Use of maternity services by pregnant women in a small Nigerian community

Pregnancy is a time when women's health is placed at risk by a host of factors; however, professionals providing antenatal care can reduce that risk by monitoring women's health regularly and offering preventive services. Hygienic delivery services by a qualified attendant also help to reduce risks associated with childbearing. We explored these considerations in a rural Nigerian town by following 60 Yoruba women through pregnancy to childbirth. Although a functioning government maternity center in the community offered a full range of antenatal and delivery services, most of the women did not register for antenatal care until their sixth month of pregnancy or later, and 65% delivered at home. This behavior is explained in terms of (a) fees for delivery services, (b) level of income, (c) cultural beliefs, and (d) education. We conclude that provision of relatively accessible services does not guarantee their use and that other social and cultural considerations must be taken into account.     

Significance of philosophy, bio-mathematics, biometry and model theory for medicine]

STUDY OBJECTIVE: Poor attendance to antenatal visits was studied to identify risk factors and to analyse the association with adverse pregnancy outcome. DESIGN: All poor attenders and a sample of good attenders were compared within three groups of women: women < 20 years, French women > or = 20 years, and foreigners > or = 20 years. SETTING: 20 French districts including 85,000 births from January to June 1993. SUBJECTS: 848 poor attenders and 759 good attenders. Poor attenders made fewer than four antenatal visits or began care during or after the sixth month. Good attenders made at least four visits and began care before the sixth month. MAIN RESULTS: 1.1% of the women were poor attenders. Risk factors for poor attendance were single status and lack of health insurance in the group under 20; young age, high parity, and single status in the French group aged over 20; and single status and lack of health insurance in the foreign group aged over 20. For poor attenders, the odds ratios for preterm delivery were 5.8 (95% CI: 3.2, 10.5) among French women and 3.3 (95% CI: 1.5, 7.4) among foreign women with health insurance. Poor attendance was not associated with poor pregnancy outcome in the group under 20, and among foreign women over 20 without health insurance, but both groups had high rates of preterm delivery and low birth weight. CONCLUSION: Lack of health insurance is an important barrier to health care during pregnancy. Poor antenatal care is an important risk factor for adverse pregnancy outcome among women who have easy access to health care services.     

Appropriateness in health care delivery: definitions, measurement and policy implications

A major focus of the current health care debate is the notion that a substantial proportion of the health care delivered in Canada is inappropriate. There are two types of appropriateness: appropriateness of a service and appropriateness of the setting in which care is provided (i.e., inpatient v. outpatient or home care). Measuring both types objectively requires the comparison of observed patterns of care with explicit criteria for appropriate care. The few studies of appropriateness conducted in Canada have shown that inappropriate services are provided and inappropriate settings are used. Reducing inappropriate health care delivery could involve active strategies for the implementation of guidelines and better cooperation and coordination within the health care system. However, lower rates of health care delivery or even inappropriate health care will not necessarily translate into higher quality care or lower costs overall.     

Pregnancy in HIV-infected women. Counseling and care--12 years' experiences and results

BACKGROUND: A specialized antenatal care unit was set up for counseling and care of HIV-infected pregnant women. The team consisted of gynecologists, a midwife, a social worker and pediatricians. METHODS: The women were referred from departments of infectious diseases, venereology or institutions for drug addicts, antenatal care units and abortion clinics, or applied themselves. Women identified in the pregnancy HIV screening program were informed primarily by the team. The women were counseled along with their partners and cared for during abortion or the antenatal period, delivery and post partum. Contraceptive services were offered and psychosocial support was given. RESULTS: Between April 1985 and March 1997, 95 HIV-infected women with 122 pregnancies attended. Twenty-one per cent were or had been drug users, 2% had been infected by transfused blood and 77% were classified as having been sexually infected, two thirds of whom were Africans. The mean age was 27.8 years. In 54 of 93 pregnancies (58%) in which the woman could make an informed decision, she elected abortion -- in 37 cases for HIV related reasons. Significantly more women with an uninfected steady partner, compared to women without a steady partner, chose to continue the pregnancy, as did women in a relatively stable social situation. Of the partners, 68 were HIV-negative, 36 HIV-positive and 18 not tested. No severe HIV-related complications occurred during pregnancy. Seven of 40 (18%) children with a known infection status were infected. During the course of follow-up, nine mothers, two fathers and three children have died. Seventeen children were at risk of being orphaned, and another five were placed in foster care. CONCLUSION: Although it is possible to reduce mother-to-infant transmission by zidovudine therapy, the negative consequences of HIV and childbearing are still substantial. Therefore HIV screening during pregnancy and pre-pregnancy counseling are important issues for the health care system.     

Can deliveries at risk be selected at smaller delivery units?

In order to explore the possibility of converting a delivery unit at a small hospital to a maternity home, we examined the medical records of those women who delivered by Caesarean section, forceps or vacuum extraction at Lofoten hospital during 1995. How many of these women might it have been necessary to transfer to an obstetrical department if Lofoten hospital had been a maternity home caring for low risk deliveries (primipara and multipara)? Out of a total of 271 deliveries (primiparas 98), 49 women delivered by Caesarean section (n = 35), forceps (n = 5) or vacuum extraction (n = 9). Using risk assessment, 22 women (45%) would have been selected for antenatal transfer, and 20 (41%) for intrapartum transport. For seven women no transfer would have been possible. These women would have delivered locally by vacuum extraction. Primipara versus multipara had a relative risk of 2.8 for Caesarean section or assisted vaginal delivery. It is estimated that 8-9% of the women would be selected prenatally for planned delivery at a hospital unit and that 7-8% would be transferred in labour if primiparas delivered at the maternity home. If primiparas were excluded, the proportions would be 41% and 1-2% respectively. In 1997 the delivery unit at Lofoten hospital was temporarily converted to a maternity home for a period of two years.     

Breast feeding at maternity hospitals in France in 1995. National perinatal survey

The objectives of the study were to estimate the current level of breast-feeding at hospital discharge in France, and to identify maternal factors and characteristics of the pregnancy and delivery associated with breast-feeding. DATA AND METHODS: The sample included all births during 1 week in France in 1995 (n = 12,179 babies). The data were collected during the postnatal stay in hospital. Factors associated with breast-feeding were identified, using bivariate analysis and multiple logistic regression. As the relations between the studied factors and breast-feeding differed between French women and women of foreign nationality, multivariate analysis was carried out separately in the two groups. RESULTS: In 1995, 52% of babies were breastfed at hospital discharge, including 10% of babies partially breastfed. Breastfeeding was more common among women of foreign nationality than among French women, 76 vs 49%. In both groups, breastfeeding was more common among older women, women with a high level of education or a qualified occupation; breastfeeding was also more frequent among non smokers during pregnancy and among women who attended antenatal classes. On the contrary, among French women, induction of labour and delivery in a small hospital were associated with a low level of breastfeeding; among women of foreign nationality, a low level of breastfeeding was observed for unmarried women, women who had an induction or a caesarean section, and those who delivered in a private hospital. CONCLUSION: France was at the lowest level among Western countries for which national data on breastfeeding were available. Efforts to promote breastfeeding are needed, both towards sub-groups of pregnant women and towards health professionals. Maternity hospitals should provide support to breastfeeding mothers, and avoid practices which may affect breastfeeding.     

Health practices and indices of a poor urban population in Indonesia. Part I: Patterns of health service utilization

This first section in a two-part study of health indices and practices among residents living in a Jakarta slum describes the use of public and private primary health care services in relation to socioeconomic and health status. As problems associated with urban poverty rapidly increase in developing countries, it is important to study the ethnic and economic diversity which exists in slums and shanty towns: results of such studies should inform the development of effective strategies for outreach and service delivery. Through a survey of 690 mothers and 593 children, we found that 1) poorer residents were more likely than relatively affluent ones to rely on local government clinics (posyandus) for primary health care; 2) regular posyandu users were more likely than non-users to be fully immunized and to use ORT correctly; 3) delivery in hospital was common among all residents, but especially among the more affluent; and 4) prevalence of contraception was high and not associated with socioeconomic status or type of primary health care service used. Strengthening primary health care services at the government's local health posts could benefit all groups in the community if wealthier residents participated more in the posyandus. Standards of care in the private sector should also be improved.     

Maternal care receptivity and its relation to perinatal and neonatal mortality. A rural study

A longitudinal study was conducted on 212 pregnant women from May 1987 to April 1988. Maternal Care Receptivity (MCR) "an innovative approach" was adopted for the assessment of maternal care services provided to pregnant mothers at their door steps. During follow-up, scores were allotted to each of the services rendered and antenatal status of pregnant women. Depending on the score--MCR was classified as high (11 to 8), moderate (7 to 4) or poor (3 to 0). Perinatal and neonatal deaths were recorded and an inverse relationship between MCR and perinatal and mortalities was observed (z = 5.46, p < 0.0001). Significantly, no perinatal or neonatal deaths occurred in women with high MCR. One of the most important cause of high PNMR and neonatal mortality rate in developing countries is poor MCR, i.e., under utilization of even the existing maternal health services. The main reasons for this under utilization appear to be poverty, illiteracy, ignorance and lack of faith in modern medicine.     

Identifying morbidity in postpartum women

Women with postpartum health problems do not readily initiate consultation, making it necessary for those providing care to devise methods by which problems can be identified. By taking detailed accounts of each woman's labour and delivery details when planning postpartum care, some morbidity could be preempted and its effect limited. Postnatal care requires a planned structure which could be modelled on current antenatal care organisation. All women could routinely be seen at three or six months post-delivery. Care could be given by midwives, with referral to GPs where necessary. Fatigue could put women at greater risk of developing postpartum depression, but few women spontaneously report fatigue as a health problem. Limiting the effects of childbirth on maternal health will have important implications for the future use of the medical services.     

Multicenter randomized clinical trial of home uterine activity monitoring: pregnancy outcomes for all women randomized

OBJECTIVE: Our purpose was to evaluate the impact of home uterine activity monitoring on pregnancy outcomes among women at high risk for preterm labor and delivery. STUDY DESIGN: Women at high risk for preterm labor at three centers were randomly assigned to receive high-risk prenatal care alone (not monitored) or to receive the same care with twice-daily home uterine activity monitoring without increased nursing support (monitored). There were 339 women with singleton gestations randomized with caregivers blinded to group assignment. The two groups were medically and demographically similar at entry into the study. RESULTS: Women in the monitored group had prolonged pregnancy survival (p = 0.02) and were less likely to experience a preterm delivery (relative risk 0.59; p = 0.04). Infants born to monitored women with singleton gestations were less likely to be of low birth weight (< 2500 gm; relative risk 0.47, p = 0.003), and were less likely to be admitted to a neonatal intensive care unit (relative risk 0.5, p = 0.01). CONCLUSION: These data show, among women with singleton gestations at high risk for preterm delivery, that the use of home uterine activity monitoring alone, without additional intensive nursing care, results in improved pregnancy outcomes, including prolonged gestation, decreased risk for preterm delivery, larger-birth-weight infants, and a decreased need for neonatal intensive care.     

A multicomponent intervention to prevent partner violence within an existing service intervention.

Intimate partner violence (IPV) is an enormous public health problem that results in injury, health problems, and substantial cost to society. Despite having a grasp of the scope of IPV, public health officials and workers know little about how to prevent it. The few empirically established primary prevention programs consist of school-based curricula targeting high school students. Additional venues for IPV prevention are needed, especially for women at elevated risk. This article describes a preventive intervention for IPV consisting of three components: (a) a structured assessment for IPV; (b) a brochure-driven intervention for women experiencing IPV, including safety planning, referrals, and advocacy; and (c) a skills-based curriculum delivered to all participants that focuses on improving relationship decisions and outcomes. While this intervention could potentially be delivered in a multitude of clinical settings, this article focuses on its delivery within a home visitation program for young, disadvantaged new mothers, a population known to be at increased risk for IPV. If found to be effective, this intervention could be incorporated into many service delivery systems, with broad-based clinical implications for IPV prevention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Identifying twin gestations at low risk for preterm birth with a transvaginal ultrasonographic cervical measurement at 24 to 26 weeks' gestation

OBJECTIVE: Because twins are a high-risk group for preterm birth, many clinicians routinely use prophylactic interventions such as home bed rest, hospital bed rest, oral tocolytics, or home uterine activity monitoring to prevent preterm delivery. We sought to identify twin gestations at low risk for spontaneous preterm birth with transvaginal ultrasonography of the cervix to avoid the unnecessary use of prophylactic interventions in these pregnancies. STUDY DESIGN: We measured cervical length at 24 to 26 weeks' gestation by transvaginal ultrasonography in women with twin gestations referred to our prematurity prevention clinic. Each delivery was classified as (1) spontaneous preterm birth < 34 weeks' gestation, (2) delivery at > or = 34 weeks' gestation with intervention, or (3) delivery at > or = 34 weeks' gestation without intervention. Intervention included strict bed rest at home or in the hospital, either parenteral or oral tocolysis, or both, or home uterine activity monitoring. Indicated preterm deliveries and patients with cerclage were excluded from this analysis. The ability of transvaginal cervical length to predict women who would deliver at > or = 34 weeks without intervention was evaluated. A cervical length of 35 mm was chosen by scatter diagram as the best cutoff to discriminate between the group delivered at term without intervention and the other two groups. RESULTS: Of 85 women with twin gestations who underwent ultrasonographic cervical length measurements at 24 to 26 weeks' gestation, 17 had spontaneous preterm birth at < 34 weeks, 23 were delivered at > or = 34 weeks but required intervention, and 45 were delivered at > or = 34 weeks without intervention. The mean cervical length for those delivered at > or = 34 weeks' gestation without intervention (36.4 +/- 5.8 mm) was significantly greater (p < 0.0001) than the mean for those delivered preterm (27.4 +/- 8.5) and those delivered at > or = 34 weeks' gestation who required intervention (27.7 +/- 10.5 mm). The sensitivity, specificity, and positive and negative predictive values of a cervical length > 35 mm for predicting delivery at > or = 34 weeks' gestation are 49%, 94%, 97%, and 31%, respectively. CONCLUSION: A transvaginal ultrasonographic measurement of the cervix of > 35 mm at 24 to 26 weeks in twin gestations can identify patients who are at low risk for delivery before 34 weeks' gestation.     

Unplanned pregnancies in Harare, Zimbabwe: what is the contraceptive history and awareness of the mothers?

OBJECTIVES: The study aimed to estimate the proportion of unplanned pregnancies among mothers delivering at the referral Harare Hospital and to describe their levels of contraceptive use and awareness in relation to the planning of pregnancy. DESIGN: Systematic sample of mothers who had just delivered identified through maternity delivery, records. The study was analysed as a case-referent study where cases where mothers who had unintended pregnancies and those with intended or planned pregnancies served as referents. SETTING: Postnatal wards of Harare Maternity Hospital. SUBJECTS: 923 mothers following delivery. MAIN OUTCOME MEASURES: Socio-demographic characteristics, pregnancy planning, contraceptive history and contraceptive knowledge. RESULTS: Of the 923 deliveries studied, 377 (41%) were unintended (cases), of which 9% were unwanted. Mothers aged 19 years or below (Odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.6 to 3.7) and those aged 35 years or above (OR = 3.2, 95% CI = 1.8 to 5.5) were significantly more likely to report the index pregnancy as having been unintended. Nulliparous (OR = 2.4) and parity five or more (OR = 8.2) mothers were at significantly increased risk of unintended pregnancy. Mothers presenting with unintended pregnancies were also significantly more likely to be single (OR = 7.8), divorced/separated or widowed (OR = 6.0). Contraceptive ever use was 53% and 58% in cases and referents, respectively. The combined oral contraceptive pill was the most commonly known and used method of contraception. Contraceptive failure was reported by 23% of mothers with unplanned pregnancies. Previous use of the progesterone only pill (OR = 2.2), the condom (OR = 2.3) or the IUCD (OR = 6.3) were significantly associated with the likelihood of reporting with unplanned pregnancy. Mothers in both groups were concerned about contraceptive method failure, irregular menstruation and perceived subsequent infertility with contraception. Failure to discuss family planning with the male partner (OR = 2.3) or partner refusing use of contraception (OR = 2.8) constituted risk factors for unplanned pregnancy. CONCLUSION: Results point to the need for wider contraceptive counselling and provisions which encourage and involve the male partner. Programmes for reproductive health services and education should target women in identified high risk circumstances.     

Comparison of oxidized low-density lipoprotein toxicity on EA.hy 926 cells and human vein endothelial cells: influence of antioxidant systems

BACKGROUND: The Government's policy of Changing childbirth gives priority to user-oriented outcomes, such as continuity of carer. It has been assumed that the organization (or pattern) of maternity care is the main determinant of continuity, with relatively little attention paid to sociodemographic factors. The aim of this study was to assess the relative contribution of social class, spoken language and pattern of care in determining continuity of carer. METHOD: Postal questionnaires were sent 14 days after delivery to East London and the City Health Authority residents delivering within a three-week period in May 1994. Bilingual interviews were carried out for non-English-speaking women. Pattern of care was assigned by the midwife as either hospital or community (including team based care, 'domino' and home births). The main outcome measure was self-reported continuity of carer in antenatal, delivery and postnatal care. RESULTS: The response rate was 69 per cent (370/533). The community pattern of care affected only antenatal continuity (62 per cent community vs 50 per cent hospital, p < 0.05). Women whose main spoken language was English or whose social class was I-IIIn reported higher levels of continuity at each phase of care, although this effect was largely confined to the community pattern of care. The odds ratios (95 per cent confidence intervals) for the effect of social class (I-IIIn vs other) on antenatal, labour and postnatal continuity within the community pattern of care were 3.64 (1.09-12.18), 3.08 (1.09-8.74) and 4.93 (1.48-16.46), respectively. CONCLUSION: Spoken English and high social class were associated with continuity of carer, although this effect was mainly confined to women with a community pattern of care. Achievement of national targets for continuity of carer may not be possible in east London without explicit consideration of sociodemographic factors.     

Delivering at the right price--the costs of primary maternity care at the Diepkloof Community Health Centre, Soweto

This paper reports on a study of the costs of primary maternity care services at the Diepkloof Community Health Centre (DK) in Soweto. DK, the Soweto community health centre system as a whole and numerous other non-hospital settings provide a wide range of maternal health services to substantial numbers of women, and relieve hospitals of a major potential clinical burden. However, no research has been done in South Africa on the relative costs of the provision of these services in different settings and by different types of health worker. The cost structure of these services at DK is presented and the costs of antenatal care, deliveries in midwife-run labour wards, postnatal care (at the health centre and at home) and family planning services detailed. Some comparisons are made with existing data for another community health centre and with Baragwanath Hospital. These results are relevant to policy and planning of maternal health services. They are also shown to be of relevance to management and several areas of potential improvement of these services are noted.     

Family psychosocial screening: should we focus on high-risk settings?

The objective of this study was to address the question of whether or not psychosocial screening should be focused on "high-risk" populations. A cross-sectional survey of mothers of young children was conducted in various clinics: 758 in teaching clinics, 444 in private practices, and 202 at a military clinic. The self-administered questionnaire covered demographic factors, problems in mothers family of origin, maternal depression, and substance abuse. Mothers in the teaching clinics were younger and had less education and lower incomes than mothers in private practices, with intermediate levels in the military clinic. However, a substantial proportion of mothers seen in all sites reported psychosocial problems. Approximately 20% of mothers in all sites reported a family history of alcoholism. Positive screens for maternal depression ranged from about 15% to 35%. Binge drinking was reported by 10% to 20% at different sites. Psychosocial problems were common even among families seen in "low-risk" settings. Focusing screening only on high-risk clinics would miss many families with psychosocial problems.     

Health situation of refugee children in Münster

The unique opportunities of databased community health promotion in cooperation with local community health authorities are pointed out. Especially within the local refugee population many organisational and psychological obstacles to otherwise widely distributed health services are obvious. Population-focused community health practice involves home health care with interdisciplinary collaboration, and promotes clients's responsibility and self-care. Health promotion depends on communal health reporting focused on specific needs of subpopulations. Health and population data concerning the refugees in Muenster show a considerably higher proportion of children than among the general population of the town, thus indicating special needs for the paediatric care of this group. Communal data concerning health-relevant indicators such as vaccination rates or routine paediatric checkup coverage illustrate the necessity for improving low levels of health care for the communal refugee population. The concept of transcultural community health nursing with vice versa information about health traditions and practices improves health services and care for the refugee population and the health-related communal culture in general.     

Patterns of general health care and STD services use among high-risk youth in Denver participating in community-based urine chlamydia screening

BACKGROUND: In the United States, youth are at highest risk for STDs, and innovative programs have been called for to increase their access to essential STD-related services. To guide the development of such programs, locally relevant information is needed on current use of general health care and STD services in this population. GOAL: To study access to and use of general health care and STD services in a purposive sample of high-risk youth in inner-city Denver. STUDY DESIGN: An interview-based survey conducted as part of a community program for urine chlamydia screening targeting black and Hispanic youth 13 years to 25 years. RESULTS: Of 221 sexually experienced youth in the survey, 72% had accessed general health services in the past year and 39% reported an STD evaluation at any time in the past. Community and school clinics were reported by 50% as a source for general health care and by 62% as a source for STD services. STD clinics were reported by only 14% as a source for STD services. Routine checkups were the most important reasons to seek general health care, yet of those who went for a routine checkup, only 34% reported an STD evaluation. Although few barriers appeared to exist in accessing general health care, anticipated anxiety about procedures and results formed the major barrier to accessing STD services. CONCLUSIONS: Use of general health services was common in this population of high-risk adolescents; however, the provision of STD services as part of general health care visits appeared to be low. On the basis of these findings, a comprehensive STD prevention strategy may be envisioned, which would include provider interventions to increase the provision of STD prevention services in general health care settings; community interventions to enhance access to general health care and STD services; and community-based screening programs for those not able or willing to seek clinic-based services.     

Epidemiologic aspects of pre-eclampsia in Saudi Arabia

Pre-eclampsia is pregnancy induced hypertension of unknown aetiology. There is a paucity of maternal data on the disease from this region and this study was undertaken to identify maternal and possible aetiologic factors associated with the disease in the north western region of Saudi Arabia. Seven hundred and five consecutive maternities which delivered from October 1990 till January 1991 at the Armed Forces Hospital were analysed. 2.8% of women in this community study developed pre-eclampsia. Women at extremes of maternal age, the nulliparous and high parity women; women with high body mass index, blood group O and those with no antenatal care or late booking in this study were at greater risk of developing pre-eclampsia when compared with controls who delivered in the same period. Of the babies born to mothers with pre-eclampsia, 46.7% were of low birthweight (< 2500g) while only 10.4% of controls were low birthweight. It is concluded that mothers with pre-eclampsia have to be identified early. Potential modifiable factors include reducing pregnancies at extremes of maternal age, among high parity women and encouraging early booking as well as regular attendance at the antenatal clinic.