SRHR Policies
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Item An evidence-based policy brief: improving the quality of postnatal care in mothers 48 hours after childbirth(Malawi Medical Journal : The Journal of Medical Association of Malawi, 2019-06) Sakala, Betty; Chirwa, EllenIntroduction: Malawi is experiencing slow progress in postnatal care of mothers within the first 48 hours after childbirth. Malawi Demographic and Health Survey (MDHS) 2015–16 reported a slow progress in postnatal care of mothers in the first 48 hours at 42% from 41% in 2010 despite a high number of institutional births. This is a critical period as a large proportion of maternal deaths occur during this period, currently at 439 per 100,000 live births. During postnatal care the mother is given important information to assist in caring for herself and her baby. The lack of well documented guidelines and funding to employ more midwives to manage mothers in postnatal ward contributes to poor quality of postnatal care. Methods: This is an evidence-based policy brief that was prepared to inform policy makers, health workers, clients, community and other stakeholders to consider the available evidence about the impact of the suggested options in order to improve postnatal care. Results: Several factors that contribute to low utilization of postnatal care among mothers after childbirth were identified. Factors included lack of clear guidelines on postnatal care, shortage of skilled health workers and inadequate resources. Conclusion: Implementation of the identified policy options may improve postnatal care.Item Strategies to improve the quality of foetal monitoring and intrapartum care in high-volume, low-resource maternity units(Utrecht University, 2020) Housseine, NatashaThe majority of maternal and newborn death occur in low and middle-income countries around the time of birth and are preventable with good quality care. In this thesis, we used mixed methodological approaches to analyse quality of care, synthesise and generate evidence for context-specific strategies to improve the quality of care at birth in high-volume, resource-limited labour wards in LMICs, such as Mnazi Mmoja Hospital (MMH), Zanzibar, Tanzania. At this hospital, we found high stillbirth rate (59 per 1000 total births) half of whom died intrahospital, and in general, suboptimal quality of care. We identified a number of inadequate areas to target intervention: 1) admission assessment of maternal foetal characteristics and wellbeing 2) routine surveillance of maternal and foetal wellbeing and progress of labour 3) diagnosis and management of pregnancy and labour complications, 4) clinical documentation and health information systems; 5) respectful maternity care and bereavement care. We also identified daily challenges to providing good care including insufficient number of well-trained skilled birth attendants, lack of essential supplies and unconducive environment. Given the persistent health system’s constraints in providing adequate resources, efforts are needed to find alternative strategies to optimise care. We identified several strategies for care improvement: 1) task-shifting of foetal heart rate monitoring to trained lay workers; however, this solution was not acceptable to local stakeholders who raised many concerns. 2) The use of partograph with management guidelines improved perinatal outcomes. However, these top-down generic guidelines are often a mismatch as they do not take context into account and are unachievable in these settings. Thus, through co-creation with skilled birth attendants at MMH, we adapted international guidelines of clinical care to the local context and implemented them through repeated training. Improvements were found in knowledge, partograph skills and clinical practice including foetal surveillance and treatment of complication during labour. These were associated with a reduction in stillbirths by 33% to 39 per 1000 total births, halving of the number of newborns with an Apgar score of 1–5 to 28 per 1000 live births. 3) We developed a high-performance (c-static: 0.8) model consisting of 15 easily-available clinical predictors to assist skilled birth attendants to identify and triage women at risk of intrapartum-related perinatal deaths for proper follow-up during labour. This thesis sets an example of how to contextualise evidence and interventions using bottom-up approaches and interdisciplinary collaboration of international and local researchers, frontline healthcare workers and service users. show lessItem Effectiveness of respectful care policies for women using routine intrapartum services: a systematic review(Reprod Health, 2018-02-06) Downe, Soo; Lawrie, Theresa A.; Finlayson, Kenny; Oladapo, Olufemi T.Background: Several studies have identified how mistreatment during labour and childbirth can act as a barrier to the use of health facilities. Despite general agreement that respectful maternity care (RMC) is a fundamental human right, and an important component of quality intrapartum care that every pregnant woman should receive, the effectiveness of proposed policies remains uncertain. We performed a systematic review to assess the effectiveness of introducing RMC policies into health facilities providing intrapartum services. Methods: We included randomized and non-randomized controlled studies evaluating the effectiveness of introducing RMC policies into health facilities. We searched PubMed, CINAHL, LILACS, AJOL, WHO RHL, and Popline, along with ongoing trials registers (ISRCT register, ICTRP register), and the White Ribbon Respectful Maternity Care Repository. Included studies were assessed for risk of bias. Certainty of evidence was assessed using GRADE criteria. Findings: Five studies were included. All were undertaken in Africa (Kenya, Tanzania, Sudan, South Africa), and involved a range of components. Two were cluster RCTs, and three were before/after studies. In total, over 8000 women were included at baseline and over 7500 at the endpoints. Moderate certainty evidence suggested that RMC interventions increases women’s experiences of respectful care (one cRCT, approx. 3000 participants; adjusted odds ratio (aOR) 3.44, 95% CI 2.45–4.84); two observational studies also reported positive changes. Reports of good quality care increased. Experiences of disrespectful or abusive care, and, specifically, physical abuse, were reduced. Low certainty evidence indicated fewer accounts of non-dignified care, lack of privacy, verbal abuse, neglect and abandonment with RMC interventions, but no difference in satisfaction rates. Other than low certainty evidence of reduced episiotomy rates, there were no data on the pre-specified clinical outcomes. Conclusion: Multi-component RMC policies appear to reduce women’s overall experiences of disrespect and abuse, and some components of this experience. However, the sustainability of the demonstrated effect over time is unclear, and the elements of the programmes that have most effect have not been examined. While the tested RMC policies show promising results, there is a need for rigorous research to refine the optimum approach to deliver and achieve RMC in all settings.