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Kim Y.-M.,Jhpiego | Zainullah P.,Jhpiego | Mungia J.,Jhpiego | Zaka N.,United Nations Childrens Fund
International Journal of Gynecology and Obstetrics | Year: 2012

Objective: To assess the availability and utilization of emergency obstetric and neonatal care (EmONC) facilities in Afghanistan, as defined by UN indicators. Methods: In a cross-sectional study of 78 first-line referral facilities located in secure areas of Afghanistan, EmONC service delivery was evaluated by using Averting Maternal Deaths and Disabilities (AMDD) Program assessment tools. Results: Forty-two percent of peripheral facilities did not perform all 9 signal functions required of comprehensive EmONC facilities. The study facilities delivered 17% of all neonates expected in their target populations and treated 20% of women expected to experience direct complications. The population-based rate of cesarean delivery was 1%. Most maternal deaths (96%) were due to direct causes. The direct and indirect obstetric case fatality rates were 0.8% and 0.2%, respectively. Conclusion: Notable progress has been made in Afghanistan over the past 8 years in improving the quality, coverage, and utilization of EmONC services, but gaps remain. Re-examination of the criteria for selecting and positioning EmONC facilities is recommended, as is the provision of high-quality, essential maternal and neonatal health services at all levels of the healthcare system, linked by appropriate communication and functional referral systems. © 2011 International Federation of Gynecology and Obstetrics.


Smith J.M.,Jhpiego | Lowe R.F.,Venture Strategies Innovations | Fullerton J.,University of California at San Diego | Currie S.M.,Jhpiego | Harris L.,University of California at Berkeley
BMC Pregnancy and Childbirth | Year: 2013

Background: Pre-eclampsia/eclampsia is one of the most common causes of maternal and perinatal morbidity and mortality in low and middle income countries. Magnesium sulfate is the drug of choice for prevention of seizures as part of comprehensive management of the disease. Despite the compelling evidence for the effectiveness of magnesium sulfate, concern has been expressed about its safety and potential for toxicity, particularly among providers in low- and middle-income countries. The purpose of this review was to determine whether the literature published in these global settings supports the concerns about the safety of use of magnesium sulfate.Methods: An integrative review of the literature was conducted to document the known incidences of severe adverse reactions to magnesium sulphate, and specific outcomes of interest related to its use. All types of prospective clinical studies were included if magnesium sulfate was used to manage pre-eclampsia or eclampsia, the study was conducted in a low- or middle-income country, and the study included the recording of the incidence of any adverse side effect resulting from magnesium sulfate use.Results: A total of 24 studies that compared a magnesium sulfate regimen against other drug regimens and examined side effects among 34 subject groups were included. The overall rate of absent patellar reflex among all 9556 aggregated women was 1.6%, with a range of 0-57%. The overall rate of respiratory depression in 25 subject groups in which this outcome was reported was 1.3%, with a range of 0-8.2%. Delay in repeat administration of magnesium sulfate occurred in 3.6% of cases, with a range of 0-65%. Calcium gluconate was administered at an overall rate of less than 0.2%. There was only one maternal death that was attributed by the study authors to the use of magnesium sulfate among the 9556 women in the 24 studies.Conclusion: Concerns about safety and toxicity from the use of magnesium sulfate should be mitigated by findings from this integrative review, which indicates a low incidence of the most severe side effects, documented in studies that used a wide variety of standard and modified drug regimens. Adverse effects of concern to providers occur infrequently, and when they occurred, a delay of repeat administration was generally sufficient to mitigate the effect. Early screening and diagnosis of the disease, appropriate treatment with proven drugs, and reasonable vigilance for women under treatment should be adopted as global policy and practice. © 2013 Smith et al.; licensee BioMed Central Ltd.


Ejembi C.L.,Ahmadu Bello University | Norick P.,Venture Strategies Innovations | Starrs A.,Family Care International | Thapa K.,Jhpiego
International Journal of Gynecology and Obstetrics | Year: 2013

New global guidance has emerged to support countries as they consider introducing or scaling-up misoprostol for postpartum hemorrhage (PPH). The World Health Organization (WHO) and the International Federation of Gynecology and Obstetrics (FIGO) recognize the critical role that community and lay health workers play in preventing PPH and increasing access to misoprostol where skilled birth attendants are not available. As case examples from Nigeria and Nepal illustrate, community engagement and empowerment are critical strategies in successful misoprostol for PPH programs, and must increasingly be viewed as part of efforts to improve maternal health and achieve Millennium Development Goal 5. © 2013 International Federation of Gynecology and Obstetrics.


Smith J.M.,Jhpiego | Gubin R.,Jhpiego | Holston M.M.,Venture Strategies Innovations | Fullerton J.,University of California at San Diego | Prata N.,University of California at Berkeley
BMC Pregnancy and Childbirth | Year: 2013

Background: Hemorrhage continues to be a leading cause of maternal death in developing countries. The 2012 World Health Organization guidelines for the prevention and management of postpartum hemorrhage (PPH) recommend oral administration of misoprostol by community health workers (CHWs). However, there are several outstanding questions about distribution of misoprostol for PPH prevention at home births.Methods: We conducted an integrative review of published research studies and evaluation reports from programs that distributed misoprostol at the community level for prevention of PPH at home births. We reviewed methods and cadres involved in education of end-users, drug administration, distribution, and coverage, correct and incorrect usage, and serious adverse events.Results: Eighteen programs were identified; only seven reported all data of interest. Programs utilized a range of strategies and timings for distributing misoprostol. Distribution rates were higher when misoprostol was distributed at a home visit during late pregnancy (54.5-96.9%) or at birth (22.5-83.6%), compared to antenatal care (ANC) distribution at any ANC visit (22.5-49.1%) or late ANC visit (21.0-26.7%). Coverage rates were highest when CHWs and traditional birth attendants distributed misoprostol and lower when health workers/ANC providers distributed the medication. The highest distribution and coverage rates were achieved by programs that allowed self-administration. Seven women took misoprostol prior to delivery out of more than 12,000 women who were followed-up. Facility birth rates increased in the three programs for which this information was available. Fifty-one (51) maternal deaths were reported among 86,732 women taking misoprostol: 24 were attributed to perceived PPH; none were directly attributed to use of misoprostol. Even if all deaths were attributable to PPH, the equivalent ratio (59 maternal deaths/100,000 live births) is substantially lower than the reported maternal mortality ratio in any of these countries.Conclusions: Community-based programs for prevention of PPH at home birth using misoprostol can achieve high distribution and use of the medication, using diverse program strategies. Coverage was greatest when misoprostol was distributed by community health agents at home visits. Programs appear to be safe, with an extremely low rate of ante- or intrapartum administration of the medication. © 2013 Smith et al; licensee BioMed Central Ltd.


Onyeneho N.G.,University of Nigeria | Orji B.C.,Jhpiego | Okeibunor J.C.,University of Nigeria | Brieger W.R.,Johns Hopkins University
International Journal of Gynecology and Obstetrics | Year: 2013

Objective: To investigate the characteristics ofwomen in Nigeriawho are likely to take sulfadoxine/pyrimethamine (SP) as recommended for the prevention of malaria in pregnancy to reduce maternal and child mortality rates. Methods: A cross-sectional survey of 1380 women was conducted using a structured questionnaire. The women had given birth within 6 months prior to the survey and were drawn from 6 local government areas in Nigeria. Results: Several demographic factors-older age bracket, ever attended school, currently living with a partner, ever married, and wealth-were significantly associated with compliance. Compliance was higher among respondents who had ever been married than among those who had never been married (χ2 = 6.733; P = 0.006). Compliance was also higher among those in paid employment (χ2 = 17.110; P<0.001) and those in a higher wealth quintile (χ2 = 34.861; P<0.001). Knowledge of malaria, which included prevention of malaria in pregnancy through use of IPTp with 2 doses of SP, showed a positive association with compliance. Compliance with 2 doses of SP among those with good knowledge was higher (63.9%) than among those with poor knowledge (46.9%) (χ2 = 26.981; P<0.001). Conclusion: The present findings could help in targeting health education programs to specific subgroups of women to increase compliance with the recommended 2 doses of SP for the prevention of malaria in pregnancy. © 2013 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.


Smith J.M.,Jhpiego | De Graft-Johnson J.,Save the Children MCHIP | Zyaee P.,International Confederation of Midwives | Ricca J.,Jhpiego | Fullerton J.,Independent Consultant
International Journal of Gynecology and Obstetrics | Year: 2015

Building upon the World Health Organization's ExpandNet framework, 12 key principles of scale-up have emerged from the implementation of maternal and newborn health interventions. These principles are illustrated by three case studies of scale up of high-impact interventions: the Helping Babies Breathe initiative; pre-service midwifery education in Afghanistan; and advanced distribution of misoprostol for self-administration at home births to prevent postpartum hemorrhage. Program planners who seek to scale a maternal and/or newborn health intervention must ensure that: the necessary evidence and mechanisms for local ownership for the intervention are well-established; the intervention is as simple and cost-effective as possible; and the implementers and beneficiaries of the intervention are working in tandem to build institutional capacity at all levels and in consideration of all perspectives. © 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.


Newman C.J.,Hill International | Fogarty L.,Jhpiego | Makoae L.N.,National University of Lesotho | Reavely E.,University of North Carolina at Chapel Hill
International Journal for Equity in Health | Year: 2011

Background: Gender segregation of occupations, which typically assigns caring/nurturing jobs to women and technical/managerial jobs to men, has been recognized as a major source of inequality worldwide with implications for the development of robust health workforces. In sub-Saharan Africa, gender inequalities are particularly acute in HIV/AIDS caregiving (90% of which is provided in the home), where women and girls make up the informal (and mostly unpaid) workforce. Men's and boy's entry into HIV/AIDS caregiving in greater numbers would both increase the equity and sustainability of national and community-level HIV/AIDS caregiving and mitigate health workforce shortages, but notions of gender essentialism and male primacy make this far from inevitable. In 2008 the Capacity Project partnered with the Lesotho Ministry of Health and Social Welfare in a study of the gender dynamics of HIV/AIDS caregiving in three districts of Lesotho to account for men's absence in HIV/AIDS caregiving and investigate ways in which they might be recruited into the community and home-based care (CHBC) workforce. Methods. The study used qualitative methods, including 25 key informant interviews with village chiefs, nurse clinicians, and hospital administrators and 31 focus group discussions with community health workers, community members, ex-miners, and HIV-positive men and women. Results: Study participants uniformly perceived a need to increase the number of CHBC providers to deal with the heavy workload from increasing numbers of patients and insufficient new entries. HIV/AIDS caregiving is a gender-segregated job, at the core of which lie stereotypes and beliefs about the appropriate work of men and women. This results in an inequitable, unsustainable burden on women and girls. Strategies are analyzed for their potential effectiveness in increasing equity in caregiving. Conclusions: HIV/AIDS and human resources stakeholders must address occupational segregation and the underlying gender essentialism and male primacy if there is to be more equitable sharing of the HIV/AIDS caregiving burden and any long-term solution to health worker shortages. Policymakers, activists and programmers must redress the persistent disadvantages faced by the mostly female caregiving workforce and the gendered economic, psychological, and social impacts entailed in HIV/AIDS caregiving. Research on gender desegregation of HIV/AIDS caregiving is needed. © 2011 Newman et al; licensee BioMed Central Ltd.


Agha S.,Bill and Melinda Gates Foundation | Williams E.,Jhpiego
Reproductive Health | Year: 2016

Background: Pakistan has a high burden of maternal and newborn mortality, which would be largely preventable through appropriate antenatal and delivery care. While the influence of socio-economic status on institutional delivery is well established in the literature, relatively little is known about the relationship between the quality of antenatal care and institutional delivery. Methods: A household survey of 4,000 currently married women who had given birth in the two years before the survey was conducted in Sindh province in 2013. The survey collected data on socio-economic and demographic variables, the quality of antenatal care provided during a woman's last pregnancy and whether she delivered at a health facility. Logistic regression was used to estimate adjusted odds ratios and 95 % confidence intervals around independent variables for institutional delivery. Results: In the multivariate analysis, a variable measuring quality of antenatal care showed the strongest association with institutional delivery. Moreover, there was a dose-response relationship between the number of elements of quality provided and the odds of institutional delivery: receiving one element of quality increased the odds of institutional delivery 1.7 times, receiving three elements increased the odds 3.8 times and receiving seven elements increased the odds 10.6 times. Household wealth had a statistically significant relationship with institutional delivery but the effect was weaker than that of quality of care. Urban-rural differentials in institutional delivery did not remain significant after adjusting for household wealth and education. Conclusions: The quality of antenatal care provided to a woman during her pregnancy is more strongly associated with institutional delivery than household wealth. Improving the quality of care at health facilities in Sindh should be the foremost priority. Improving the quality of antenatal care services is likely to contribute to rapid increases in skilled birth attendance and better health outcomes for women and children. © 2016 The Author(s).


Stender S.C.,Jhpiego
The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease | Year: 2013

The ultimate goal of government health systems is to provide highly effective equitable services that save lives and reduce morbidity and mortality. The pressure to conform to duplicative global and donor initiatives compounds existing challenges to health systems strengthening such as shortages of human resources for health, weak supply chains, inadequate laboratory services and parallel data management systems. This article illustrates how primary health care, as the point of entry into the health care system for the majority of individuals in sub-Saharan Africa, should be strengthened to ensure that individuals and their communities receive essential, holistic care.


During the last two decades, the use of maternal health services has increased dramatically in Pakistan, with nearly 80% of Pakistani women making an antenatal care (ANC) visit during their pregnancy. Yet, this increase in use of modern health services has not translated into significant increases in the adoption of contraception. Even though Pakistan has had a national family planning programme and policies since the 1950s, contraceptive use has increased slowly to reach only 35% in 2012-13. No evidence is currently available to demonstrate whether the utilization of maternal health services is associated with contraceptive adoption in Pakistan. This study uses data from a large-scale survey conducted in Sindh province in 2013 to examine whether ANC utilization is a significant predictor of subsequent contraceptive use among women. In an analysis which controls for a range of variables known to be important for family planning adoption, the findings show that ANC is the strongest predictor of subsequent family planning use among women in Sindh. The antenatal visit represents an enormous opportunity to promote the adoption of family planning in Pakistan. The family planning programme should ensure that high-quality family planning counselling is provided to women during their ANC visits. This approach has the potential for contributing to substantial increases in contraceptive use in Pakistan. © The Author 2015.

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