The maternal health-related issues that matter most to women in Ireland as they transition to motherhood - A qualitative study

BackgroundMany studies on women’s maternity care experiences reveal recurring issues that are poor or less than optimal. Women’s opinions on the maternal health-related issues that matter most to them are essential if care and services are to be improved.AimsTo identify the maternal health-related issues that matter most to women in Ireland, based on their own experiences of maternity care, services and motherhood.MethodsA qualitative exploratory study with 24 women. Following university ethical approval, audio-recorded one-to-one telephone interviews were conducted and thematically analysed.FindingsWe identified two themes, each with four subthemes, connected to a central concept of the invisible woman. Pendulum of care, and subthemes Inconsistent services, All about the baby, Induced anxiety and Information seesaw, illustrated the extremes of care and services that women experienced. Magnitude of motherhood, and subthemes Weight of responsibility, Real-time reassurance, Change of identity and Growth into advocacy, depicted the intensity of their new role while transitioning to motherhood.DiscussionFindings articulate the issues that mattered most to women in Ireland as they transitioned to motherhood. Some women identified specific research topics/areas, but all of the issues identified can be translated into researchable topics that seek to improve local care and service provision.ConclusionGiven the recurring nature of women’s less than satisfactory experiences of aspects of maternity care in many countries, it is likely that conducting research on issues that matters most to women will have the greatest impact on their health, wellbeing and lives as they transition to motherhood.     

Who uses reproductive health services in the Philippines (and who doesn't)?

Data from the 1993 National Demographic Survey and the Safe Motherhood Survey have filled gaps in knowledge about the accessibility and use of reproductive health services in the Philippines. Analysis of the data by the East-West Center's Program on Population has revealed that the number of women using family planning (FP) and maternal health services has risen to 40% in 1993 from 17% in 1973. Modest gains were also seen in the past five years despite disruption to program efforts. Prenatal care showed the greatest maternal care coverage rate increase, but 70% of births occurred at home, with only 51% attended by a trained person, and only 32% of postpartum women received care. Adolescents and women who are over age 40, uneducated, Muslim, and/or live in a rural setting have the most unmet need. In addition, less than half of the women reporting symptoms of a sexually transmitted disease sought treatment from a trained practitioner. Most women use public sector services, including 71% of those using modern contraceptives. While trained midwives provided 58% of prenatal care, traditional birth attendants delivered 52% of all births, and a high incidence of maternal mortality persists (209/100,000). Recommendations arising from this analysis include 1) improving prenatal and delivery care, 2) strengthening postpartum FP services, 3) expanding the program to reach more women, 4) extending the range of reproductive health services offered, 5) integrating traditional practitioners into the reproductive health system, and 6) balancing cost and service variations between the public and private sectors.     

Mothers’ Marital Status and Type of Delivery Medical Care in Guatemala

The use of modern medical care for child delivery in rural Guatemala is low relative to other Latin American countries. In the previous literature, factors such as a woman’s age, education, ethnicity, religious affiliation and income are found to be important determinants of the type of delivery medical care she receives. This study hypothesizes that a woman’s marital status influences her decision as well. Using a binomial logit framework, the study finds that unmarried women are more likely to see a modern medical provider in delivery than married women, even after controlling for demographic, socioeconomic, and husbands’ characteristics. Therefore, unmarried women seem to make more informed decisions in terms of their attitudes in childbearing and maternal health relative to their married counterparts. As a result, both economic as well as social developments seem necessary to induce changes in the high incidence of maternal mortality and morbidity in Guatemala.     

Son preference, use of maternal health care, and infant mortality in rural China, 1989-2000

This study assesses the effects of socio-economic conditions and the interaction between son preference and China's one-child family planning policy on the use of maternal health care services and their effects on infant mortality in rural China, using nationally representative data from the 2001 National Family Planning and Reproductive Health Survey. The results show that while the use of maternal health care services has continued to increase over time, large gaps still exist in the use of these services and in infant survival by mother's education, community income, and parity. Further improvements in the reproductive health of all women and in infant survival will require effective reduction of the obstacles to the use of maternal health care among those women in rural China who are less educated, poor, and of higher parity.     

Integrating reproductive health services into family planning programs

A recent Population Council publication, Reproductive Health Approach to Family Planning, discusses integration of reproductive health into family planning programs in a series of edited presentations that Council staff and colleagues gave at a 1994 meeting of the US Agency for International Development (USAID) cooperating agencies. The presentations reflect the Council's view that family planning programs ought to help individuals achieve their own reproductive goals in a healthful manner. The report discusses four areas of reproductive health: reproductive tract infections (RTIs), including sexually transmitted diseases; prevention and treatment of unsafe abortion; pregnancy, labor, and delivery care; and postpartum care. Christopher Elias (Senior Associate, Programs Division) argued that family planning programs ought to provide services that target RTIs, given that these illnesses afflict a significant proportion of reproductive-age women. The family planning community has an ethical responsibility to provide services to women who experience an unwanted pregnancy. They must have access to high-quality postabortion care, including family planning services. Professional midwives are ideally suited to serve as integrated reproductive health workers trained to combat the five major maternal killers: hemorrhage, sepsis, pregnancy-induced hypertension, obstructed labor, and unsafe abortion. This was demonstrated in a highly successful Life-Saving Skills for Midwives program undertaken in Ghana, Nigeria, and Uganda, and soon to start in Vietnam in conjunction with the Council's Safe Motherhood research program. Family planning services should be viewed as part of a comprehensive set of health services needed by postpartum women, which include appropriate contraception, maternal health checks, well-baby care, and information about breastfeeding, infant care, and nutrition. Family planning programs should incorporate breastfeeding counseling into their services. When programs aim to help individuals meet their own reproductive goals in a healthful manner, this implies that services will not increase clients' risk of morbidity.     

Is Maternal and Child Health Service use a Causal Gateway to Subsequent Contraceptive use?: A Multi-Country Study

The purpose of this study is to examine the relationship between MCH service utilization and contraceptive use in five countries: Bolivia, Guatemala, Indonesia, Morocco, and Tanzania. The analysis is carried out at the level of the individual woman, with contraceptive-use status modeled as a function of: (1) the availability, quality, and packaging of MCH and family planning services; (2) community- and individual-level determinants of health service and contraceptive use; and (3) intensity of prior MCH service use. Data for the analysis comes from DHS data on women of reproductive age linked with data from service-availability surveys. We use full-information, maximum-likelihood regression techniques to control for the effects of unobserved heterogeneity that might otherwise bias our estimates. In three of the five countries (Morocco, Guatemala, and Indonesia) the results of the analysis suggest that the intensity of MCH service use is positively associated with subsequent contraceptive use among women, even after controlling for observed and unobserved individual- and community-level factors. This result lends support to the proposition that, at least in the context of these three countries, the intensity of MCH service per se use does have a “causal” impact on subsequent contraceptive use, even after controlling for factors that “predispose” sample women to use health care services.     

Delaying factors for maternal health service utilization in eastern Ethiopia: A qualitative exploratory study

BackgroundIn Ethiopia, maternal health service utilization is still unacceptably low. The societal and cultural factors that constrain women from attending these services have not yet been sufficiently explored. Using qualitative methods, we aimed to explore the factors that delay maternal health service utilization in eastern Ethiopia.MethodA total of 13 audio-recorded focus group discussions were conducted comprising 88 participants. We conducted separate group discussions with reproductive aged women, mothers-in-law, traditional birth attendants, husbands, and Health Extension Workers to capture their knowledge, practices, feelings, thoughts and attitudes towards maternal health service utilization. The recorded sessions were transcribed into the local language and then translated into English for analysis.ResultThe study identified a number of factors that may delay maternal health service utilization. Factors were grouped using the Three Delays model as a framework. Low level of awareness regarding need, poor involvement of husband, perceived absence of health problems, social power, community misperceptions and cultural restrictions, negative attitudes towards male midwives, acceptance of traditional birth attendants and poor social networking were Delay One factors. Lack of physical accessibility and high transportation costs were categorised as Delay Two factors for skilled birth care attendance. Perceived or experienced poor quality of care were categorised as Delay Three factors for both skilled birth and postnatal care utilization.ConclusionDespite the ongoing government measures to improve maternal health service utilization in Ethiopia, numerous factors continue to contribute to delays in service use, which in turn contribute to high maternal mortality.     

Latin American hospitals improve postabortion care. Maternal health

Approximately 4 million women undergo illegal abortions each year in Latin America and the Caribbean, and hundreds of thousands of women with postabortion medical emergencies or incomplete abortions seek hospital care. Once in an emergency ward, a woman may await treatment for 24 hours, bleeding, frightened, and in pain. A woman in such a situation may also experience nurses who chastise her for becoming pregnant or committing a sin, be examined with several staff members observing, undergo unexplained treatment without anesthesia, and/or leave the service facility without knowing whether she is still fertile or how to avoid pregnancy. INOPAL, Population Council's operations research program on family planning and reproductive health in the region, is working to find the best ways, medically and financially, for hospitals to deliver high-quality, comprehensive services to postabortion patients. Most maternal deaths and injuries could be prevented by access to family planning services and information about contraceptive use. The Population Council and colleagues from hospitals, governments, and nongovernmental organizations are conducting studies in Guatemala, Peru, and Mexico on the emergency treatment of incomplete abortions with the goal of improving and standardizing postabortion services.     

Estimating maternal mortality differentials using census data: experience in Honduras

High levels of maternal mortality in developing countries are considered a major public health problem. Over the past decade several international conferences on health have stated the necessity to reduce maternal mortality in developing countries. This is a challenge not only in terms of achieving it but also from the point of view of monitoring it. I use national population censuses to measure maternal mortality and study mortality regional differentials in Honduras, which identified maternal mortality in its most recent census. I also use standard demographic methods to evaluate the census data quality, for both population and death counts, and to evaluate the completeness and coverage of household death data.     

The Pervasive and Persistent Influence of Caste on Child Mortality in India

This study examines the effect of caste on child mortality and maternal health care utilization in rural India using data from the National Family Health Survey (NFHS-2) carried out during 1998–1999. Results from multilevel discrete-time hazard models indicate that, net of individual-level and community-level controls, children belonging to low castes have higher risks of death and women belonging to low castes have lower rates of antenatal and delivery care utilization than children and women belonging to upper castes. At the same time, the controls account for most of the differences within the low castes. Further analysis shows that the mortality disadvantage of low castes is more pronounced in poorer districts. These results highlight the need to target low caste members in the provision of maternal and child health services.     

The association between mistreatment of women during childbirth and postnatal maternal and child health care: Findings from “Birth in Brazil”

BackgroundThe mistreatment of women during pregnancy, childbirth, and the puerperium is a global public health problem besides being a violation of human rights. However, research exploring the consequences of mistreatment of women and newborns is scarce.QuestionTo shed light on this issue, we investigated the association between the mistreatment of women during childbirth and the subsequent use of postnatal health services by women and their newborns.MethodsWe used data from the study “Birth in Brazil”, a national hospital-based survey of puerperal women and their newborns, carried out in 2011/2012. This analysis involved 19,644 women. Mistreatment was a latent variable composed of seven indicators. We assessed the attendance of women and newborns to a review consultation following birth, and the timing of this appointment. We applied multigroup structural equation modeling (based on childbirth payment source) and considered separate analysis for women (vaginal births and0 caesarean-sections) and newborns.FindingsWe found a causal association between mistreatment during childbirth and decreased and/or delayed use of postnatal health services, for both women and their newborns. These results also revealed that women who use the public sector are affected more than those who pay for private healthcare.ConclusionMistreatment during childbirth has broader implications than “maternal mental health”, and it would be useful to understand that experience of care has vast implications for families. In Brazil, the mistreatment must be mitigated via the implementation of public policy. This is part of the path to dignified and respectful childbirth care for all women.     

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.     

Race,Remarital Status,and Infertility in 1910: More Evidence of Multiple Causes

The dominant approach to studying historical race-related fertility differences has been to limit samples to first-married and younger women. We argue that studying historical race-related fertility differences in the context of remarriage is also important: remarriage and fertility patterns are both rooted in the biosocial conditions that produce racial disparities in health. We employ a multiple causes framework that attributes variation in fertility patterns to voluntary limitation and involuntary factors (infecundity/subfecundity). We use data from the 1910 Integrated Public Use Microdata Series and estimate zero-inflated negative binomial models that simultaneously distinguish those who are infecund (vs. fecund) and estimate the number of remarital births among the fecund. Our approach allows us to evaluate historical remarital (in)fertility differences, accounting for marital, socioeconomic, and geographic influences on fecundity and fertility, while empirically accounting for the influence of children “missing” from the household due to mortality and fostering/aging out. Consistent with past studies that emphasized poorer African American health as a major influence on involuntary infertility, we find that African American women were more likely than white women to be in the always-zero (infecund) group and to have fewer remarital births. Supplemental analyses nuance these findings but indicate that these results are robust. Overall, we find support for a multiple-causes perspective: while the findings are consistent with the adoption of deliberate fertility control among urban and higher-status women at higher parities, remarital fertility differences in 1910 also reflected greater infecundity/subfecundity among subgroups of women, especially African American women.     

New perspectives on population: lessons from Cairo

The lessons from the 1994 World Population Conference in Cairo, Egypt, are summarized in this publication. The topics of discussion include the evolution of population policies, the changing policy environment, demographic trends, and solutions in the form of gender equity, provision of reproductive health services, and sustainable social and economic development. The program of action supported by 180 governments and targeted for 2015 articulated the goals of universal access to a full range of safe and reliable family planning methods and reproductive health services, a specified level of reduction in infant and child mortality, a specified level of reduction in maternal mortality, an increase in life expectancy to 70-75 years or more, and universal access to and completion of primary education. Other features include goals for improving women's status and equity in gender relations, expansion of educational and job opportunities for women and girls, and involvement of men in childrearing responsibilities and family planning. Steps should be taken to eliminate poverty and reduce or eliminate unsustainable patterns of production and consumption. Population policy must be integrated within social and economic development policies. About $22 billion will be needed for provision of family planning and reproductive health services by the year 2015. Costs will increase over the 10-year period due to the increased population to be served. Per person user costs for family planning alone are higher in countries without infrastructure and technical skills. Actual costs vary with the cost of contraceptive supplies, patterns of use, and efficiency of delivery systems. Although the plan offers 16 chapters worth of advice and recommends 243 specific actions, countries will have to be selective due to cost limitations. The 20/20 Initiative is proposed for sharing social service costs between international donors (20%) and host countries (20%). A separate UN projection of need is for 33% of support from international donors for family planning and related programs. The constraints to the implementation of the action plan are identified as the rate of demographic change, the extent of public support for population limitation and provision of family planning services, and potential conflicts of interests and funding between cooperating agencies. The World Bank has developed guidelines for policy development according to a country's identification as an emergent, transitional, or advanced country.     

The Impact of Social and Economic Indicators on Maternal and Child Health

As early as 1985, Rosenfield and Maine began to look at what is called the maternal child field (MCH). More than two decades later, maternal and infant mortality is still among the worst performing health indicator in resource-poor countries and regions, and it has barely changed since 1990. Although three of the eight United Nations Millennium Development Goals aim at reducing child mortality, maternal mortality, and promoting gender equality, most literature in the field is either clinical or exclusively deals with women’s health problems. In this study, I proposed an empirical model that tests the impact of gender equality, women’s human rights, and maternity care on MCH with economic and political development as background factors. The proposed model was tested by using structural equation analysis. Data were obtained from 137 developing countries. The proposed model is partially supported by the data. Empirical findings demonstrate that gender equality has a pivotal role to play in the promotion of MCH. The relationship between MCH and maternity care is found to be strong and statistically significant. This finding may permit a probable verification given the current social conditions in some developing countries, particularly the neglect of many of women’s health needs and the assignment of their primary responsibilities in childrearing. The women’s human rights hypothesis is not supported by the data. It is perhaps that human rights instruments provide a legal discourse for political functions and social welfare issues, but that the legal approach alone does not necessarily provide a moral and social foundation to ensure the implementation of social welfare and human well-being, particularly maternal and child health in developing countries. The findings also indicate the importance of economic development in predicting maternity care. Finally, a positive and statistically significant relationship is found between economic development and gender equality. Implications and limitations of the study are discussed.     

Birth and death in cities in the developing world

City dwellers in Sub-Saharan Africa have increased roughly 600% in the last 35 years. Throughout the developing world, cities have expanded at a rate that has far outpaced rural population growth. Extensive data document lower fertility and mortality rates in cities than in rural regions. But slums, shantytowns, and squatters' settlements proliferate in many large cities. Martin Brockerhoff studies the reproductive and health consequences of urban growth, with an emphasis on maternal and child health. Brockerhoff reports that child mortality rates in large cities are highest among children born to mothers who recently migrated from rural areas or who live in low-quality housing. Children born in large cities have about a 30% higher risk of dying before they reach the age of 5 than those born in smaller cities. Despite this, children born to migrant mothers who have lived in a city for about a year have much better survival chances than children born in rural areas to nonmigrant mothers and children born to migrant mothers before or shortly after migration. Migration in developing countries as a whole has saved millions of children's lives. The apparent benefits experienced in the 1980s may not occur in the future, as cities continue to grow and municipal governments confront an overwhelming need for housing, jobs, and services. Another benefit is that fertility rates in African cities fell by about 1 birth per woman as a result of female migration from villages to towns in the 1980s and early 1990s. There will be an increasing need for donors and governments to concentrate family planning, reproductive health, child survival, and social services in cities, particularly in Sub-Saharan Africa, because there child mortality decline has been unexpectedly slow, overall fertility decline is not yet apparent in most countries, and levels of migration to cities are anticipated to remain high.     

Comic revisions? Motherhood and women’s comedy in contemporary Germany

Maternal stereotypes and the realities of mothering are prominent themes in Anke Engelke’s Ladykracher and Martina Hill’s Knallerfrauen, two of the most popular sketch shows in twenty-first-century Germany. This article relates their success to social anxieties about motherhood, which Engelke and Hill illuminate through the theme of their sketches as well as through their very use of comedy to do so. I begin by using close-readings of Ladykracher and Knallerfrauen to illuminate the political potential of the sketch form to challenge maternal myths and articulate taboo feelings such as maternal ambivalence. I then consider the innovation of these maternal sketches in view of traditional theories of comedy, which paradoxically draw their imagery from the realm of the maternal even though they discount real women and mothers as comic agents. I argue that the maternal sketches of Engelke and Hill are thus doubly subversive, challenging maternal taboos as well as the discursive and generic norms they sustain.     

India's National Family Health Survey provides new information on maternal and child health and AIDS awareness

Teams surveyed a sample of 88,562 households, drawn from 99% of the population of India in 24 states plus the National Capital Territory of Delhi, between April 1992 and September 1993 to collect a basic set of information on all 500,492 household members, with more details on the 89,777 women in the households who had ever been married and were aged 13-49 years. This National Family Health Survey (NFHS) collected information from the women on a range of health topics including child immunization, women's knowledge of AIDS, services and facilities use during pregnancy and childbirth, infant feeding and treatment for diarrhea, and infant, child, and maternal mortality. Levels of infant and child mortality declined in India, but 8% of all children still die before their first birthday and 11% die before reaching age 5. As for maternal mortality, there are an estimated 420 maternal deaths per 100,000 live births annually. That rate implies that at least 100,000 Indian women die each year due to causes related to pregnancy and childbirth. Survey results indicate the need to strengthen vaccination programs and teach women about proper infant feeding practices. They also highlight the need to increase antenatal care and other medical services. In all of these areas, the NFHS results indicate wide variation among India's regions and states. Furthermore, a general lack of AIDS awareness suggests that the government's AIDS awareness campaign, relying primarily upon electronic media, has not yet reached the majority of India's population.     

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.     

Childbirth evacuation among rural and remote Indigenous communities in Canada: A scoping review

ProblemRoutine evacuation of pregnant Indigenous women from remote regions to urban centres for childbirth is a central strategy for addressing maternal health disparities in Canada. Maternal evacuation continues despite mounting evidence of its negative impacts on Indigenous women and families.BackgroundSince the 1960s, pregnant Indigenous women living in remote regions in Canada have been transferred to urban hospitals for childbirth. In the following decades, evidence emerged linking maternal evacuation with negative impacts on Indigenous women, their families, and communities. In some communities, resistance to evacuation and the creation of local birthing facilities has resulted in highly diverse experiences of childbirth and evacuation.AimA scoping review mapped the evidence on maternal evacuation of Indigenous women in Canada and its associated factors and outcomes from 1978 to 2019.MethodsWe searched MEDLINE, Embase, and CINAHL, and grey literature from governmental and Indigenous organizations. We collated the evidence on maternal evacuation into 12 themes.ResultsFactors related to evacuation include (a) evacuation policies (b) institutional coercion (c) remoteness and (d) maternal-fetal health status. Evacuation-related outcomes include (e) maternal-child health impacts (f) women’s experience of evacuation (g) financial hardships (h) family disruption (i) cultural continuity and community wellness (ij) engagement with health services (k) self-determination, and (l) quality of health services.DiscussionNumerous emotional, social and cultural harms are associated with evacuation of Indigenous women in Canada. Little is known about the long-term impacts of evacuation on Indigenous maternal-infant health. Evidence on evacuation from remote Métis communities remains a critical knowledge gap.