Effect of Conflict on Age at Marriage and Age at First Birth in Rwanda

Using Rwanda Demographic and Health Survey 2005 data, we estimate a Cox proportional hazard model to identify the determinants of age at marriage and age at first birth and whether these decisions were affected by conflict. We find that women living in clusters accounting for a larger proportion of sibling deaths in 1994, the year of the genocide, were more likely to marry later and have children later compared with those living in clusters accounting for a lower proportion of sibling deaths. Women living in regions with higher levels of under-five mortality were more likely to have their first child earlier compared with women living in regions with lower infant mortality. The age at marriage was probably affected by two reasons: the change in age structure and sex ratio of the population following the genocide, and the breakdown of kinship in the case of women who lost their siblings.     

The Effect of Antenatal Care on Professional Assistance at Delivery in Rural India

Delivering births in a medical institution or at home with professional medical assistance has been shown to promote safe motherhood and child survival. Yet three-quarters of births in rural India continue to take place at home, most of them without the assistance of any trained health worker. This study examines the role of antenatal care (ANC) in promoting professional assistance at delivery, using data from India’s 1992–93 and 1998–99 National Family Health Surveys (NFHS-1 and NFHS-2). We estimate the effect of number of antenatal care visits (0, 1–2, 3+) on professional assistance at delivery (no assistance, professional assistance at home, delivery in a medical institution), using multinomial logistic regression, controlling for demographic, geographic, and socioeconomic factors, pregnancy complications, and two measures of access to health facilities. The results indicate that, after controlling for other variables (including ANC), pregnancy complications and access to health facilities do not have much effect on assistance at delivery. By contrast, ANC has a large effect, even after all other variables are controlled. The effect of ANC on professional assistance at delivery is larger in South India than in North India, and predicted percentages receiving professional assistance are higher in South India than in North India. A policy implication is that increased antenatal care coverage can be an effective means of increasing professional assistance at delivery, especially delivery in a medical institution.

Choosing children over career? Changes in the postpartum labor force behavior of professional women

In recent years, the popular press in the U.S. hasrepeatedly profiled professionalwomen who have elected to leave the labor force inorder to devote their full-timeenergies to child rearing. The conclusion of thesearticles is often that mothers havetired of trying to be superwomen and have decidedthat high achievement in thelabor force is not compatible with a successful homelife. The purpose of this paperis to explore whether this impression is, in fact,based in truth. Using a sample ofprofessional women drawn from the PSID during theyears 1968–1992, we estimatethe probability of withdrawing from the labor forceat one, two and five year intervalsafter the birth of a child. We use several differentmeasures of labor force withdrawaland find that women who gave birth in recent years aremore likely to report zero hoursof work two years after the birth of a child when comparedto women who gave birthearlier in the sample period. Thus, we find some supportfor the conjecture that moreprofessional women are opting to stay home and raisechildren in lieu of aggressivelypursuing their careers. We do not find any differencesby cohort, indicating that thisphenomenon cuts across women of all childbearingages. However, our results are notrobust across different measures of labor forcewithdrawal, nor are they consistent acrosspostpartum time intervals.     

子女孩次性别结构与女性再生育——基于孩次性别递进生育率的分析

现有子女的孩次性别结构是影响女性再生育的重要因素。使用中国2000年人口普查数据和时期孩次性别递进生育指标对女性生育水平进行了测算。结果显示,女性普遍生育但终身只生育一个孩子的比例很大,基于孩次性别结构的生育行为体现了男孩偏好;城市和镇在生育第一孩时就存在性别选择;第一个孩子是女孩的女性生育二孩的可能性较大,且二孩是男孩的比例显著大于是女孩的比例;第一个孩子是男孩的城市和镇的女性大部分不再生育,而农村女性有很大比例会生育二孩,但几乎不存在性别选择。采用某地区2019年的数据进行补充验证,同样发现:只有一个女孩的女性相比较只有一个男孩的女性生育者生第二孩的可能性要高很多,以上研究发现对当前二孩生育行为具有一定的启示意义。     

Is it possible to incorporate evidence-based professional midwifery practices into public health services in Mexico?

Problem and backgroundDuring the past two decades, Mexico has launched innovative maternal health initiatives to improve maternal and neonatal outcomes, placing emphasis on the incorporation of professional midwifery practices into the healthcare system. This study explored the perceptions of healthcare providers and women using public birth care services regarding professional midwifery practices and how can the inclusion of evidence-based midwifery techniques improve the quality of service.MethodologyWe conducted a qualitative, cross-sectional study of three healthcare networks in Mexico. A content analysis was performed of data collected through 109 semi-structured interviews: 72 with healthcare providers and 37 with women.ResultsHealthcare providers and women had minimal knowledge of the competencies and skills of professional midwives. Medical personnel accepted the incorporation of some evidence-based midwifery practices. Women had experienced fear and anguish during childbirth so they considered that incorporating professional midwifery practices into maternal health services would be favourable in that it would render birth care more respectful.Discussion and conclusionsHealthcare providers are willing to consider the inclusion of some evidence-based midwifery practices in health services and regard assistance from professional midwives. They believe that structural conditions will complicate their incorporation. Although the women interviewed had experienced fear, anxiety and loneliness during childbirth, most of them admitted to feeling “safer” in a hospital (secondary-care health centre) setting where possible complications could be resolved. This perception of safety served to justify the delivery of healthcare in a manner that is inattentive to women’s needs, which go beyond biomedical issues and include emotions and the positive experience of childbirth.     

Health after childbirth: Patterns of reported postpartum morbidity from Lebanon

Problem and backgroundThe postpartum period is under-researched in low and middle income countries. The scarce literature reveals heavy burden of ill health experienced in that period and under utilisation of health services. Understanding the postpartum morbidity burden and identifying the care-seeking behaviours is essential to improve service delivery.QuestionThis paper examines reported postpartum morbidity, care seeking behaviour and whether postpartum morbidity is associated with method of birth.MethodsA cross sectional study of women delivering in 18 private hospitals from two regions in Lebanon was undertaken. Women in their second or third trimester of pregnancy, visiting private obstetric clinics affiliated with participating hospitals were interviewed for baseline information. Reported postpartum morbidity was assessed in an interview conducted at women's homes from 40 days up to six months postpartum.FindingsOf the 269 women recruited, physical postpartum health problems were reported by 93.6% and psychological health problems by 84.4% of women, with more health problems being reported beyond two months postpartum. Women were less likely to seek professional care for psychological health problems. Reporting postpartum health problems was not associated with method of birth.ConclusionA heavy burden of postpartum morbidity is experienced by women with gaps in utilisation of relevant health services. Efforts should be directed towards the organisation and delivery of comprehensive maternity care services.     

Traditional birth attendants’ roles and homebirth choices in Ethiopia: A qualitative study

BackgroundIn Ethiopia, it is encouraged that labour and delivery care are performed under the observation of skilled/trained midwifery or medical professionals. However, 70% of all births occur outside the healthcare system under the care of unskilled birth attendants, family members, or without any assistance at all.ObjectiveThis study aimed to assess the reasons for choosing homebirth and the role of traditional birth attendants in Arba Minch Health and Demographic Surveillance Site.MethodA qualitative, exploratory study was carried out between May and June 2017. Twenty-nine semi-structured interviews were conducted with various respondent groups such as traditional birth attendants, pregnant women, skilled birth attendants, and health extension workers. Data were transcribed and for analysis, structured as per the participants’ responses, sorted and categorized as per the topic guide, and presented in narrative form.FindingsThe study revealed that traditional birth attendants are actively engaged in assisting homebirths in the selected area. It was also found that many women still prefer traditional birth attendants for childbirth assistance. Reasons for choosing homebirth included lack of transport to health care facilities, distance to health care facilities, lack of respectful care at health care facilities, and the friendliness of traditional birth attendants. Lack of formal partnerships between traditional birth attendants and the health system was also observed.ConclusionsThere is a need to incorporate traditional birth attendants as a link between healthcare facilities and pregnant women; thereby, improving respectful care at the healthcare facilities.     

The cost of vaginal birth at home,in a birth centre or in a hospital setting in New South Wales: A micro-costing study

BackgroundWomen want greater choice of place of birth in New South Wales, Australia. It is perceived to be more costly to health services for women with a healthy pregnancy to give birth at home or in a birth centre. It is not known how much it costs the health service to provide care for women planning to give birth in these settings.AimThe aim of this study was to determine the direct cost of giving birth vaginally at home, in a birth centre or in a hospital for women at low risk of complications, in New South Wales.MethodsA micro-costing design was used. Observational (time and motion) and resource use data collection was undertaken to identify the staff time and resources required to provide care in a public hospital, birth centre or at home for women with a healthy pregnancy.FindingsThe median cost of providing care for women who plan to give birth at home, in a birth centre and in a hospital were similar (AUD $2150.07, $2100.59 and $2097.30 respectively). Midwifery time was the largest contributor to the cost of birth at home, and overhead costs accounted for over half of the total cost of BC and hospital birth. The cost of consumables was low in all three settings.ConclusionIn this study, we have found there is little difference in the cost to the health service when a woman has an uncomplicated vaginal birth at home, in a birth centre or in a hospital setting.     

Factors affecting rural women's utilisation of continuum of care services in remote or isolated villages or Pakistan – A mixed-methods study

IntroductionAn effective continuum of care for pregnancy and childbirth connects women and girls with essential reproductive and maternity care services. This study aimed to estimate the continuum of care utilisation rate of women who lived in remote and isolated regions of Pakistan and explored factors that influence women's utilisation of reproductive and maternity care services.MethodsA mixed-methods study was conducted in five rural villages of Sindh, Pakistan. A cross-sectional survey with 669 women who gave birth between July 2010 and September 2014 investigated women's maternity-care service utilisation during pregnancy, childbirth, and in the postpartum period. In-depth interviews with 15 women explored their maternity-care experiences with health providers.ResultsOnly 6.4% of 669 women participants reported to have completed the continuum of care for their last pregnancy. Skilled birth attendants, including health professionals, were used by 56.1% for antenatal care, 40.8% for both antenatal and childbirth, 22.3% for antenatal, childbirth and postnatal, and only 6.4% reported using all pregnancy-related and postpartum services. Limited knowledge about affordable health services, poor health literacy, and access to health services was associated with women's fragmented utilisation of maternity care. A lack of respectful maternity-care was also identified as a major barrier to women's utilisation of primary health care facilities, especially for childbirth.ConclusionThe existing primary health structure in Pakistan provides a good foundation to deliver continuity of care services; however, health services utilisation for reproductive and maternity care remains suboptimal in women who live in geographically remote regions of Pakistan.     

Care Arrangement Choices for Older Widows: Decision Participants' Perspectives

SUMMARY

This research examines how a wide range of care arrangement decisions for frail older women are made. Interviews were conducted with 11 older women (ten of whom are widows), nine of their family members, and six professional service providers. Maintaining the older woman's independence was identified as a major theme. While all decision participants identified it as an explicit or implicit decision-making goal, their meanings of independence were different. The older women's meanings were flexible, changing in response to changes in their physical condition and need for assistance. Adult children tended to identify their mothers as independent when they did not actually need assistance, or when they received help from other sources (e.g., home health care). Professional service providers were inclined to define independence narrowly, as avoiding nursing home placement. Minor themes associated with independence include responsibility, reciprocity, and the family's importance in maintaining independence. These themes help to clarify the complex dynamics that take place during care arrangement decisions and explain how care arrangement choices are made.     

Who is holding the baby? Women's experiences of contact with their baby immediately after birth: An Australian population-based survey

BackgroundSeeing and holding their baby immediately after the birth is the pinnacle of the childbearing process for parents. Few studies have examined women's experiences of seeing and holding their baby immediately after birth. We investigated women's experiences of initial contact with their newborns using data from an Australian population-based survey.MethodsAll women who gave birth in September/October in 2007 in two Australian states were mailed questionnaires six months following the birth. Women were asked three questions about early newborn contact including where their baby was held in the first hour after birth and whether they were able to hold their baby as soon and for as long as they liked. We examined the association between model of maternity care and early newborn contact stratified by admission to SCN/NICU.ResultsThe majority (92%) of women whose babies remained with them reported holding their babies as soon and for as long as they liked in the first hour after birth. However, for women whose babies were admitted to SCN/NICU only a minority (47%) reported this. Women in public models of care (with the exception of primary midwifery care) whose babies remained with them were less likely to report holding their babies as soon and for as long as they liked compared to women in private care.ConclusionOur findings suggest that there is potential to increase the proportion of mothers and fathers who get to hold their baby immediately after the birth by modifying birth suite and operating room practices.     

Homebirth, freebirth and doulas: casualty and consequences of a broken maternity system

In Australia private homebirth remains unfunded and uninsured and publicly funded homebirth models are not widely available. Doulas are increasingly hired by women for support during childbirth and freebirth (birth intentionally unattended by a health professional) appears to be on the rise. The recently released Improving Maternity Services in Australia--The Report of the Maternity Services Review (MSR) exclude homebirth from the funding and insurance reforms proposed. Drawing on recent research we argue that homebirth has become a casualty of a broken maternity system. The recent rise in the numbers of women employing doulas and choosing to birth at home unattended by any health professional, we argue, is in part a consequence of not adequately meeting the needs of women for continuity of midwifery care and non-medicalised birthing options.     

The Impact of the AIDS Pandemic on Health Services in Africa: Evidence from Demographic and Health Surveys

We document the impact of the AIDS crisis on non-AIDS-related health services in 14 sub-Saharan African countries. Using multiple waves of Demographic and Health Surveys (DHS) for each country, we examine antenatal care, birth deliveries, and rates of immunization for children born between 1988 and 2005. We find deterioration in nearly all these dimensions of health care over this period. The most recent DHS survey for each country collected data on HIV prevalence, which allows us to examine the association between HIV burden and health care. We find that erosion of health services is the largest in regions that have developed the highest rates of HIV. Regions of countries that have light AIDS burdens have witnessed small or no declines in health care, using the measures noted above, while those regions shouldering the heaviest burdens have seen the largest erosion in non-HIV-related health services for pregnant women and children. Using semiparametric techniques, we can date the beginning of the divergence in the use of antenatal care and in children’s immunizations between high- and low-HIV regions to the mid-1990s.     

Another country,another language and a new baby: A quantitative study of the postnatal experiences of migrant women in Australia

BackgroundGovernments and service providers have consistently acknowledged the importance of support for women and families in the transition to parenthood. Lower levels of satisfaction and concern about postnatal depression have highlighted women's needs at this time. Migrant women may also face relocation, distant family and support networks, language barriers and potentially discriminatory or culturally insensitive care.ObjectiveThe present study evaluates the unique contribution of migrant status, comparing the experience of this group to that of native-born English-speaking women.MethodSecondary analysis of data from a population-based survey of maternity care in Queensland. Experiences of 233 women born outside Australia who spoke another language at home were compared to 2722 Australian-born English-speaking women with adjustment for demographic differences.ResultsAfter adjustment, differences between the groups included physical, psychological aspects and perceptions of care. Women born outside Australia were less likely to report pain after birth was manageable, or rate overall postnatal physical health positively. They more frequently reported having painful stitches, distressing flashbacks and feeling depressed in the postnatal period. Few differences in ratings of care providers were found, however, women born outside Australia were less likely to feel involved in decisions and to understand their options for care. However, they were more likely to report being visited by a care provider at home after birth.ConclusionsThe findings represent an important addition to existing qualitative reports of the experiences of migrant women, reflecting poorer postnatal health, issues associated with migration and parenthood and highlighting areas for care improvement.     

The commonalities and differences in health professionals’ views on home birth in Tasmania,Australia: A qualitative study

ObjectivesHome birth has attracted great controversy in the current context. There is a need for the public and health professionals to understand why maternity care providers have such different views on home birth, why they debate, what divides them into two opposite sides and if they have anything in common.MethodA qualitative study involving twenty maternity health providers in Tasmania was conducted. It used semi-structured interview which included closed and open-ended questions to provide opportunities for exploring emerging insights from the voices of the participants.FindingsHealth practitioners who support home birth do so for three reasons. Firstly, women have the right to choose the place of birth. Secondly, home birth may be more cost effective compared to hospital birth. Thirdly, if home birth is not supported, some women might choose to have a free birth. Those who opposed home birth argue that complications could occur at childbirth and the transfer time is critical for women's and babies’ safety. These differences in opinions can be due to the differences in the training and philosophy of the maternity care providers. Despite the differing views on home births, health professionals share a common goal to protect the women and the newborns from unexpected situations during childbirth.ConclusionThis article provides some significant insights derived from the study of home birth from the maternity health professionals’ perspectives and could contribute to the enhancement of mutual understanding and collaboration of health professionals in their services to expectant mothers.     

Care arrangement choices for older widows: decision participants' perspectives

This research examines how a wide range of care arrangement decisions for frail older women are made. Interviews were conducted with 11 older women (ten of whom are widows), nine of their family members, and six professional service providers. Maintaining the older woman's independence was identified as a major theme. While all decision participants identified it as an explicit or implicit decision-making goal, their meanings of independence were different. The older women's meanings were flexible, changing in response to changes in their physical condition and need for assistance. Adult children tended to identify their mothers as independent when they did not actually need assistance, or when they received help from other sources (e.g., home health care). Professional service providers were inclined to define independence narrowly, as avoiding nursing home placement. Minor themes associated with independence include responsibility, reciprocity, and the family's importance in maintaining independence. These themes help to clarify the complex dynamics that take place during care arrangement decisions and explain how care arrangement choices are made.     

Determinants of prenatal health care utilisation by low-risk women: A prospective cohort study

BackgroundPrenatal health care is pivotal in providing adequate prevention and care to pregnant women.AimWe examined the determinants of inadequate prenatal health care utilisation by low-risk women in primary midwifery-led care in the Netherlands.MethodsWe used longitudinal data from the population-based DELIVER study with 20 midwifery practices across the Netherlands in 2009 and 2010 as the experimental setting. The participants were 3070 pregnant women starting pregnancy care in primary midwifery care.FindingsWe collected patient-reported data on potential determinants of prenatal care utilisation derived from the Andersen model. Prenatal health care utilisation was measured by a revised version of the Kotelchuck Index, which measures a combination of care entry and number of visits. Low-risk pregnant women (not referred during pregnancy) were more likely to use prenatal care inadequately if they intended to deliver at a hospital, if they did not use folic acid adequately periconceptionally, or if they were exposed to cigarette smoke during pregnancy. Among those who were referred to secondary care, women reporting a chronic illnesses or disabilities, and women who did not use folic acid periconceptionally were more likely to make inadequate use of prenatal care.ConclusionInadequate prenatal health care use in primary midwifery care is more likely in specific groups, and the risk groups differ when women are referred to secondary care. The findings suggest routes that can target interventions to women who are at risk of not adequately using prenatal prevention and care services.     

The needs of women and their partners regarding professional smoking cessation support during pregnancy: A qualitative study

BackgroundDespite the health risks of smoking, some women continue during pregnancy. Professional smoking cessation support has shown to be effective in increasing the proportion of pregnant women who quit smoking. However, few women actually make use of professional support.AimTo investigate the needs of women and their partners for professional smoking cessation support during pregnancy.MethodsSemi-structured interviews were held with pregnant women and women who recently gave birth who smoked or quit smoking during pregnancy, and their partners, living in the north of the Netherlands. Recruitment was done via Facebook, LinkedIn, food banks, baby stores and healthcare professionals. The interviews were recorded, transcribed and thematically analysed.Results28 interviews were conducted, 23 with pregnant women and women who recently gave birth, and five with partners of the women. The following themes were identified: 1) understanding women’s needs, 2) responsibility without criticism, and 3) women and their social network. These themes reflect that women need support from an involved and understanding healthcare professional, who holds women responsible for smoking cessation but refrains from criticism. Women also prefer involvement of their social network in the professional support.ConclusionFor tailored support, the Dutch guideline for professional smoking cessation support may need some adaptations. The adaptations and recommendations, e.g. to involve women and their partners in the development of guidelines, might also be valuable for other countries. Women prefer healthcare professionals to address smoking cessation in a neutral way and to respect their autonomy in the decision to stop smoking.     

Effect of audit and feedback on the availability, utilisation and quality of emergency obstetric care in three districts in Malawi

BACKGROUND: Facility-based maternal death reviews and criterion-based clinical audit, were introduced in three districts in Malawi in 2006. RESEARCH QUESTION: Can audit and feedback improve the availability, utilisation and quality of emergency obstetric care (EmOC)? PARTICIPANTS AND METHODS: Observational study in which emergency obstetric care offered to women who gave birth in 73 health facilities (13 hospitals and 60 health centres) in three districts in Malawi in 2005 (baseline, 41,637 women) was compared to 2006 (43,729 women) and 2007 (51,085 women). RESULTS: The number of comprehensive and basic EmOC facilities did not change over the 3-year period (p for trend=1.000). Although institutional delivery rate decreased in 2006, overall it increased over 3 years (p for trend<0.001) - 31.8% (2005), 31.1% (2006) and 34.7% (2007), and Caesarean section rate was low and did not change (p for trend=0.257) - 1.7% (2005), 1.6% (2006) and 1.5% (2007). There was a significant increase in the met need for EmOC (p for trend<0.001) - 15.2% for 2005, 17.0% for 2006 and 18.8% for 2007. Maternal mortality decreased significantly from 250 per 100,000 women in 2005 to 222 in 2006 and 182 in 2007 (p for trend<0.001). Similarly, the case fatality rate decreased monotonically (p for trend<0.001) - 3.7% (2005), 3.0% (2006) and 1.5% (2007). DISCUSSION: Audit and feedback can improve availability, utilisation and quality of emergency obstetric care in countries with limited resources. CONCLUSION: There is need to increase availability of emergency obstetric care by upgrading some health centres to EmOC level through training of staff and provision of equipment and supplies.