unable to ask questions in the consultation. Medical terms such as wart virus and precancer were difficult to understand. Not being able to see their cervix also made it hard for women to understand what their abnormality meant and what treatment entailed. Most women tried to make sense of their abnormality in the context of their everyday lives. For some women their gynaecological care was not consistent with the way they understood their abnormality. CONCLUSIONS: The inherent power structure of medical practice combined with time pressures often make it difficult for doctors to give the detailed information and reassurance patients need when a diagnosis is distressing or when investigation and treatment are strange and upsetting.     

An evolutionary perspective on the association between grandmother-mother relationships and maternal mental health among a cohort of pregnant Latina women

Grandmothers are often critical helpers during a mother's reproductive career. Studies on the developmental origins of health and disease demonstrate how maternal psychological distress can negatively influence fetal development and birth outcomes, highlighting an area in which soon-to-be grandmothers (henceforth “grandmothers”) can invest to improve both mother and offspring well-being. Here, we examine if and how a pregnant woman's mental health– specifically, depression, state-anxiety, and pregnancy-related anxiety– is influenced by her relationship with her fetus' maternal and paternal grandmother, controlling for relationship characteristics with her fetus' father. In a cohort of pregnant Latina women in Southern California (N = 216), we assessed social support, geographic proximity, and communication between the fetus' grandmothers and pregnant mother. We assessed maternal mental health with validated questionnaire-based instruments. We find that both social support from and communication with the maternal grandmother were statistically associated with less depression, while no paternal grandmother relationship characteristics were statistically significant in association with any mental health variable. These results align with the idea that maternal grandmothers are more adaptively incentivized to invest in their daughters' well-being during pregnancy than paternal grandmothers are for their daughters-in-law. Results suggest that the positive association of maternal grandmothers with mothers' mental health may not hinge on geographic proximity, but rather, potentially function through emotional support. This work represents a novel perspective describing a psychological and prenatal grandmaternal effect.     

Obstetric care,Medicaid, and family physicians. How policy changes affect physicians' attitudes.

Recent expansion of Medicaid eligibility for pregnant women and increased reimbursement to physicians who provide perinatal services were designed to improve access to care. Family physicians provide a relatively high proportion of care to pregnant women on Medicaid, especially in rural areas. We surveyed all family physicians who provide obstetric services in 26 northern California counties regarding these changes and perceived barriers to providing obstetric care to women on Medicaid. Of surveyed physicians who limited the number of their Medicaid obstetric patients, 58% stated that recent Medicaid policy changes had increased their willingness to accept new Medicaid obstetric patients. Despite these policy changes, administrative issues and poor reimbursement were cited as the two most notable barriers to providing obstetric care to women on Medicaid. Fear of being sued by Medicaid patients is still seen as a barrier by physicians who have recently discontinued practicing obstetrics and by those who continue to care for a large number of Medicaid obstetric patients.     

Life on the edge: immigrants confront the American health system

Abstract

On the basis of a study of forty health care delivery institutions in Florida, California, and New Jersey, this paper examines the interaction between the immigration and health systems in the USA. We investigate barriers to care encountered by the foreign born, especially unauthorized immigrants, and the systemic contradictions between demand for their labour and the absence of an effective immigration policy. Lack of access and high costs have forced the uninsured poor into a series of coping strategies, which we describe in relation to commercial medicine. We highlight regional differences and the importance of local politics and history in shaping health care alternatives for the foreign born.     

Access to Tuberculosis Services for Individuals with Disability in Rural Malawi,a Qualitative Study

Tuberculosis occurs in all populations, but with higher prevalence in poor contexts. Vulnerable groups, including individuals with disability, run a particular risk due to poorer access to information and health services. Studying access to tuberculosis services for vulnerable groups in poor contexts may provide useful insight into the quality of such services in low-income contexts. This article aims to present a contextual understanding of access to tuberculosis services for people with disabilities in one district in southern Malawi. A qualitative method with semi-structured interviews and site observations was applied. In all, 89 participants were interviewed: 47 persons with disability, 11 parents/guardians of youths with disability, and the remaining 31 comprising eight health workers, four community rehabilitation assistants and volunteers, and 19 leaders in the community.Our main findings are that lack of information and knowledge, and considerable confusion related to tuberculosis, its cause and how to protect oneself, are major barrier to accessing services. Disease awareness and personal risk perception are key factors in this regard. Further findings concerns the pathways to tuberculosis related health services, in particular having a test and completing the treatment. The combination of lack of knowledge and barriers in accessing tests implies substantial availability and access problems.It is of importance to understand the combined impact of individual, social, contextual, and systems barriers to fully address the complexity of accessing tuberculosis services for vulnerable groups in poor populations. Lack of disability specific strategies in the local health services may be part of the reason why individuals with disability to not access such services.     

Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study

ObjectivesTo explore the circumstances and factors that explain the association between private health insurance cover and a high rate of caesarean sections in Chile.DesignQualitative analysis of audiotaped in-depth interviews with obstetricians and pregnant women; quantitative analysis of data from face to face semistructured interview survey conducted postnatally (with women who had given birth in the previous 24-72 hours), and of a review of medical notes at a public hospital, a university hospital, and a private clinic.SettingSantiago, Chile.ParticipantsQualitative arm: 22 obstetricians, 21 pregnant women; quantitative arm: 540 postnatal women.ResultsPrivate health insurance cover requires the primary maternity care provider to be an obstetrician. In the postnatal survey, women with private obstetricians showed consistently higher rates of caesarean section (range 57-83%) than those cared for by midwives or doctors on duty in public or university hospitals (range 27-28%). Only a minority of women receiving private care reported that they had wanted this method of delivery (range 6-32%). With the diversification in the healthcare market, most obstetricians now have demanding peripatetic work schedules. Private maternity patients are a lucrative source of income. The obstetrician is committed to attend these private births in person, and the “programming” (or scheduling) of births is a common time management strategy. The rate of elective caesarean sections was 30-68% in women with private obstetricians and 12-14% in women not attended by private obstetricians.ConclusionsPolicies on healthcare financing can influence maternity care management and outcomes in unforeseen ways. The prevailing business ethos in health care encourages such pragmatism among those doctors who do not have a moral objection to non-medical caesarean section.     

Delivering post-abortion care through a community-based reproductive health volunteer programme in pakistan

Summary This qualitative study was conducted in May-June 2010 with women using post-abortion care (PAC) services provided by the Marie Stopes Society in Pakistan during the six month period preceding the study, more than 70% of whom had been referred to the clinics by reproductive health volunteers (RHVs). The aim of the study was to establish the socio-demographic profile of clients, determine their preferred method of treatment, explore their perceptions of the barriers to accessing post-abortion services and to understand the challenges faced by RHVs. The sample women were selected from six randomly selected districts of Sindh and Punjab. Eight focus group discussions were conducted with PAC clients and fifteen in-depth interviews with RHVs. In addition, a quantitative exit interview questionnaire was administered to 76 clients. Medical, rather than surgical, treatment for incomplete and unsafe abortions was preferred because it was perceived to 'cause less pain', was 'easy to employ' and 'having fewer complications'. Household economics influence women's decision-making on seeking post-abortion care. Other restraining factors include objection by husbands and in-laws, restrictions on female mobility, the views of religious clerics and a lack of transport. The involvement of all stakeholders could secure social approval and acceptance of the provision of safe post-abortion care services in Pakistan, and improve the quality of family planning services to the women who want to space their pregnancies.     

Refugees' perspectives on barriers to communication about trauma histories in primary care

Objective This study explores refugees'' perspectives regarding the nature of communication barriers that impede the exploration of trauma histories in primary care.Method Brief interviews were conducted with 53 refugee patients in a suburban primary care clinic in the Midwest USA. Participants were asked if they or their doctors had initiated conversations about the impact of political conflict in their home countries. Qualitative data analysis was guided by grounded theory. Peer debriefings of refugee healthcare professionals were incorporated into the analysis.Results Two-thirds of refugee patients reported that they never shared how they were affected by political conflict with their doctors and that their doctors never asked them about it. Most refugees stated that they would like to learn more about the impact of trauma on their health and to discuss their experiences with their doctors.Conclusion Refugees are hesitant to initiate conversations with physicians due to cultural norms requiring deference to the doctor''s authority. They also lack knowledge about how trauma affects health. Physicians should be educated to inquire directly about trauma histories with refugee patients. Refugees can benefit from education about the effects of trauma on health and about the collaborative nature of the doctor–patient relationship.