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Exploring women's experience of healthcare use during pregnancy and childbirth to understand factors contributing to perinatal deaths in Pakistan: A qualitative study.

ABSTRACT: Understanding key healthcare system challenges experienced by women during pregnancy and birth is crucial to scale up available interventions and reduce perinatal mortality. A community perspective about preferences and experience of care during this period can be used to improve community-based programs to reduce perinatal mortality. Using a qualitative exploratory approach, we examined women's experience of perinatal loss, aiming to understand the main factors, as perceived and experienced by women, leading to perinatal loss. Qualitative in-depth Interviews were conducted with 25 mothers with a recent perinatal loss, three family members, six healthcare officials, and two focus group discussions with 17 lady health workers. Data were analysed using inductive and deductive coding, by thematic analysis. Our findings revealed three distinct but interrelated themes, which include: 1) poor access to care during pregnancy and birth, 2) unavailability of appropriate healthcare services, and 3) poor quality of care during pregnancy and birth. Women frequently delayed seeking formal care around birth because of delays by themselves, their family members, or the local traditional birth attendants who frequently induced births at women's homes without recognising the dangers to the mothers or their babies. Preference for private care was common, however they often could not bear the cost of care when they needed caesarean section or in-patient care for their sick newborns because these services were absent in public health facilities of the district. Referral to the regional tertiary care hospital was often not officially arranged leading to risky births in small and crowded private clinics. Women's views about negative staff attitudes and the lack of attention given to them in public health facilities highlighted a lack of quality and respectful antenatal care. Improvement in women's access to essential care during pregnancy and around birth, availability of emergency obstetric and newborn care, improving the quality of maternal and newborn care in both public and private health facilities at the district level might reduce perinatal mortality in Pakistan.

SUBMITTER: Ahmed J

PROVIDER: S-EPMC7205296 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Exploring women's experience of healthcare use during pregnancy and childbirth to understand factors contributing to perinatal deaths in Pakistan: A qualitative study.

Ahmed Jamil J Alam Ashraful A Khokhar Saadat S Khowaja Sadiq S Kumar Ramesh R Greenow Camille Raynes CR

PloS one 20200507 5

Understanding key healthcare system challenges experienced by women during pregnancy and birth is crucial to scale up available interventions and reduce perinatal mortality. A community perspective about preferences and experience of care during this period can be used to improve community-based programs to reduce perinatal mortality. Using a qualitative exploratory approach, we examined women's experience of perinatal loss, aiming to understand the main factors, as perceived and experienced by ...[more]

PMID: 32379843

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Project description:BackgroundPreventable maternal and infant mortality continues to be significantly higher in Latin American indigenous regions compared to non-indigenous, with inequalities of race, gender and poverty exacerbated by deficiencies in service provision. Standard programmes aimed at improving perinatal health have had a limited impact on mortality rates in these populations, and state and national statistical data and evaluations of services are of little relevance to the environments that most indigenous ethnicities inhabit. This study sought a novel perspective on causes and solutions by considering how structural, cultural and relational factors intersect to make indigenous women and babies more vulnerable to morbidity and mortality.MethodsWe explored how structural inequalities and interpersonal relationships impact decision-making about care seeking during pregnancy and childbirth in Wixarika communities in Northwestern Mexico. Sixty-two women were interviewed while pregnant and followed-up after the birth of their child. Observational data was collected over 18 months, producing more than five hundred pages of field notes.ResultsOf the 62 women interviewed, 33 gave birth at home without skilled attendance, including 5 who delivered completely alone. Five babies died during labour or shortly thereafter, we present here 3 of these events as case studies. We identified that the structure of service provision, in which providers have several contiguous days off, combined with a poor patient-provider dynamic and the sometimes non-consensual imposition of biomedical practices acted as deterrents to institutional delivery. Data also suggested that men have important roles to play supporting their partners during labour and birth.ConclusionsStillbirths and neonatal deaths occurring in a context of unnecessary lone and unassisted deliveries are structurally generated forms of violence: preventable morbidities or mortalities that are the result of systematic inequalities and health system weaknesses. These results counter the common assumption that the choices of indigenous women to avoid institutional delivery are irrational, cultural or due to a lack of education. Rather, our data indicate that institutional arrangements and interpersonal interactions in the health system contribute to preventable deaths. Addressing these issues requires important, but achievable, changes in service provision and resource allocation in addition to long term, culturally-appropriate strategies.

Project description:BackgroundWomen's satisfaction with childbirth experience is considered as one of the quality indicators of the maternity services across the world. However, there is no guideline for improving the experience of childbirth in Iran that is suitable for women with different cultural, economic, and social statuses. The aim of this study is to make recommendations for practice and propose a clinical guideline for improving the experience of women with vaginal births.Methods/designThe study design was a mixed method study with a sequential explanatory approach consisting of three phases. The first phase of the study was a cross-sectional study to identify the predictors of traumatic vaginal childbirth experience among 800 primiparous women from Tabriz health centers who had vaginal birth. Data collection tools in this phase were Childbirth Experience Questionnaire (CEQ) and Support and Control in Birth (SCIB). Both tools were validated for Farsi language. The second phase was a qualitative study with 17 in-depth individual interviews among women who took part in the first phase to better understand their reasons that influenced their childbirth experience either positively or negatively. The third phase of the study was to develop recommendations for a proposed clinical guideline through a Delphi study where maternal health experts were selected and invited to take part in the panel. They first rated the proposed recommendations individually and provided written responses on their own agreement or disagreement with each statement in terms of its impact on childbirth experience, feasibility, acceptability, and cost-effectiveness. After three confirmation rounds, the final conscience was reached by the panel members.ResultsThe results of the quantitative phase showed that the probability of negative experience of childbirth was increased when physical exercise was not implemented during pregnancy, lacking pain relief options, having fear of childbirth, lacking skin to skin contact with the newborn and being unable to initiate breastfeeding in the first hour after birth (P < 0.05). The analysis of qualitative data revealed 13 major theme categories which were related to women's sense of internal control, external control and support. In the third phase of the study, culturally appropriate recommendations were made and an evidence-based clinical guideline was proposed. The proposed guideline was based on the combination of the quantitative and qualitative phases, a review of the literature, and the opinions of Iranian experts using the Delphi technique.ConclusionGiven the high prevalence of negative childbirth experience among Iranian primiparous women, the present study may be of great interest for managers, leaders, policymakers, and care providers to improve the quality of the maternity services. However, further studies are required to translate the recommendations into practice and identify enablers and barriers during the implementation of the proposed guideline. To adopt the recommendations at national level, there is a need to further studies to assess the effectiveness of the proposed guideline within different communities across the region and the country.

Project description:BackgroundKenya continues to have a high maternal mortality rate that is showing slow progress in improving. Peri-urban settings in Kenya have been reported to exhibit higher rates of maternal death during labor and childbirth as compared to the general Kenyan population. Although research indicates that women in Kenya have increased access to facility-based birth in recent years, a small percentage still give birth outside of the health facility due to access challenges and poor maternal health service quality. Most studies assessing facility-based births have focused on the sociodemographic determinants of birthing location. Few studies have assessed women's user experiences and perceptions of quality of care during childbirth. Understanding women's experiences can provide different stakeholders with strategies to structure the provision of maternity care to be person-centered and to contribute to improvements in women's satisfaction with health services and maternal health outcomes.MethodsA qualitative study was conducted, whereby 70 women from the peri-urban area of Embakasi in the East side of Nairobi City in Kenya were interviewed. Respondents were aged 18 to 49 years and had delivered in a health facility in the preceding six weeks. We conducted in-depth interviews with women who gave birth at both public and private health facilities. The interviews were recorded, transcribed, and translated for analysis. Braune and Clarke's guidelines for thematic analysis were used to generate themes from the interview data.ResultsFour main themes emerged from the analysis. Women had positive experiences when care was person-centered-i.e. responsive, dignified, supportive, and with respectful communication. They had negative experiences when they were mistreated, which was manifested as non-responsive care (including poor reception and long wait times), non-dignified care (including verbal and physical abuse lack of privacy and confidentiality), lack of respectful communication, and lack of supportive care (including being denied companions, neglect and abandonment, and poor facility environment).ConclusionTo sustain the gains in increased access to facility-based births, there is a need to improve person-centered care to ensure women have positive facility-based childbirth experiences.

Project description:BackgroundIn clinical settings and research studies, childbirth experience is often measured using a single-item question about overall experience. Little is known about what women include in this rating, which complicates the design of adequate follow-up, as well as the interpretation of research findings based on ratings of overall childbirth experience. The aim of this study was to examine which known dimensions of childbirth experience women include in the rating on a single-item measure.MethodsRatings of overall childbirth experience on a 10-point numeric rating scale (NRS) from 2953 women with spontaneous or induced onset of labour at two Swedish hospitals were evaluated against the validated Childbirth Experience Questionnaire 2 (CEQ2), completed on one of the first days postpartum. The CEQ2 measures four childbirth experience domains: own capacity, perceived safety, professional support and participation. Internal consistency for CEQ2 was evaluated by calculating Cronbach's alpha. NRS ratings were explored in relation to CEQ2 using empirical cumulative distribution function graphs, where childbirth experience was defined as negative (NRS ratings 1-4), mixed (NRS ratings 5-6) or positive (NRS ratings 7-10). A multiple linear regression analysis, presented as beta coefficients (B) and 95% confidence intervals (CI), was also performed to explore the relationship between the four domains of the CEQ2 and overall childbirth experience.ResultsThe prevalence of negative childbirth experience was 6.3%. All CEQ2-subscales reached high or acceptable reliability (Cronbach's alpha = 0.78; 0.81; 0.69 and 0.66, respectively). Regardless of overall childbirth experience, the majority of respondents scored high on the CEQ2 subscale representing professional support. Overall childbirth experience was mainly explained by perceived safety (B = 1.60, CI 1.48-1.73), followed by own capacity (B = 0.65, CI 0.53-0.77) and participation (B = 0.43, CI 0.29-0.56).ConclusionsIn conclusion, overall childbirth experience rated by a single-item measurement appears to mainly capture experiences of perceived safety, and to a lesser extent own capacity and participation, but appears not to reflect professional support. CEQ2 shows good psychometric properties for use shortly after childbirth, and among women with induced onset of labour, which increases the usability of the instrument.

Project description:BackgroundIn the UK approximately half of women requiring perinatal mental health (PNMH) care do not receive treatment despite having routine contact with midwives (MWs) and health visitors (HVs). Limited research has been undertaken regarding MWs'/HVs' decision-making around referring women for secondary PNMH care. In particular, the impact that the level of local secondary PNMH services may have on MWs'/HVs' referral decisions is unexplored.AimTo understand MWs'/HVs' decision-making in relation to referring women with identified PNMH problems, to identify barriers and facilitators to effective and timely referrals including any impact of the local secondary PNMH service provision.MethodsParticipants were recruited from four National Health Service (NHS) Trusts in England, located across two geographical areas, that provided different types of PNMH services. One area had PNMH services that met National Institute for Health and Care Excellence (NICE) guidelines; the other area had no secondary PNMH services. A sequential mixed methods design was used: In-depth semi-structured interviews with practising MWs/HVs (n = 24) to explore their approach to PNMH referral decision-making, analysed using thematic analysis; Questionnaire offered to all practising MWs/HVs in the two geographical areas to measure factors that may impact on PNMH referral decision-making allowing for statistical comparisons to be made between the professional groups/geographical areas.FindingsThree themes were identified from the interviews that impacted on MWs'/HVs' PNMH referral decision-making: identifying need; education, skills and experience; and referral pathways.Questionnaire response rate 13.1% (n = 99). The most reported facilitators to referral decision-making were a trusted relationship between MWs/HVs and women and routine enquiry about women's mental health; the most reported barriers were stigma associated with mental ill-health and women's perceived fear of child removal.ConclusionFundamental to MWs'/HVs' decision-making was their perceived relationship between themselves and women. Although PNMH service provision is important for women to ensure they receive appropriate PNMH care, service provision appeared less important to MWs'/HVs' referral decision-making than how maternity/health visiting services were delivered. Further important factors to MWs/HVs were to the ability to provide continuity of carer with women allowing MWs/HVs to identify women who would benefit from referral for secondary PNMH care.

Dataset Information

Exploring women's experience of healthcare use during pregnancy and childbirth to understand factors contributing to perinatal deaths in Pakistan: A qualitative study.

Publications

Exploring women's experience of healthcare use during pregnancy and childbirth to understand factors contributing to perinatal deaths in Pakistan: A qualitative study.

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