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March 4, 2021
Community-Based Models to Improve Maternal Health Outcomes and Promote Health Equity
Stephanie Dixon, left, and Deundra Hundon, a mother-daughter doula duo and owners of Bare With Me, demonstrate how a birthing person can be supported while in the bathroom. Bare With Me is part of a new partnership with the San Francisco Department of Public Health aimed at providing doulas to low-income Black and Pacific Islander women. Photo: Carlos Avila Gonzalez/San Francisco Chronicle via Getty Images
Equity-centered approaches to maternity care may help reduce the rising rate of maternal mortality in the U.S. among women of color
Community-based models of care, including group prenatal care and pregnancy medical homes, may improve maternal health outcomes
- Issue: In the United States, high spending on maternity care does not translate to better maternal health outcomes. People of color, particularly Black and Indigenous women, are at heightened risk for negative outcomes.
- Goal: To examine models for delivering maternity care that could improve outcomes and reduce racial inequities in maternal morbidity and mortality.
- Methods: Review of research literature on the maternal health outcomes associated with community-based, perinatal care models.
- Findings and Conclusions: Research shows a wide range of community-based approaches could improve maternal health outcomes and patients’ experiences while also potentially reducing costs. Such approaches could especially benefit those most at risk for poor outcomes, particularly people of color and those with low income. One policy option is expanding reimbursement for providers like doulas and midwives, whose care has been associated with improved maternal and infant health outcomes in some research. Other options include enhancing patient access to a broader range of services and incentivizing health systems and providers to adopt evidence-based, equity-centered models of care.
Note: We at times use “women” and “mothers” when referring to people who are pregnant or recently gave birth. We acknowledge that not all people who become pregnant or give birth identify as women.
INTRODUCTION
The United States has one of the highest rates of maternal mortality among high-income countries, with nearly 17.4 deaths for every 100,000 live births, despite significantly higher spending on maternity care. 1 Further, risks for maternal mortality are disproportionately higher among Black women, who have a pregnancy-related mortality ratio more than double that of white women, regardless of educational level (see exhibit). Similarly elevated risks of maternal mortality are also reported for Indigenous women. 2
Transformation of the maternity care system will require new models of health care delivery developed with input from community stakeholders and designed to reduce racial health inequities. 3 Such models are being examined not only for their overall effectiveness and cost-savings potential but specifically for their likelihood to improve maternity care for people of color and those with low income. The need for new approaches has perhaps never been greater: as the coronavirus pandemic continues to rage in the U.S., evidence shows that Black, Hispanic, and Indigenous women are being disproportionately affected by COVID-19 during pregnancy. 4
In this issue brief, we review the evidence for new maternity care models and discuss how policymakers, payers, providers, and health care systems can help to advance them.
INCORPORATING DIVERSE GROUPS OF HEALTH CARE PROVIDERS
Community-based doulas and nurse-midwifery care are rooted in the centuries-old practice of women receiving help from other women during childbirth, and a growing demand from women to have greater agency during their own birth process. 5
Community-Based Doulas
What They Are and What They Do: Community-based doulas are trusted individuals, often from local communities, who are trained to provide psychosocial, emotional, and educational support during pregnancy, childbirth, and the postpartum period. 6 They are particularly critical in labor and delivery, serving as patient advocates, and providing comfort and coaching. Community-based doula programs build on the strong relationship doulas establish with mothers throughout pregnancy, birth, and the postpartum period to promote ongoing care and support. 7
Evidence of Effectiveness: Doulas can improve perinatal and postpartum outcomes while being cost-effective, particularly for those facing inequities in birth outcomes. 8 For example, those at high risk for adverse birth outcomes receiving care from doulas, compared with those not receiving care from doulas, are:
- Two times less likely to experience a birth complication
- Four times less likely to have a low birthweight baby
- More likely to breastfeed
- More likely to be satisfied with their care. 9
Capacity to Advance Equity: The evidence suggests doulas are beneficial particularly for women of color, low-income women, and other marginalized communities. For example, a study of Medicaid beneficiaries receiving doula support found lower rates of C-sections and preterm births, compared with other pregnant women enrolled in Medicaid. 10 Similar findings were reported for a community-based doula program serving predominantly Black and Latinx neighborhoods in New York City. 11 Additionally, a recent study in California found that doulas have the potential to provide a “buffer” against racism in health care for pregnant women of color by providing patient-centered, tailored, and culturally appropriate care. 12
To enable community-based doulas to provide care for Medicaid beneficiaries, fair compensation for doula work is critical. At least five states (Indiana, Minnesota, New Jersey, New York, and Oregon) have passed legislation implementing third-party reimbursement for doula services through Medicaid. 13 Unfortunately, during the COVID 19 pandemic, certain states have had to pull back their focus on these programs. Low reimbursement rates as well as expensive, time-consuming licensure processes may also need to be addressed, as they create barriers to entry into community-based doula work.
What They Are and What They Do: Midwives provide reproductive health care and attend births in multiple settings including at home, in a birth center, or in the hospital. They oversee the spectrum of maternity care, helping birthing people to identify their labor preferences and the appropriate site of delivery. Many individuals prefer working with midwives over M.D.s. 14
Evidence of Effectiveness: The positive impact of midwifery on maternity care outcomes is well documented. An extensive literature review shows midwife-led maternity care results in substantially higher rates of vaginal delivery and lower rates of C-sections, as well as significantly lower rates of preterm births and low-birthweight infants compared with other maternity models. 15
Although integration of midwives into health systems is demonstrated to be a key determinant of optimal maternal–newborn outcomes, only 8 percent of births nationally are delivered by certified nurse midwives. 16 Rates vary significantly by states, in part because of differences in scope of practice laws that may limit what services midwives are permitted to provide independently.
Capacity to Advance Equity: There is less evidence on the success of midwifery at reducing racial inequities, perhaps because of the shifting demographic makeup of midwives themselves. 17 In 2019, 49 percent of births in the U.S. were to people of color, but the nurse midwifery workforce remained 90 percent white. 18 This reflects the historical exclusion and denigration of the long tradition of Black midwifery in the U.S. Prior to the early 20th century, the majority of U.S. births were attended by Black or immigrant lay midwives. 19
For nurse midwifery to effectively address racial disparities in birth outcomes, one policy option is intentional investment in pipelines to train a racially and culturally diverse midwifery workforce. This may be especially valuable, as evidence suggests that racial concordance between provider and patient can improve satisfaction and quality of care. 20
OFFERING NON-HOSPITAL-BASED CARE
Freestanding birth centers.
What They Are and What They Do: Birth centers are stand-alone facilities that provide prenatal and labor and delivery care. They emphasize relationship-building between providers and pregnant people, and patient-centered birth planning and labor. Unlike costly hospital-based labor and delivery, birth centers are midwifery-led and typically do not employ anesthesiologists, obstetricians, and pediatricians. Because of this, birth centers are only recommended for low-risk labors. 21
Evidence of Effectiveness: Birth centers reduce the number of interventions used in the course of labor and delivery while improving patient experience and lowering costs — saving more than $1,000 per birth. 22 A review of 32 studies of birth centers found positive health outcomes for women, including lower rates of C-sections compared with women delivering in hospitals. 23 Few severe maternal outcomes and no maternal deaths were reported in any of these studies, and overall, women were satisfied with the comprehensive, personalized care that they received. Another recent study of more than 15,000 birth center labors found only 6 percent resulted in C-sections with no maternal deaths. 24 Although less consistent, some research also suggests improved infant outcomes. 25
Hospital-affiliated birth centers may be particularly effective because they ensure higher levels of care are available in an emergency. 26 For example, birth centers may be colocated with hospitals, with midwives maintaining admitting privileges. Some states also are leveraging the birth center model during the COVID-19 pandemic as a safe alternative to overcrowded hospitals and to prevent infection for birthing parents. 27
Capacity to Advance Equity: Black-owned, culturally sensitive birth centers are a promising means of reducing racial disparities in maternal morbidity and mortality. 28 However, while there are more than 384 birth centers in the United States, it is estimated that only about 20 are led by people of color. 29 Limited access to capital and resources is a significant barrier to people of color starting and owning birth centers. Another obstacle to the growth of birth centers is Medicaid’s limited, or sometimes lack of, reimbursement for the services they provide.
EXPLORING INNOVATIVE MODELS OF MATERNITY CARE
Group prenatal care.
What It Is and What It Does: Group prenatal care has been widely tested as an alternative to traditional, individualized care. Under the model, providers offer the same physical health care services for individual patients, who also convene as a group for facilitated discussions on topics ranging from preparations for parenthood and stress management to breastfeeding and nutrition. 30
Evidence of Effectiveness: Preliminary, observational studies on the impact of group prenatal care demonstrate reduced rates of preterm birth (upwards of 41%), neonatal intensive care unit (NICU) admissions, low birthweight, and emergency department use during pregnancy, as well as increases in breastfeeding, patient and physician satisfaction, and parental knowledge of childbirth and child-rearing. 31 A study of a group prenatal care program for pregnant Medicaid beneficiaries in South Carolina found the model was cost-effective; by preventing premature births, group prenatal care resulted in cost savings of $2.3 million for the state. However, some studies, particularly randomized clinical trials, found no differences in health outcomes like preterm births between women in group versus individual prenatal care. 32 Whether group prenatal care programs were able to successfully move online during the COVID-19 pandemic, and the impact of that transition, remains an open question.
Capacity to Advance Equity: There is evidence that group prenatal care is particularly helpful for improving health outcomes among Black people with low income, suggesting the model could help reduce racial disparities in maternal and infant mortality. 33 Despite the promising evidence, the use of this model is not widespread. 34 Some have been piloting diverse, culturally centric models to increasing awareness and interest. One group program, EMBRACE, was developed to provide prenatal care integrated with intentional racial consciousness to Black mothers and Black pregnant people. 35 Group prenatal care models can be culturally responsive and aware and have diverse staff and leadership that represent the community served.
Pregnancy Medical Homes
What They Are and What They Do: The pregnancy medical home (PMH) provides comprehensive perinatal health care. PMHs provide early prenatal care in the first trimester, expand patient access through increased office hours, and engage patients in shared decision-making. 36 Teams are financially incentivized for achieving specific milestones toward these goals and for meeting program requirements, such as screening for risk, collaborating with a care coordinator, and using data and analytics to monitor their own performance.
Evidence of Effectiveness: A medical home pilot in Texas resulted in better outcomes, fewer emergency department visits, and fewer C-sections, while pilots in Wisconsin and Texas increased likelihood of attending a postpartum visit. 37 North Carolina formed a PMH model in which teams of maternity care providers aim to prevent preterm births and reduce C-sections for individuals enrolled in Medicaid. The program resulted in a nearly 7 percent decrease in the low-birthweight rate among the state’s Medicaid population. 38
Several states that have implemented PMHs have realized savings from decreased hospitalizations and emergency department visits. 39 However, some evidence suggests PMH models are not as effective as other models like group prenatal care at preventing maternal and child mortality and morbidity, and reducing overall health care costs. 40
Capacity to Advance Equity: There is promising evidence that the PMH model, with its integrated care teams that address behavioral health and social needs, could play a role in reducing racial disparities in maternity outcomes. For example, North Carolina had the second-lowest rate of maternal mortality of all 25 reporting states, according to 2018 data from the Centers for Disease Control and Prevention. The state’s success in part may be the result of its PMH model, which was implemented among 95 percent of prenatal care providers who accept Medicaid payment. 41
ROLE OF PAYMENT AND DELIVERY SYSTEM REFORM
Equity-centered approaches to maternity care may help curb the rising rate of maternal mortality in the United States, particularly among women of color. Several approaches to maternity care have demonstrated that they can improve maternal and infant health outcomes — and, in some cases, reduce costs. To scale and spread these models, payment and delivery system reforms could focus on the following three areas:
- Expanding and improving reimbursement for the provider types that have helped reduce negative maternal and infant health outcomes, including doulas and midwives. States have a key role in defining scope of practice and allowing these providers to deliver services within their training and ability without physician supervision. The federal government also could financially support accreditation programs and create and expand loan forgiveness and training programs for these provider types to increase access to racially and culturally diverse maternity care providers.
- Improving access to services. The largest insurer of pregnant people, Medicaid, ends coverage for women 60 days postpartum, which leaves them without critical follow-up care. To reduce the racial inequities in maternal and infant morbidity and mortality, Medicaid coverage could be extended to at least one year postpartum. Additionally, Medicaid and other delivery system models could include more services addressing medical, behavioral, and social health needs.
- Incentivizing health systems and providers to adopt evidence-based models of care, like pregnancy medical homes, birth centers, and group prenatal care. Additionally, using value-based payments to incentivize use of equity-centered models could promote a more diverse set of providers and services. Creating accountability and incentives would help ensure that these policies and programs are equity-centered and create the desired outcomes.
A large and growing body of research suggests that a wide range of approaches could improve maternal health outcomes and the patient experience, while potentially reducing costs. This is especially true for those most at risk for negative outcomes, including people of color and those with low income.
As policymakers, providers, payers, and health system leaders rethink care delivery during the COVID-19 pandemic, they may consider how these evidence-based models can be modified, leveraged, and expanded to ensure access to high-quality maternity care now and in the future.
1. Munira Z. Gunja et al., What Is the Status of Women’s Health and Health Care in the U.S. Compared to Ten Other Countries? (Commonwealth Fund, Dec. 2018); and “ Maternal Mortality ,” National Center for Health Statistics, Centers for Disease Control and Prevention, Nov. 9, 2020.
2. Emily E. Peterson et al., “ Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017,” Morbidity and Mortality Weekly Report 68, no. 18 (May 10, 2019): 423–29.
3. Zoë Julian et al., “ Community-Informed Models of Perinatal and Reproductive Health Services Provision: A Justice-Centered Paradigm Toward Equity Among Black Birthing Communities ,” Seminars in Perinatology 44, no. 5 (Aug. 2020): 151267.
4. Sascha Ellington et al., “ Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22–June 7, 2020 ,” Morbidity and Mortality Weekly Report 69, no. 25 (June 2020): 769–75; and Bryant Furlow, “ A Hospital’s Secret Coronavirus Policy Separated Native American Mothers from Their Newborns ,” ProPublica, June 13, 2020.
5. Katy Dawley, “ Origins of Nurse‐Midwifery in the United States and Its Expansion in the 1940s ,” Journal of Midwifery & Women’s Health 48, no. 2 (Mar.–Apr. 2003): 86–95.
6. Nora Ellmann, “ Community-Based Doulas and Midwives: Key to Addressing the U.S. Maternal Health Crisis ,” Center for American Progress, Apr. 14, 2020.
7. Asteir Bay et al., Advancing Birth Justice: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities (Ancient Song Doula Services, Village Birth International, Every Mother Counts, Mar. 25, 2019).
8. Mary-Powel Thomas et al., “ Doula Services Within a Healthy Start Program: Increasing Access for an Underserved Population ,” Maternal and Child Health Journal 21, no 1 (suppl. 2017): 59–64.
9. Kenneth J. Gruber et al., “ Impact of Doulas on Healthy Birth Outcomes ,” Journal of Perinatal Education 22, no. 1 (Winter 2013): 49–58.
10. Katy Backes Kozhimannil, Rachel R. Hardeman, and Michelle O’Brien, “ Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries ,” American Journal of Public Health 103, no. 4 (Apr. 2013): e113–e121.
11. Thomas el al., “Doula Services,” 2017.
12. Amy Chen and Alexis Robles-Fradet, Building a Successful Program for Medi-Cal Coverage for Doula Care: Findings from a Survey of Doulas in California (National Health Law Program, May 2020).
13. Christina Gebel and Sarah Hodin, Expanding Access to Doula Care: State of the Union (Maternal Health Task Force, Jan. 8, 2020); National Partnership for Women and Families, Overdue: Medicaid and Private Insurance Coverage of Doula Care to Strengthen Maternal and Infant Health (National Partnership, Jan. 2016); and New Jersey Legislature, NJ S1784, Medicaid Coverage for Doula Care , May 22, 2019.
14. American College of Nurse-Midwives, Fact Sheet: Essential Facts About Midwives (ACNM, May 2019).
15. Jane Sandall et al., " Midwife-Led Continuity Models Versus Other Models of Care for Childbearing Women ,” Cochrane Database of Systematic Reviews 8 (Aug. 21, 2013): CD004667; and Laura B. Attanasio, Fernando Alarid-Escudero, and Katy B. Kozhimannil, “ Midwife-Led Care and Obstetrician-Led Care for Low-Risk Pregnancies: A Cost Comparison ,” Birth 47, no. 1 (Mar. 2020): 57–66.
16. Sarawathi Vedam et al., “ Mapping Integration of Midwives Across the United States: Impact on Access, Equity, and Outcomes ,” PLoS One 13, no. 2 (Feb. 2018); and Georgetown University School of Nursing, How Does the Role of Nurse-Midwives Change from State to State? (Georgetown University, Feb. 5, 2019).
17. Hannah Yoder and Lynda R. Hardy, “ Midwifery and Antenatal Care for Black Women: A Narrative Review ,” SAGE Open (Jan.–March 2018): 1–8.
18. Jyesha Wren Serbin and Elizabeth Donnelly, “ The Impact of Racism and Midwifery’s Lack of Racial Diversity: A Literature Review ,” Journal of Midwifery & Women’s Health 61, no. 6 (Nov.–Dec. 2016): 694–706.
19. Serbin and Donnelly, “Impact of Racism,” 2016.
20. Julian et al., “Community-Informed Models,” 2020; Thomas A. LaVeist and Amani Nuru-Jeter, “ Is Doctor–Patient Race Concordance Associated with Greater Satisfaction with Care? ” Journal of Health and Social Behavior 43, no. 3 (Sept. 2002): 296–306; Marcella Alsan, Owen Garrick, and Grant C. Graziani, Does Diversity Matter for Health? Experimental Evidence from Oakland (National Bureau of Economic Research, Aug. 2019); and Brian D. Smedley et al., eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (The National Academies, 2003).
21. American Association of Birth Centers, Standards for Birth Centers (AABC, 2017).
22. Embry Howell et al., “ Potential Medicaid Cost Savings from Maternity Care Based at a Freestanding Birth Center ,” Medicare & Medicaid Research Review 4, no. 3 (Sept. 2014): mmrr.004.03.a06.
23. Jill Alliman and Julia Phillippi, “ Maternal Outcomes in Birth Centers: An Integrative Review of the Literature ,” Journal of Midwifery & Women’s Health 61, no. 1 (Jan. 2016): 21–51.
24. Susan Rutledge Stapleton, Cara Osbourne, and Jessica Illuzzi, “ Outcomes of Care in Birth Centers: Demonstration of a Durable Model ,” Journal of Midwifery & Women’s Health 58, no. 1 (Feb. 2013): 3–14.
25. Sarah Benatar et al., “ Midwifery Care at a Freestanding Birth Center: A Safe and Effective Alternative to Conventional Maternity ,” Health Services Research 48, no. 5 (Oct. 2013): 1750–68.
26. Victoria G. Woo, Arnold Milstein, and Terry Platchek, “ Hospital-Affiliated Outpatient Birth Centers: A Possible Model for Helping to Achieve the Triple Aim in Obstetrics ,” JAMA 316, no. 14 (Oct. 11, 2016): 1441–42; and Alliman and Phillippi, “Maternal Outcomes in Birth Centers,” 2016.
27. State of New York, COVID-19 Maternity Task Force: Recommendations to the Governor to Promote Increased Choice and Access to Safe Maternity Care During the COVID-19 Pandemic (NY State, Apr. 2020).
28. Rachel Hardeman et al., “ Roots Community Birth Center: A Culturally-Centered Care Model for Improving Value and Equity in Childbirth ,” Healthcare 8, no. 1 (Mar. 2020): 100367.
29. “ Highlights of Four Decades of Developing the Birth Center Concept in the U.S. ,” American Association of Birth Centers, May 2020; and Leseliey Welch and Nashira Baril, “ Birth Centers Are Crucial for Communities of Color, Especially in a Pandemic ,” Rewire News , Apr. 2020.
30. American College of Obstetricians, Committee Opinion: Group Prenatal Care (ACOG, Mar. 2018).
31. ACOG, Committee Opinion, 2018.
32. Christine J. Catling et al., “ Group Versus Conventional Antenatal Care for Women ,” Cochrane Database of Systematic Reviews 2 (Feb. 4, 2015): CD007622; and Ebony B. Carter et al., “ Group Prenatal Care Compared with Traditional Prenatal Care: A Systematic Review and Meta-Analysis ,” Obstetrics & Gynecology 128, no. 3 (Sept. 2016): 551–61.
33. Jeannette Ickovics et al., “ Group Prenatal Care and Perinatal Outcomes: A Randomized Controlled Trial ,” Obstetrics & Gynecology 110, no. 2 (Aug. 2007): 330–39.
34. Allissa Anne Desloge, Scaling Up Group Prenatal Care: Analysis of the Current Situation and Recommendations for Future Research and Policy Analysis (Yale School of Public Health, Jan. 1, 2019).
35. “ EMBRACE: Group Perinatal Care for Black Families ,” University of California, San Francisco National Center of Excellence in Women’s Health, 2020.
36. Jeff Rakover, “ The Maternity Medical Home: The Chassis for a More Holistic Model of Pregnancy Care ,” Institute for Healthcare Improvement (blog), March 22, 2016.
37. Texas Health and Human Services, Pregnancy Medical Home Pilot Program Final Evaluation Report (THHS, Sept. 2017); and Anisha Agrawal, Case Study: Wisconsin’s Obstetric Medical Home Program Promotes Improved Birth Outcomes (National Academy for State Health Policy, Sept. 2017).
38. Kate Berrien et al., “ Pregnancy Medical Home Care Pathways Improve Quality of Perinatal Care and Birth Outcomes ,” North Carolina Medical Journal 76, no. 4 (Sept. 2015): 263–66.
39. “ Expanding Access to Outcomes-Driven Maternity Care Through Value-Based Payment ,” Health Care Transformation Task Force, July 2019.
40. Ian Hill et al., Strong Start for Mothers and Newborns Evaluation: Year 1 Annual Report (Urban Institute, Oct. 2014); and Caitlin Cross-Barnet, Strong Start for Mothers and Newborns Evaluation: Year 5 Project Synthesis (Urban Institute, Oct. 2018).
41. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Maternal Mortality by State, 2018 (NCHS, 2018); and Community Care of North Carolina, “ Pregnancy Medical Home: Improving Maternal & Infant Outcomes in the Medicaid Population ,” accessed Feb. 25, 2021.
Publication Details
Laurie Zephyrin, Senior Vice President, Advancing Health Equity, The Commonwealth Fund
Laurie Zephyrin et al., Community-Based Models to Improve Maternal Health Outcomes and Promote Health Equity (Commonwealth Fund, Mar. 2021). https://doi.org/10.26099/6s6k-5330
- Advancing Health Equity
Maternal Health , Community Health
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Determinants of women's satisfaction with maternal health care: a review of literature from developing countries
Affiliations.
- 1 Public Health Foundation of India, Plot no. 47, Sector 44, Institutional Area, Gurgaon, Haryana, 122002, India. [email protected]
- 2 Faculty of infectious and tropical diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. [email protected]
- 3 Public Health Foundation of India, Plot no. 47, Sector 44, Institutional Area, Gurgaon, Haryana, 122002, India. [email protected]
- 4 Public Health Foundation of India, Plot no. 47, Sector 44, Institutional Area, Gurgaon, Haryana, 122002, India. [email protected]
- PMID: 25928085
- PMCID: PMC4417271
- DOI: 10.1186/s12884-015-0525-0
Background: Developing countries account for 99 percent of maternal deaths annually. While increasing service availability and maintaining acceptable quality standards, it is important to assess maternal satisfaction with care in order to make it more responsive and culturally acceptable, ultimately leading to enhanced utilization and improved outcomes. At a time when global efforts to reduce maternal mortality have been stepped up, maternal satisfaction and its determinants also need to be addressed by developing country governments. This review seeks to identify determinants of women's satisfaction with maternity care in developing countries.
Methods: The review followed the methodology of systematic reviews. Public health and social science databases were searched. English articles covering antenatal, intrapartum or postpartum care, for either home or institutional deliveries, reporting maternal satisfaction from developing countries (World Bank list) were included, with no year limit. Out of 154 shortlisted abstracts, 54 were included and 100 excluded. Studies were extracted onto structured formats and analyzed using the narrative synthesis approach.
Results: Determinants of maternal satisfaction covered all dimensions of care across structure, process and outcome. Structural elements included good physical environment, cleanliness, and availability of adequate human resources, medicines and supplies. Process determinants included interpersonal behavior, privacy, promptness, cognitive care, perceived provider competency and emotional support. Outcome related determinants were health status of the mother and newborn. Access, cost, socio-economic status and reproductive history also influenced perceived maternal satisfaction. Process of care dominated the determinants of maternal satisfaction in developing countries. Interpersonal behavior was the most widely reported determinant, with the largest body of evidence generated around provider behavior in terms of courtesy and non-abuse. Other aspects of interpersonal behavior included therapeutic communication, staff confidence and competence and encouragement to laboring women.
Conclusions: Quality improvement efforts in developing countries could focus on strengthening the process of care. Special attention is needed to improve interpersonal behavior, as evidence from the review points to the importance women attach to being treated respectfully, irrespective of socio-cultural or economic context. Further research on maternal satisfaction is required on home deliveries and relative strength of various determinants in influencing maternal satisfaction.
Conceptual framework of maternal satisfaction.
Flow Diagram summarizing searches.
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- صفحه اصلی
- تماس با ما
سامانه مدیریت نشریات علمی دانشگاه علوم پزشکی مشهد
HEATHER L. PALADINE, MD, MEd, CAROL E. BLENNING, MD, AND YORGOS STRANGAS, MD
Am Fam Physician. 2019;100(8):485-491
Related editorial: What Family Physicians Can Do to Reduce Maternal Mortality .
Related letter: Postpartum Relapse Prevention: The Family Physician's Role
Patient information: A handout on this topic is available at https://familydoctor.org/recovering-from-delivery .
Author disclosure: No relevant financial affiliations.
The postpartum period, defined as the 12 weeks after delivery, is an important time for a new mother and her family and can be considered a fourth trimester. Outpatient postpartum care should be initiated within three weeks after delivery in person or by phone, and may require multiple contacts with the patient to fully address needs and concerns. A full assessment is recommended within 12 weeks. Care should initially focus on acute needs and risks for morbidity and mortality and then transition to care for chronic conditions and health maintenance. Complications of pregnancy, such as hypertensive disorders and gestational diabetes mellitus, affect a woman's long-term health and require specific attention. Women diagnosed with gestational diabetes should receive a 75-g two-hour fasting oral glucose tolerance test between four and 12 weeks postpartum. Patients with hypertensive disorders of pregnancy should have a blood pressure check performed within seven days of delivery. All women should have a biopsychosocial assessment (e.g., depression, intimate partner violence) screening in the postpartum period, and preventive counseling should be offered to women at high risk. Additional patient concerns may include urinary incontinence, constipation, breastfeeding, sexuality, and contraception. Treating these issues during the postpartum period is important to the new mother's immediate and long-term health.
The 12 weeks after delivery, known as the postpartum period or the fourth trimester, are a critical time in the life of a mother and her infant. Maternal mortality, which is defined as deaths that occur during pregnancy and the first year postpartum, is highest in the first 42 days postpartum and represents 45% of total maternal mortality. 1 , 2 Early postpartum visits should evaluate complications from pregnancy as well as common postpartum medical complications. 3 – 5 Subsequent care should include a full biopsychosocial assessment and be tailored to individual patient needs going forward. 3 Family physicians should be aware of the importance of social determinants of health and disparities in maternal outcomes according to race, ethnicity, and public health insurance status.
Timing and Frequency of Postpartum Visits
Historically, physicians have performed a single postpartum visit between four and six weeks after delivery to close the prenatal care relationship. 1 There is a growing consensus to initiate care within the first three weeks postpartum, and to extend the postpartum period to transition to care of chronic conditions. 6 – 8 The American College of Obstetricians and Gynecologists (ACOG) recommends a postpartum evaluation within the first three weeks after delivery in person or by phone, with a complete biopsychosocial assessment to be completed within 12 weeks postpartum. 3 The World Health Organization recommends visits at three days, seven to 14 days, and six weeks postpartum, inclusive of newborn care. 3 , 9 A routine pelvic examination is not indicated unless there are patient concerns.
Postpartum Health Issues and Patient Concerns
Health issues in the postpartum period include medical complications, patient concerns, and conditions that may cause future health risks ( Table 1 ) . 4 , 10 – 52 Family physicians may need to continue to provide medical care for these conditions beyond 12 weeks after delivery. Complications that occur during the prenatal period may reveal areas for intervention and surveillance. 20 , 21
SECONDARY POSTPARTUM HEMORRHAGE
Secondary postpartum hemorrhage is defined as significant vaginal bleeding that occurs beyond 24 hours postpartum. Rates may be as high as 2%, 10 and retained placental tissue and infection are the most common causes. Women with secondary postpartum hemorrhage may need to be examined in the emergency department or hospital for prompt evaluation, including ultrasonography to investigate for retained placental tissue. 11 Treatment may include uterotonic medications, uterine curettage, or antibiotic treatment for endometritis. 12
ENDOMETRITIS
Women with a fever and tachycardia during the postpartum period should be evaluated for endometritis. Patients may also have uterine tenderness or vaginal discharge. Late postpartum endometritis occurs more than seven days after delivery. Risk factors include chorioamnionitis and prolonged rupture of membranes. 13 Endometritis usually requires treatment with intravenous antibiotics, with most evidence supporting the use of gentamicin and clindamycin. 14
THROMBOEMBOLIC DISORDERS
The risk of venous thromboembolic disease, including deep venous thrombosis and pulmonary embolism, is five times higher during the six weeks postpartum than during pregnancy. 17 A lesser degree of increased risk persists up to 12 weeks postpartum. 5 Additional risk factors are increasing age, cesarean delivery, postpartum hemorrhage or infection, and a history of preeclampsia. 15
Patients with a history of thromboembolism should be treated with anticoagulation for at least the first six weeks postpartum, and potentially longer if there are other risk factors. Warfarin (Coumadin) is teratogenic during pregnancy; however, it is minimally excreted in breast milk and is considered safe for women who are breastfeeding. There is a lack of data on the use of direct oral anticoagulants in breastfeeding, and they are not recommended for these patients. 16
HYPERTENSIVE DISORDERS
Up to 10% of women have elevated blood pressure during pregnancy, including chronic hypertension, gestational hypertension, and preeclampsia. Women with hypertensive disorders of pregnancy should have a follow-up blood pressure check within seven days of delivery and be evaluated for signs or symptoms of end organ damage such as hepatic injury or pulmonary edema. 4 , 18 Patients with new-onset blood pressure of 150/100 mm Hg or higher or with signs of end organ damage should be treated with antihypertensive medications. Patients with signs of end organ damage or a blood pressure of 160/110 mm Hg or higher should be hospitalized and treated with parenteral magnesium sulfate to prevent eclampsia. 18 Nonsteroidal anti-inflammatory drugs are preferred over opioid analgesia and have been shown to be safe for women with a history of hypertension in pregnancy. 19 , 53 , 54
Women with hypertensive disorders have an increased risk of cardiovascular events later in life. 18 , 55 , 56 They also have an elevated risk of cardiovascular disease, cerebrovascular disease, and venous thromboembolic disorders, and are at risk of these complications at an earlier age than the general population. All patients with a history of hypertensive disorders of pregnancy should be counseled on behavior modification and have blood pressure and body weight monitored at least once a year. 18 , 55
GESTATIONAL DIABETES MELLITUS
Gestational diabetes mellitus is a significant risk factor for the development of type 2 diabetes mellitus, hypertension, and subsequent heart disease. A woman with a history of gestational diabetes has an eight- to 20-fold risk of developing type 2 diabetes during her lifetime. 20 , 21 Women with gestational diabetes should be screened for impaired glucose tolerance with a 75-g two-hour fasting oral glucose tolerance test at four to 12 weeks postpartum , and should be evaluated for development of hypertension with blood pressure monitoring. 20 , 53 They should continue to be screened for diabetes every one to three years because the risk of type 2 diabetes is elevated. 21
THYROID DISORDERS
Postpartum thyroiditis can affect up to 10% of women during the first year postpartum, with similar rates of hyperthyroidism and hypothyroidism. 23 Postpartum hyperthyroidism is usually transient and does not need to be treated. Hypothyroidism is treated with thyroid hormone therapy. The risk of Graves disease is also increased postpartum, and women with a history of this disease are more likely to relapse. Positive thyroid-stimulating hormone receptor antibodies can distinguish Graves disease from postpartum thyroiditis. Infants of women who are breastfeeding and being treated for thyroid disorders should be monitored for growth and development; however, laboratory monitoring of infants' thyroid function is not necessary. 23 , 24 The American Thyroid Association recommends annual thyroid function screening in women with a history of postpartum thyroiditis. 23
POSTPARTUM DEPRESSION
Up to 10% of women will experience depression in the first year postpartum. The U.S. Preventive Services Task Force (USPSTF), ACOG, and American Academy of Pediatrics recommend one or more screening examinations for postpartum depression in settings where systems are in place to ensure diagnosis, treatment, and follow-up. 25 – 27 The American Academy of Pediatrics has specific recommendations for timing of screening at the one-, two-, four-, and six-month well-child visits. The Patient Health Questionnaire-2, Patient Health Questionnaire-9, and Edinburgh Postpartum Depression Scale are appropriate screening tools.
The USPSTF also recommends preventive counseling for women at high risk of perinatal depression. 28 Risk factors include a personal or family history of depression, a history of intimate partner violence, stressful life events including unplanned or undesired pregnancy, poor social or financial support, and medical complications. A previous American Family Physician ( AFP ) article reviewed identification and management of peripartum depression. 29
INTIMATE PARTNER VIOLENCE
The USPSTF recommends screening women of reproductive age for intimate partner violence with a validated screening tool such as HARK (humiliation, afraid, rape, kick; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034562/table/T1/ ) or HITS (hurt, insult, threaten, scream; https://www.aafp.org/afp/2016/1015/p646.html#afp20161015p646-t2 ), followed by referral to support services if indicated. 30 Interventions such as counseling and home visits can reduce intimate partner violence for women postpartum.
URINARY INCONTINENCE
In one large cohort study, 28.5% of women reported moderate or severe urinary incontinence in the first year postpartum. 32 Bladder training, fluid management, body weight loss, and pelvic floor muscle exercises improve symptoms for all types of urinary incontinence, but studies have included women who are perimenopausal and not postpartum. 34 It is uncertain whether pelvic floor muscle training during the postpartum period has an effect on urinary incontinence; however, it does reduce postpartum urinary incontinence by about one-third when initiated prenatally. 33
HEMORRHOIDS AND CONSTIPATION
Hemorrhoids may be caused by constipation or by pushing during the second stage of labor. Initial therapy involves treatment for constipation. 35 Up to 17% of women report constipation in the first six weeks postpartum. Iron supplements taken orally during pregnancy can be a contributing factor. First-line treatments include increased intake of water and fiber, and osmotic laxatives such as polyethylene glycol (Miralax) or lactulose. Patients with hemorrhoids should also be treated with stool softeners.
BREASTFEEDING PROBLEMS
A previous AFP article addressed breastfeeding recommendations and common problems. 36 The USPSTF found moderate evidence that primary care–based interventions to increase breastfeeding are beneficial. 37 Individual-level interventions have stronger evidence of effectiveness. These include professional support by physicians, midwives, or lactation counselors; peer support; or formal education sessions. A Cochrane review found that support by trained personnel (e.g., medical professionals, volunteers), face-to-face interventions, and interventions that took place over multiple encounters were more effective. 38
POSTPARTUM WEIGHT RETENTION AND METABOLIC RISK
Although data are limited on postpartum body weight retention, a National Academy of Sciences report estimates that most women at six months postpartum will weigh about 11.8 pounds (5.4 kg) more than their prepregnancy body weight. Risk factors for higher postpartum weight retention include more body weight gain during pregnancy, black race, and lower socioeconomic status. Postpartum weight retention is a risk factor for later metabolic risk including development of obesity, higher weight in future pregnancies, and type 2 diabetes in women who have previously had gestational diabetes. 39 Counseling about dietary modifications or dietary and exercise modifications together are effective in helping women lose weight postpartum. 40
SEXUALITY AND CONTRACEPTION
Libido and sexuality are common concerns during the postpartum period. 41 Some studies have shown that pre-pregnancy estrogen levels may not return for as long as one year postpartum, particularly in women who are breastfeeding, which may contribute to a low libido. 41 , 42 The length of time for women to wait to have intercourse following delivery is variable; the average is six to eight weeks in the United States. 41 , 42 No consistent correlation exists between delivery complications (e.g., vaginal lacerations) and a delay in resuming intercourse. 41 , 42 Because most patients report some type of sexual problem postpartum, 42 it is important to assess patients, validate concerns, address contributing factors, reassure when appropriate, and offer support including counseling.
The prenatal period is the best time to discuss postpartum contraception. A 2015 Cochrane review reported low-quality evidence for the effectiveness of birth control method education in the postpartum period; however, a more recent study demonstrated the effectiveness of motivational interviewing resulting in a decrease in rapid repeat pregnancy and a higher use of long-acting reversible contraception in pregnant adolescents. 43 , 44
Women who are breastfeeding may also use the lactational amenorrhea method, alone or with other forms of contraception. The woman must be breastfeeding exclusively on demand, be amenorrheic (i.e., no vaginal bleeding after eight weeks postpartum), and have an infant younger than six months. This method is less reliable once the infant starts eating solid food. The failure rate is less than 2% if these criteria are fulfilled. 45 , 46
This article updates a previous article on this topic by Blenning and Paladine . 1
Data Sources: PubMed searches were done using the terms postpartum care, secondary/late postpartum hemorrhage/hemorrhage, postpartum endometritis, postpartum thyroid, hypertensive disorders of pregnancy, postpartum thromboembolism, postpartum mood disorders, postpartum substance use, postpartum urinary incontinence, postpartum constipation, postpartum hemorrhoids, breastfeeding, postpartum weight, postpartum sexuality, postpartum contraception, maternal infant dyad, and postpartum complications. Also searched were the Cochrane database, Essential Evidence Plus, and recommendations from the American College of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention, the U.S. Preventive Services Task Force, and the World Health Organization. Search dates: July and September 2018, and June 2019.
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- Open Access
- Published: 30 April 2019
Evidence-based design for neonatal units: a systematic review
- N. O’Callaghan 1 ,
- A. Dee 1 &
- R. K. Philip ORCID: orcid.org/0000-0002-6097-9869 2 , 3
Maternal Health, Neonatology and Perinatology volume 5 , Article number: 6 ( 2019 ) Cite this article
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Evidence-based design (EBD) of hospitals could significantly improve patient safety and make patient, staff and family environments healthier. This systematic review aims to determine which neonatal intensive care unit design features lead to improved neonatal, parental and staff outcomes. Medline, CINAHL, Web of Science Citation Index and Cochrane Central Register of Controlled Trials Registry, were searched in January 2017. Using combinations of the relevant key words, review was performed following the recommended guidelines for reporting systematic reviews. English language limitation was applied and term limited to 2006–2016. Included studies were assigned a grade based upon their level of evidence and critically appraised using defined tools. Data were not synthesized for meta-analysis due to nature of literature reviewed and heterogeneity. Three thousand five hundred ninety-two titles were screened with 43 full-texts assessed for eligibility. Twenty nine studies were deemed eligible for inclusion. These included 19 cohort studies, two qualitative studies, seven cross-sectional studies, and one randomised control trial. Grey literature search from guidelines, and repositories yielded an additional 10 guidelines. ‘Single family room’ (SFR) design for neonatal units is recommended. An optimally designed neonatal unit has many possible health implications, including improved breastfeeding, infection and noise control, reduced length of stay, hospitalisation rates and potentially improved neonatal morbidity and mortality. High quality, family centred care (FCC) in neonatology could be assisted through well grounded, future proofed and technology enabled design concepts that have the potential to impact upon early life development.
Introduction
The last century has seen improvements in maternal and perinatal mortality with significant advances, particularly in neonatology. Although immature organ systems contribute towards morbidity, these outcomes may be compounded by unfavourable neonatal intensive care environments [ 1 ].
Recently, attention has focused upon hospital design and its effect on patient safety [ 2 ]. Similar to evidence-based medicine, evidence-based design (EBD) uses the best available information from credible research to construct patient rooms, improve lighting and air quality, reduce noise, way-finding and walking distance, promote hand-hygiene, incorporate nature and accommodate families’ needs [ 3 ]. Evidence has shown that hospital design can significantly improve patient safety [ 2 , 4 ] and make patient, staff and family environments healthier [ 2 , 5 , 6 , 7 ].
This systematic review aims to identify NICU design features which improve neonatal, parental and staff outcomes.
This review was performed according to PRISMA guidelines for reporting on systematic reviews. Medline, CINAHL, Web of Science Citation Index and Cochrane Central Register of Controlled Trials Registry, were searched electronically in January 2017, using combinations of the relevant key words and word variants for “hospital design” and “newborn intensive care unit”. The inclusion criteria were studies written in English which evaluated NICU design features ( rather than practice ) and their impacts upon newborn infants, their families and staff, included a comparison group, and were published between January 2006 and December 2016. Grey literature was also searched, details of which are available in the addendum.
Title screening was carried out by one reviewer based on agreed, pre-piloted structured forms. Full-text articles were assessed for eligibility by two reviewers with agreement by consensus. Included studies were assigned a grade based upon their level of evidence [ 8 ] and critically appraised using a number of tools. Meta-analysis was not undertaken due to insufficient numerical data. Included studies and grey literature were divided into themes or subject areas, which are expanded upon in the results section. Further details of this and the methodology used are available in the addendum.
Three thousand five hundred ninety-two titles were screened with 43 full-text articles assessed for eligibility (Fig. 1 ). Twenty nine articles were deemed eligible for inclusion in the review (Table 1 ). These included 19 cohort studies, two qualitative studies, seven cross-sectional studies, and one randomised control trial. The grey literature search resulted in the inclusion of ten guidelines (Table 2 ).
Flow diagram of results
Quality of included evidence
Studies tended to be observational and carried out in a single facility and consequently sample sizes were small. When outcomes such as mortality were assessed, the numbers were further reduced. Mortality was not often a primary outcome of these studies. Very few experimental trials were found. Efficacy in enhancing patient care is multivariate and it was difficult to establish causal relationships with any certainty. However, it must be accepted that experimental study designs may not be appropriate in this context and the evidence presented is the best possibly available for this research question.
Limited information on methodology was provided in the guidelines which were included, which hindered their critical appraisal. However, particularly in the case of US guidelines, these have been adapted internationally and adopted by many groups. Also, expert guidance based upon recommendations of those who work in this field is important, however not taken into account in a systematic review.
Single family rooms versus open-bay units
Infant outcomes.
Open-bay NICUs have the advantage of developing communication and interaction with medical staff and nurses and the ability to monitor multiple infants simultaneously. Single family rooms (SFR) were noted to improve sleep, increase privacy and parental involvement [ 9 ] and assist with infection control and noise limitation [ 9 ]. Infants were found to have fewer apnoeic events, reduced nosocomial sepsis and mortality as well as improved neonatal nutritional outcomes [ 10 ] and earlier transition to enteral feeding [ 9 ]. They have not been associated with an increased risk to patients [ 10 ].
Very low birth weight (VLBW) infants (< 1500 g) cared for in the SFR NICU weighed more on discharge, had greater rate of weight gain, needed less medical procedures, had a lower gestational age at full enteral feeding and less sepsis [ 11 ]. They showed better attention, had less hypertonicity, lethargy, pain and physiologic stress [ 11 ].
In contrast to the above studies Pineda et al expressed concerns that environmental sound and language exposure in single rooms may be reduced to levels that are detrimental to child development, with diminution of normal hemispheric asymmetry, lower language scores and a trend towards lower motor scores by two years [ 12 ]. Relatively low rates of parental visitation and holding with skin-to-skin interaction may have affected the generalizability of findings in this study.
Length of stay
SFRs have been noted to reduce length of hospital stay and rehospitalisation [ 9 ]. Providing “family centred care” (where parents stay overnight in the hospital) has significantly reduced length of stay (LOS) from a mean of 32.8 days in standard care (with limited opportunities for parental stay overnight) to 27.4 days in family centred care ( p = 0.05) [ 13 ]. The authors postulated this reduction in LOS occurred as parents who spend most of their time with their newborn may have a greater opportunity to interpret and act on signs of distress and other needs of the infant compared to NICU staff who may have more than one infant under their care. In FCC units parents quickly became primary care givers and the greater continuity of care could possibly have contributed to more individualised care.
Parental satisfaction
When SFR and open-bay NICUs were compared for parental experiences, the SFR design resulted in greater parental satisfaction with care received [ 10 ], particularly with the environment, which was more conducive to family-centred care [ 14 ]. Premature infants cared for in single rooms experienced significantly more hours of visitation in the first two weeks of life and in weeks three and four. However, more stress has been reported by mothers in single rooms [ 12 ]. Smaller rooms where the number of infants were limited to one or two, provided space for parents to come to terms with their situation and to start the bonding process [ 15 ]. In one instance open-bay units were felt to be more conducive to social interaction with other parents [ 16 ]. However, when LOS increased parents were more appreciative of the comfort, privacy and environmental control aspects of SFRs. Those familiar with both showed a strong preference for SFRs which were felt to be preferable regarding issues of environmental control, privacy for bonding with the infant and breastfeeding [ 16 ].
The design and practices of the NICU has been found to dictate when parents first interact with their infants [ 17 ]. In general, parents who were facilitated to stay 24/7 in a unit experienced many “first moments” earlier [ 17 ].
Staff perceptions
Higher staff satisfaction scores for quality of physical [ 18 , 19 ] or work environment [ 20 , 21 ], patient care, job quality in the NICU [ 18 , 21 ], health and safety [ 20 , 21 , 22 ], security [ 21 ], interaction with technology [ 18 , 21 ] and overall satisfaction were noted for the SFR [ 10 , 21 ]. Following the transition to an SFR model staff reported improved satisfaction [ 20 , 23 ] and communication [ 20 ] as well as a reduction in isolation [ 22 ]. SFR design was felt to be better for patient therapy [ 19 , 20 ] and recovery as well as their overall development [ 20 , 22 ], including brain development [ 20 ]. The new unit (SFR) was also perceived as quieter and with lower perceptions of fatigue [ 20 ] and stress [ 19 , 20 , 23 ].
In contrast, Domanico et al raised concerns regarding SFR design. Early detection of medical crises (reflecting staff interaction) and adequate patient care was felt to be compromised in the SFR. However, the reduced mortality and length of stay in the SFR in this particular study did not support this perception [ 16 ]. Quality of team interaction was also noted to be initially poor [ 22 ] or show significantly decline [ 18 ]. This finding was not sustained in all instances [ 22 ]. Appropriate use of virtual audio-visual technology was suggested to improve staff visibility of others in the NICU [ 18 ]. A greater personnel need was also felt to exist with SFR use [ 10 ].
Sound, light, temperature and humidity
The degree of environmental control of sound and light was enhanced in SFR NICUs [ 10 ]. Median sound levels were significantly lower in the single-room or enclosed space NICU design compared to the open- bay models in four studies [ 24 , 25 , 26 , 27 ]. Although Liu et al. did note that when high frequency oscillatory ventilation (HFOV) was used similar measures were observed between the two units [ 24 ].
In contrast, Szymczak et al. found no statistically significant difference in sound level variance, nor percent time with peak sound variance in single-room and open-ward designs [ 28 ]. However, single-room design may offer significantly more time at lower noise levels as time below 0.05 standard deviations was higher in the single-room NICU [ 28 ].
Contrasting results were found for light level measurements. One study found that mean light levels were higher in the single (private) room design, due of the increased number of windows [ 25 ] and another recorded lower median levels of minimum and maximum illumination in the SFR NICU [ 27 ]. Low level of illumination favoured by nurses in the SFR has also been highlighted [ 10 ].
Temperature and humidity were assessed in only one study which found the single (private) room environment was cooler (two degrees), with greater temperature stability [ 25 ]. Mean humidity readings in the two environments were the same, but again humidity levels in SFR were more stable [ 25 ].
Specific acoustic and illumination guidance can be found in Additional file 1 : Tables S1 and S2 in the addendum.
Providing family-centred care in SFR in the NICU has been found to result in fewer acute care visits, phone consultations and rehospitalizations when compared to those cared for in traditional open plan units [ 29 ]. When compared to open-bay units, care was provided in single-room NICUs at no additional cost [ 30 ] or lower costs [ 10 ].
Infection prevention and control
Studies examining infection control in SFR and open NICUs have shown mixed results. Incidence of nosocomial sepsis in SFRs has been shown by Domanico et al. to reduce to almost half that seen in an open unit [ 9 ]. Whereas, Julian et al., comparing MRSA colonisation, found that colonisation was impacted by hand-hygiene compliance regardless of room configuration [ 31 ]. It is also recommended that newly built acute hospital inpatient accommodation should be comprised of 100% single rooms [ 32 ].
Airborne infection
Regardless of overall NICU room configuration, an expert group in the US recommend that a negative pressure airborne infection isolation room, with a clear floor space of 14 m 2 , containing hand-washing facilities, space for storage, means of emergency communication and self-closing doors should be provided (41).
Hand-washing
Two studies demonstrated significantly increased rates of nosocomial infection when infants were moved to less spacious, temporary NICUs and subsequently decreased when infants were moved to a newly constructed facility with improved sink-to-bed ratios [ 11 , 33 ]. In one further cohort study conducted as part of a Salmonella outbreak in a Tennessee NICU, a high number of inpatients were believed to have resulted in reduced attention to infection control procedures [ 34 ]. The inaccessibility of hand sinks was also felt to impede adequate hand-washing [ 34 ]. Several sink design specifications are available to view in Additional file 1 : Table S3 in the addendum.
Water safety
Prevention and control of Pseudomonas aeruginosa and Legionnella in NICUs is important. Those designing or renovating NICUs should carefully consider water safety in healthcare buildings, water safety plans as well as the materials, fixtures and fittings which will be used [ 35 , 36 , 37 ]. Specific water safety recommendations which could be incorporated into a new building can be viewed in Additional file 1 : Table S4 in the addendum.
Feeding facilities
Infant formula, when prepared at the bedside, was shown by Steele et al. to be 24 times more likely to be contaminated than those prepared in a centralised feeding preparation room [ 38 ]. Space for preparation and storage of formula distant from the bedside is recommended [ 39 ].
SFR design has resulted in more mothers sustaining lactation and more infants discharged with successful breastfeeding [ 9 ]. In contrast SFR design has also not been shown to increase breastfeeding duration by mothers of hospitalised preterm infants [ 40 ]. This study was underpowered, which perhaps contributed to the non-significance of findings. Participating mothers did express preference for pumping in their own homes due to enhanced privacy and environmental control [ 40 ].
NICU location in relation to other departments
Co-location of delivery rooms and the NICU has resulted in the reduction of moderate hypothermia and morbidity [ 41 ]. It is recommended that the NICU should be a distinct and controlled area immediately adjacent to the labour suite and rooms specified for operative deliveries [ 42 , 43 , 44 ].
Support areas
Several support areas are recommended. These include: clinical support areas, located as close as possible to clinical care areas [ 44 ]; a clerical area, located near the entrance to the NICU; one or more staff work areas each serving 8 to 16 beds [ 39 ]; staff support space, which may account for at least one-third of the floor space of the entire unit [ 39 ]; and family and infant room(s) should be provided for transitional care within or immediately adjacent to the NICU to allow those families who wish to stay with their infants the opportunity to do so [ 39 , 42 ].
Further detailed specifications for these areas can be viewed in Additional file 1 : Table S5 in the addendum. Also included in the addendum are design specifications for space requirements, enhancing unit security, finishes and measures to improve the NICU sustainability (Additional file 1 : Tables S6 to S9).
This systematic review was set out to determine what NICU design elements lead to better neonatal, staff or parental outcomes.
Evidence suggests that SFR’s have improved privacy and sleep [ 45 ] infection control [ 9 , 45 ], noise control [ 14 , 45 ], wider environmental control [ 14 ], parental involvement and satisfaction [ 12 , 45 ], reduced length of stay [ 9 , 45 ], reduction in hospitalisation [ 45 ], fewer apnoeic events [ 9 ], improved mortality [ 9 ] and increased breastfeeding [ 9 ]. Staff preferences appear to tend toward SFR with some studies showing reduced stress in these settings [ 19 , 46 ] although this was not replicated in all studies [ 12 ]. Concerns have been voiced over increased personnel need [ 45 ] compromised early detection of crises [ 16 ] and reduced staff interaction with the SFR design [ 18 ]. However, other studies have shown reductions in staff stress and fatigue and refutations to claims of staff isolation [ 20 ]. Although, in general evidence supports the use of SFR’s, one aspect of their use which showed mixed results was the impact such designs had upon neurodevelopmental outcomes. Research into this area is at an early stage and further studies are required.
Infection prevention and control is especially important in NICU settings where critically ill babies are at increased risk of hospital-acquired infection due to their immunological immaturity and the increased number of invasive procedures [ 33 ]. Most evidence for infection control focuses on creating an atmosphere which promotes hand-hygiene, with every infant bed, within six metres of a hands-free hand washing station [ 39 ]. Indeed two studies highlighted an increase in infection rates in settings where there was a lower sink-to-bed ratio and a third linked the inaccessibility of hand sinks to a Salmonella outbreak. The single room NICU is touted as a strategy which addresses environmental concerns and reduces iatrogenic effects by reducing the risk of infection and stress on preterm infants [ 11 ]. This hypothesis is supported by one study which noted a halving of the incidence of nosocomial infection when a SFR setting was compared to an open bay unit. Pseudomonas infection also poses a risk in NICUs. This may be offset by the detailed water safety advice mentioned previously.
Hospitals play an important role in health promotion and an environment supportive of breastfeeding is highly desirable. This is especially the case in the NICU setting where breastfeeding is of such importance to preterm population in reducing necrotising enterocolitis and sepsis. Limited evidence suggests environmental control and privacy is desirable. Given the premature population and requirement for expressed breast milk, if single patient rooms were unavailable privacy and maternal comfort could aid pumping and sustainability of breastfeeding.
Even though none of the eligible studies included in our systematic review addressed the concept of ‘blended design’ neonatal units; this practical approach perhaps optimise the available footprint and merges an open-bay (often pre-existing) design with designated SFR areas. Often such an innovative approach enhances clinical effectiveness at a reduced initial capital cost or renovation cost and ‘adapts’ a traditional open-bay unit to offer FCC. In response to a new transformational design of NICU, healthcare practitioners could develop new practices and this could also influence outcomes [ 47 ].
Limitations
This systematic review was carried out with some shortcomings. Included studies had certain inherent limitations, as detailed previously. English language restrictions were applied, meaning some studies may have been omitted from the review. We have restricted the review period commencement from 2006, thus not including literature prior to that. Bias inherent to the individual studies would be reflected in our analysis. We did not progress with a meta-analysis considering the wide heterogeneity and variability of the studies, wide variations in the primary aims of the studies included, inclusion of both quantitative and qualitative studies as well as our inclusion of grey literature and guidelines in the analysis. We could not register our systematic review with PROSPERO as it was conducted as ‘part of the best evidence gathering process’ to design and construct a New Maternity Hospital with Neonatal Unit attached to University Hospital Limerick and the timelines preceded our study registration.
Conclusions and recommendations
An optimally designed NICU has many possible health implications, including improved breastfeeding rates, infection and noise control, reduced length of stay and hospitalisations and potentially improved neonatal morbidity and mortality. The impact of early life development on later child health and development is well recognised [ 48 ]. NICU is the first extra-uterine setting for an increasing number of premature babies [ 1 ]. Preliminary evidence suggests that the NICU design may influence environmental exposures during a crucial period of brain development which can lead to long-term health implications. A well designed NICU has the potential to improve developmental outcomes and reduce chronic illness [ 49 ].
‘Single family room’ design for neonatal units is recommended. Careful consideration should also be given to infection prevention and control, including sink frequency and positioning, water safety features and airborne isolation facilities. Finishes used should have acoustic and illuminative suitability, as well as allowing for infection prevention and where possible, be environmentally sustainable. Support areas for families, staff and clinical activity are also important, as is the need to support mothers in breastfeeding.
Nature of the topic poses inherent limitations for conduct of randomized trials; however observational studies using standardised methodologies could add further evidence. Health service planners and design teams should be equipped with the evidence-base for positive design features that would impact the care of newborn infants, support to the caring families and wellbeing of the staff. High quality, family centred neonatal care could be supported through a well grounded, technology enabled and future proofed design concepts.
Further detailed recommendations are available in the addendum.
Abbreviations
Cumulative index of nursing and allied health literature
Graduate entry medical school
High frequency oscillatory ventilation
Health protection surveillance centre
Health service executive
Intensive care unit
Methicillin resistant Staphylococcus aureus
- Neonatal intensive care unit
Preferred reporting items for systematic reviews and meta-analyses
International prospective register for systematic reviews
Strategy for control of antimicrobial resistance in Ireland
- Single family room
University Maternity Hospital Limerick
Very low birth weight
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Acknowledgements
Authors wish to acknowledge the advice on systematic reviews by Dr. Helen Purtill, Statistician, Department of Mathematics, University of Limerick, Ireland and the search support from HSE and University of Limerick Library.
Authors received no specific funding for this work.
Availability of data and materials
Primary data availability of the included studies as disclosed in the respective manuscripts. Details of the methodologies and studies selected for the systematic review, including the grey literature and guidelines are available in the addendum.
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Niamh O’Callaghan (NOC) conducted the preliminary literature search following the PRISMA guidelines, tabulated and analysed the collected data and developed the first draft of the manuscript; Anne Dee (AD) verified and cross- checked the eligible studies and grey literature, supervised the systematic review, contributed the public health expertise and edited the manuscript; Roy K Philip (RKP) designed the systematic review as part of the New Maternity Hospital Design & Development Committee, supervised the study, contributed the neonatal intensive care expertise and edited the manuscript. All authors read and approved the final manuscript.
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This manuscript does not contain any studies with human participants or animals performed by any of the authors. Systematic review to support the evidence-based design of New Maternity Hospital in Limerick, Ireland was approved by the Design & Development Committee of the Hospital Group.
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Additional file
Additional file 1:.
Table S1. Design specifications for an optimum acoustic environment. Table S2 . Design specifications for optimum lighting. Table S3. Recommended sink design specifications. Table S4. Design features to enhance water safety. Table S5. Design specifications for clinical, staff and family support areas. Table S6. Recommended space requirements for the NICU. Table S7. Design specifications to ensure NICU security. Table S8. Design specifications for NICU finishes. Table S9. Design specifications to improve building sustainability. (DOCX 72 kb)
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O’Callaghan, N., Dee, A. & Philip, R.K. Evidence-based design for neonatal units: a systematic review. matern health, neonatol and perinatol 5 , 6 (2019). https://doi.org/10.1186/s40748-019-0101-0
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An overview of the implementation of the continuity of care model in maternal health services: a literature review ☆.
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Literature is obtained from online journal databases, namely PubMed, EBSCO, and ScienceDirect, and other related sources, systematically from 2012 to 2019.
Sixteen articles on the implementation of the continuity of care model of antenatal, intranatal, and postnatal care were described by demographic characteristics, scope, and impact. Barriers and facilitators for three categories include process, communication, information and education, organization and human resources, caseload, burnout, psychological, expectation, and satisfaction.
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Research Article
Maternal health literacy on mother and child health care: A community cluster survey in two southern provinces in Laos
Contributed equally to this work with: Sysavanh Phommachanh, Dirk R. Essink, Pamela E. Wright, Jacqueline E. W. Broerse, Mayfong Mayxay
Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Writing – original draft
* E-mail: [email protected]
Affiliation Institute of Research and Education Development, University of Health Sciences, Ministry of Health, Vientiane, Lao PDR
Roles Conceptualization, Supervision, Writing – review & editing
Affiliation Vrije Universiteit Amsterdam, Athena Institute and Amsterdam Public Health Institute, Amsterdam, The Netherlands
Affiliation Guelph International Health Consulting, Amsterdam, The Netherlands
Affiliations Institute of Research and Education Development, University of Health Sciences, Ministry of Health, Vientiane, Lao PDR, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR, Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Sysavanh Phommachanh,
- Dirk R. Essink,
- Pamela E. Wright,
- Jacqueline E. W. Broerse,
- Mayfong Mayxay
- Published: March 29, 2021
- https://doi.org/10.1371/journal.pone.0244181
- Reader Comments
Increased maternal health literacy (MHL) has contributed considerably to maternal and child health outcomes in many countries. Malnutrition, and low coverage of child vaccination and breastfeeding are major health concerns in Laos, but there is little insight into mothers’ literacy on these issues. The aim of this study was to identify the level of MHL of Lao mothers and to explore factors influencing it, in order to provide evidence that can inform policies and planning of health services.
A cross-sectional survey was conducted using a questionnaire on health literacy (ability to access, understand, appraise and apply health-related information) in relation to care during pregnancy, childbirth, and the postpartum period. We interviewed 384 mothers with children aged under five years; 197 from urban and 187 from rural areas. Descriptive and inferential statistics were applied to analyze the data.
Overall, MHL of Lao mothers was very low in both urban and rural areas; 80% of mothers had either inadequate or problematic MHL, while only 17.4% had sufficient and 3.5% excellent MHL. The MHL scores were significantly higher in urban than in rural areas. One third of mothers found it very difficult to access, understand, appraise and apply information on mother and child (MCH). Health personnel were the main source of MCH information for the mothers. Years of schooling, own income, health status, and number of ANC visits significantly predicted a higher level of MHL (R square = 0.250; adjusted R square = 0.240, P = <0.001).
Conclusions
MHL of Lao mothers was inadequate in both urban and rural areas. Socio-demographics and key practices of the mothers were significantly associated with a better level of MHL. Health education on MHL to mothers in both urban and rural areas needs attention, and could best be done by improving the quality of health providers’ provision of information.
Citation: Phommachanh S, Essink DR, Wright PE, Broerse JEW, Mayxay M (2021) Maternal health literacy on mother and child health care: A community cluster survey in two southern provinces in Laos. PLoS ONE 16(3): e0244181. https://doi.org/10.1371/journal.pone.0244181
Editor: Florian Fischer, Charite Universitatsmedizin Berlin, GERMANY
Received: November 6, 2019; Accepted: December 4, 2020; Published: March 29, 2021
Copyright: © 2021 Phommachanh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The research was conducted under the support of the European Union funded LEARN Project (Number: DCI/SANTI/2014/342-306) through the Medical Committee Netherlands- Vietnam (MCNV) in Lao PDR. The first author is the principal investigator and received a scholarship from the project. We would like to certify that the funder had no role in the study design, data collection and analysis, decision to publish, and or preparation of the manuscript.
Competing interests: EPW was employed in an advisory capacity by the Vrije Universiteit Amsterdam as a retired researcher, through this small consulting company. SP received a PhD scholarship from the LEARN Project. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There were no competing interests of financial or other nature.
List of abbreviations: ANC, Antenatal Care; IEC, Information Education Communication; MHL, Maternal Health Literacy; MCH, Maternal and Child Health
Introduction
Maternal and child mortality remains a global concern, particularly in low- and middle-income countries [ 1 , 2 ]. In Laos, the maternal mortality ratio is one of the highest in Asia with 197 deaths per 100,000 live births [ 3 ]. Maternal health literacy (MHL) is the ability of mothers to access, understand, appraise and apply information on mother and child health that contributes to reducing maternal and child mortality [ 4 – 8 ], which subsequently contributes to achievement of sustainable development goals numbers 2 (zero hunger: reducing underweight and stunting among young children) and 3 (good health and well-being: reducing maternal and child mortality ratio) [ 9 , 10 ]. Previous studies in Nigeria demonstrated that there was a significant relationship between MHL and pregnancy outcomes [ 11 ] and children’s nutritional status [ 12 ]. Another study in India also showed that better MHL was independently associated with higher child vaccination, leading to the suggestion that “initiatives targeting health literacy could improve vaccination coverage” [ 13 ].
Low MHL is one of several important factors, including social and demographic issues, poor accessibility and poor quality of maternal and child health services [ 14 – 20 ] that contribute to poor mother and child health outcomes and to unhealthy practices of Lao mothers. For example, malnutrition continues to be a serious health concern, with approximately 33% of Lao children under five years stunted, 21.1% underweight and 9.0% wasted [ 14 , 21 ].
In Laos, traditional practices are still commonly followed during pregnancy and the postpartum period, for example, the practice of eating dry food with only rice and ginger as well as staying on a heated bed during the postpartum period to stop bleeding and keep the body dry and healthy. A lack of awareness about maternal and child health would probably lead to unhealthy practices such as food taboos, particularly low intake of protein-rich foods such as, meat, fish, and eggs [ 22 ]. Even in the urban setting of Vientiane, 97% of women stayed for one or two weeks on a hot bed under which burning coals are placed; and 90% of postpartum women practiced food taboos [ 22 ]. One Lao study illustrated that malnutrition was associated with maternal health knowledge and that children of the mothers with greater health knowledge had lower rates of stunting [ 18 ]. Also, child immunization coverage against preventable diseases is very low (48.3–83.1%) in Laos, with a full vaccination rate of only 40.7% [ 14 ]. Despite the availability of a comprehensive vaccination service, the population is apparently not yet sufficiently aware of the benefits of immunization and children are not immunized. A previous study demonstrated that mothers had weak knowledge about vaccine-preventable diseases and about immunization schedules associated with child vaccination [ 15 ].
Lao women could possibly access different sources of mother and child health (MCH) information, such as media (through smart phone, TV, or radio), health personnel (doctor, nurse, midwife, and other health workers), and social networks (friend, relative, and neighbor). Our recent studies demonstrated that women received MCH information from health providers when they accessed ANC services at health facilities [ 16 , 17 , 23 ]. However we do not know other sources of MCH information that women might receive, besides outreach activities of health workers providing MCH service in the villages [ 24 ]. Community campaigns by health workers with the assistance of village health volunteers and local authorities might be another important source of MCH information for women.
Lack of comprehensive awareness of MCH information in Laos is an important factor for maternal and child health outcomes as mentioned above, but we do not yet know to what extent mothers have health literacy on mother and child health care, and what factors may be influencing maternal health literacy.
The conceptual model of health literacy refers to “the personal characteristics and social resources needed for individuals and communities to access, understand, appraise and apply information and services to make decisions about health” [ 6 ]. This conceptual model would help to measure the level of maternal health literacy in relation to accessing, understanding, appraising, and applying information on mother and child health care during pregnancy and childbirth and in the postpartum period. Although health literacy can support individuals to take control of decisions and actions that will affect their health status [ 7 ], MHL remains poor in both low- and middle-income countries and high-income countries. For example, 39% of Indian mothers, 34% of mothers in Iran, 83% of rural perinatal African-American mothers, 72% of mothers in Texas (USA) and 24% of mothers in Philadelphia had scores of ‘inadequate’ when tested for MHL [ 13 , 25 – 28 ].
Factors that influence MHL are related to socio-demographic characteristics of mothers as found in previous studies and certain key practices of mothers in relation to pregnancy, childbirth, and postpartum care, as taken from WHO guidelines [ 29 ]. A study in Iran showed a significant relationship between MHL and both women’s education and family income [ 24 ]. Another study in Nigeria demonstrated that there was a significant positive correlation between ANC visits and MHL [ 11 ], and in Texas (USA), MHL was positively correlated with education, income, language, social support, parenting self-efficacy, and early parenting practices, but negatively correlated with number of children [ 28 ].
There has been little research on health literacy in Laos. One study in Vientiane city measured general health literacy among university students [ 30 ] while another focused on sexual and reproductive health literacy among school adolescents [ 31 ]. Both studies indicated low levels of health literacy in those parts of the population. To the best of our knowledge, no studies have yet been conducted on MHL of Lao mothers.
The primary objective of this study was to determine the levels of maternal health literacy on topics of mother and child health care in urban and rural areas, and to determine the factors influencing MHL among Lao mothers. Gaining insights into MHL contributes to raising awareness on MHL. The factors associated with MHL could enable policy makers to develop more targeted interventions.
Study design and site
A cross-sectional study was conducted from April to July 2018 at the community level in the two southern provinces of Saravane and Attapeu. Two of the eight districts (one urban and one rural) and two of the five districts (one urban and one rural) of Saravane and Attapeu provinces, respectively, were purposively selected. Four villages (two urban and two rural) of two selected districts in each province were chosen for the study (see below in the sampling technique). This study was part of a larger research project on maternal and child health care, which started in 2017 in these two provinces with a special emphasis on quality improvement of ANC [ 22 , 32 ].
Sample size and sampling method
Sample size was calculated using a formula ( http://www.calculator.net/sample-size-calculator.html ) based on the total number of mothers with children aged under five years according to the latest available data from 2016 (192,000) [ 14 ], using a 95% confidence interval and margin of error of 5%. Since there was no information on MHL available in Laos, we assumed a proportion of eligible mothers with adequate MHL level of 50%. Therefore it was estimated that we had to recruit at least 384 mothers for this study. Given that 5% of eligible mothers may not be available and/or willing to participate, an additional 19 mothers should be invited for an interview–therefore a total sample size of 403 mothers was considered adequate for the study.
The provinces and districts were purposively selected because of their involvement in a larger study looking into different aspects of mother and child health. A two-stage cluster sampling was done at the levels of village and household as described below.
- Stage 1 village selection (cluster sampling): A list was made of all villages (clusters) in each district. Four villages (four clusters) were selected from districts using a simple random sampling method, generated by Microsoft Excel, giving a total of eight villages (8 clusters) for the two districts of the two provinces.
- Stage 2 household selection: A list of all households of mothers with children aged under five years was made for each village (cluster) just before the survey. The Probability Proportional to Size (PPS) sampling method was applied. A village (cluster) with more eligible households had a greater number of households to be studied, and the total sample size of 403 households was allocated to each sample village/cluster. Then the number of the households to be studied in each village/cluster was selected using a simple random sampling method, also generated by Microsoft Excel.
Population and recruitment
Eligible participants were Lao women living in the selected areas with children aged under five years. Since child immunization is one important component of MCH and we wanted to measure literacy on that topic as one of the MHL items, we therefore aimed to include mothers with children whose ages were within the period of receiving basic vaccination (from birth to 23 months). However, in the area of the study, to reach the desired sample size we had to select mothers whose children were aged from birth to 5 years. This is also consistent with most child health policies in Laos, aimed at children under 5 years. We acknowledge that there could be recall bias when we enrolled the mothers with older children. However, the mothers were only asked to reflect on the information related to the last child, not any earlier children.
The study unit was a household, and one eligible mother per household was included in the study. Each head of the village assisted to inform the household members two days before the planned interviews. If interviewers found respondents who were not eligible or declined to participate, then the interviewers randomly selected another household to get a new respondent until sufficient data was collected. The response rate was 95%, so finally 384 mothers were enrolled. The reasons for the 19 mothers not to participate were: six no longer lived in their villages and 13 were not available at the time planned for the interview. No mothers declined to be interviewed.
Research tools
The health literacy model of Sørensen is widely used in Europe and Asia [ 28 – 31 , 33 ]. There was no specific tool for MHL in Laos, although it has been measured in other countries [ 7 , 34 – 36 ]. The research tool used in this study was based on the one previously used for general literacy tool (rating ability to access, understand, appraise/judge/evaluate, and apply/use health information), adapted to MCH care. Maternal health literacy refers to the ability of mothers to access, understand, appraise, and apply information on mother and child health care during pregnancy, at childbirth and in the postpartum period with emphasis on specific attention was paid to key practices of ANC visits, childbirth, and postpartum care at health facilities, nutrition, and immunization, following WHO guidelines and the National Strategic Action Plan [ 24 , 29 , 37 ].
The research tool for data collection covered three sections:
- socio-demographic data such as age, religion, ethnicity, language, literacy, education, and income, taken from previous studies [ 4 , 11 , 28 , 33 , 38 ];
- possibly related factors or practices (positive and negative), such as ANC visits, place of childbirth, number of children, food restrictions/taboos, the use of hotbeds, smoking, and receiving information, all taken from previous studies [ 22 , 39 , 40 ]; and
- MHL in relation to the ability of mothers to access, understand, appraise, and apply information on mother and child health care during pregnancy, at childbirth and in the postpartum period, according to WHO guidelines and the National Strategic Action Plan [ 24 , 29 ] as mentioned above.
In sections 1 and 2, literacy was defined as the ability of mothers to read, and education was recorded as the number of years of schooling. Ages of mothers, own income per month, and years of schooling were categorized into two groups by median (range). Mothers were asked to rate their own health status from 0 to 10; their status was categorized as poor if their score fell below the mean and good if the score was at the mean or higher. Complete child vaccination means that a child has completed all basic required vaccinations from childbirth to the age it had reached at the time of survey (can be up to 23 months), based on the Expanded Program Immunization schedule of Laos; the vaccination card was checked to confirm the completeness. Food restrictions/taboos mean that mothers followed local traditional food restrictions such as “low intake of protein-rich foods such as meat, fish, and eggs” during pregnancy and the postpartum period. Hotbed stay refers to the postpartum mother staying in a bed under which hot coals are placed and maintained for one or two weeks. Examples of the questions asked are: “Did you visit ANC for the last child ? Did you have food restriction/taboo for the last childbirth ? Did you practice a hotbed stay for the last childbirth ? Have you ever heard any information on mother and child health care ? If yes…where have you ever received/heard information on mother and child health care ? ” How is your health in general ? Please ask the respondent to grade her health condition using a ruler with 1 to 10 scores . ”
In section 3, the MHL questionnaire comprised 49 items in relation to mother and child health care during pregnancy, childbirth and postpartum period, which were developed based on WHO guidelines and the National Strategic Action Plan [ 24 , 29 ]. Items of MHL were adapted to the structure of a health literacy survey tool in Asia [ 41 ] and sexual reproductive health literacy tool in Laos [ 31 ]. It included 15 items on accessing information about prenatal care, childbirth, and postpartum care, 11 on understanding information about nutrition and immunization, 12 on appraising information about maternal and child health care, and 11 on applying information about maternal and child health care practices. Examples of questions are: “ how is it easy for you to find health education materials on MCH (e . g . brochure , poster , etc) disseminated in the village when you want to know ? … to understand information that If a pregnant woman practiced food restriction during pregnancy , it will be a risk of low birth weight and unhealthy baby ?…. to judge whether the information you received from health providers is sufficient ? … to use ANC service earlier when recognize that you have missed period to make sure on getting pregnancy” .
Measurement of health literacy
To measure MHL, each item was rated on a 4-point Likert scale (4 very difficult, 3 difficult, 2 easy, and 1 very easy), with a possible lowest mean score of 1 and a possible highest mean score of 4. The mean of all participating items for each individual was calculated for their specific index score. The indices for health literacy were standardized to unified metrics from 0 to 50 using the formula index = (mean-1)*50/3). A minimum value of the index score was 0 if minimal possible value of the mean was 1 and 50 was maximum value of index score [ 36 , 41 , 42 ]. The cut-off based on health literacy measurements in Asia and in Europe [ 36 , 41 , 42 ]; levels were reported as ‘inadequate’ (0–25), ‘problematic’ (>25–33), ‘sufficient’ (>33–42) and ‘excellent’ (>42–50) levels of health literacy. For certain groups of final results, the ‘sufficient’ and ‘excellent’ levels were combined to a single level, called ‘adequate health literacy’ index scores (33–50) and below 33, index scores were combined to become ‘inadequate’. These two levels facilitate comparison of mothers’ socio-demographics and key practices with adequate and inadequate maternal health literacy. The total index scores were applied for correlation analysis (using either Pearson or Spearman tests), and multiple-linear regression helped to predict maternal health literacy by independent variables.
The research tools were firstly developed in English; thereafter back and forth translation was made between English and Lao languages to ensure accuracy. The Lao language was used in the field work; it is the language mainly used in this area. The research assistant did the translation from English to Lao language, then the PI translated back from Lao to English. The local supervisor helped with a final edit before the pilot test. The Lao language version was pilot tested at villages in the study area different from the study sites but with similar conditions, with 30 mothers who had children under five years old for internal consistency with Cronbach’s alpha, for which a value of greater than or equal to 0.7 indicates satisfactory reliability [ 33 ]; the consistency value for this study was 0.934.
Data collection
Eight research assistants were recruited and trained for data collection. Authors SP and MM trained them for four days on how to do face-to-face interviews and on completing the questionnaires accurately. During the training, the eight data collectors practiced data collection in communities not included in the study. We conducted interviews in the participants’ households, for the privacy and convenience of the respondents. During the interview the information was recorded in the answer sheet and the interviewer checked the mother’s record book and vaccination card; child complete vaccination, ANC visits, and place of childbirth (if that was at a health facility) could be checked against the mothers’ responses. Nearly all (95%). Before interviews, mothers were fully informed about the study objectives and given an overview of the interview process. They were assured of anonymity to ensure confidentiality, and were told that they could refuse to answer any specific question or to withdraw from the interview at any time without explaining why. The completion of each answer sheet was double checked by the research team and team leaders to ensure the quality and completeness of the data. The approximate length of each interview was 45–60 minutes.
Data analysis
Data were entered into Microsoft Excel (2011) for Mac then transferred to ‘IBM SPSS 25’ for analysis (IBM Corp., Armonk, NY). Descriptive statistics, such as percentage, mean (standard deviation; SD) and median (range), were applied to describe personal information and the patterns of maternal health literacy.
Comparison of proportions between two groups was made using χ 2 or Fisher’s exact tests as appropriate. Mann Whitney U test or Student’s t tests were applied to compare medians or means between groups (see Tables 1 and 4 ). In multiple logistic regressions, socio-demographic and key practices of Lao mothers were identified as independent variables and dependent variables as inadequate and adequate MHL levels. These variables were entered forwardly into the model to determine the Odds Ratio (OR), 95% confidence interval (95% CI), and significance level when P-Value was less than 0.05 (see Table 5 ).
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https://doi.org/10.1371/journal.pone.0244181.t001
Ethical approval and participants’ consent
This study was part of a research project on the situation analysis of MCH care in Laos, which received ethical approval from the Ethics Committee of the University of Health Sciences, Ministry of Health, Laos. We obtained written consent from eligible mothers before beginning each interview. Fingerprints were provided by mothers who could not sign to give consent.
Characteristics and key practices of the study mothers
A total of 384 mothers, 197 from urban and 187 from rural areas, were enrolled in the study. Their characteristics and practices are shown in Table 1 . The overall median (range) age was 28 (14–46) years. Most of the mothers could read and speak the Lao language (70.8% and 76.3%); these proportions were significantly higher in urban than in rural areas ( P <0.001) Z .
The median (range) number of ANC visits made by the mothers was 3 (0–9); only one third of mothers visited ANC more than four times during their pregnancies. Two thirds of mothers had given birth at health facilities for their last child, this was also significantly higher in urban than in rural areas ( P = <0.001 )Z . Approximately three quarters of the mothers had practiced food restriction during the postpartum period, and 22% had practiced it during pregnancy. Nearly 90% of mothers had stayed on a hotbed in both urban and rural areas. The overall proportion of the children with complete immunization was lower than 50%, but significantly lower in rural than in urban areas ( P = 0.001) Z .
Information received by respondents on maternal and child health
Table 2 illustrates whether and how mothers had received (MCH information. Nearly 90% of mothers reported that they had received MCH information. Of these, 80% said they received it from health personnel at health facilities and 58% from health personnel during outreach sessions. Other sources of MCH information included media and their social network (family, relatives, friends, and neighbors) but these were reported by less than 50% of the respondents as a source of information.
https://doi.org/10.1371/journal.pone.0244181.t002
Comparison of maternal health literacy levels and index scores between urban and rural mothers
Despite the mothers having received information, overall MHL levels were largely inadequate, as shown in Table 3 . Approximately 80% of the mothers had either inadequate or problematic MHL, while only 17.4% reached adequate and 3.5% had excellent MHL. Two thirds of mothers found it difficult to access, understand, appraise and apply MCH information. For example, 69% of mothers reported that they encountered difficulties in finding health education materials on MCH (e.g. brochures and posters disseminated in the village) when they wanted to know more; 74% of mothers found it difficult to understand information, for example, that after delivery, the mother should eat fruits. Also, more than two thirds of mothers had trouble appraising and applying any MCH information they received. For example, 77.9% of mothers reported that they found it very difficult to judge whether information about the benefits of food diversity for mother and child was correct or not; 84.4% of mothers reported that they could not easily use information about physical and mental health care (e.g. exercise, swimming, yoga, listening to music, getting enough sleep, keeping a good mood) during pregnancy. The total mean MHL scores varied between urban and rural areas, although the index scores were very low in both ( Table 3 ). The overall MHL index score was 30, but it was significantly higher in urban than in rural areas ( P = 0.001) M .
https://doi.org/10.1371/journal.pone.0244181.t003
Comparison between mothers with inadequate and adequate maternal health literacy levels
Socio-demographics and key practices of Lao mothers who had inadequate and adequate MHL levels are shown in Table 4 . Significantly higher proportions of appropriate MHL levels were found among mothers who speak the Lao language, who have high income, who frequently visited ANC, who gave birth at health facilities, and who had a child with complete vaccination, as compared to the other group of mothers ( P = 0.001 Z , P = <0.001 ZM , P = 0.011 Z , P = 0 . 003 Z , P = 0.006 Z , P = 0.002 Z , and P = 0.042 Z respectively). However, having heard MCH information was not significantly associated with MHL.
https://doi.org/10.1371/journal.pone.0244181.t004
Socio-demographic and key practice factors associated with MHL of Lao mothers
Factors associated with MHL level are shown in Table 5 . There are three independent variables associated with the MHL level in multiple logistic regression analysis. For example, mothers who have high income, who frequently visited ANC, and who live in urban areas were significant associated with higher MHL level [ Adjusted OR = 0.52, 95% CI (0.289–0.934, P = 0.029); Adjusted OR = 2.198, 95% CI (1.278–3.782), P = 0.004; and Adjusted OR = 0.189, 95% CI (0.268–2.582, P = 0.029)] respectively. However, having heard any MCH information ( Adjusted OR = 2.631) was not significantly associated with MHL ( P = 0.056).
https://doi.org/10.1371/journal.pone.0244181.t005
This is the first study conducted in Laos to measure maternal health literacy (MHL) of mothers, emphasizing the care during pregnancy, childbirth, and postpartum periods. The results show that their MHL was very poor with ~80% having either inadequate or problematic MHL. The finding also revealed that MHL was significantly lower in rural than in urban areas ( P = 0.001), probably because urban mothers had better literacy and more years of schooling than did rural mothers, and we found that mothers’ years of schooling was significantly associated with MHL. Improving MHL in both rural and urban areas could increase mothers’ ability to make decisions and take actions that would be good for their own and their children’s health [ 7 ]. Poor MHL of the mothers has also been reported in India, in USA, and in Iran [ 13 , 25 – 27 , 43 – 45 ].
Women received mother and child health (MCH) information from different sources. A study in Vietnam indicated that family members were very important for mothers in ethnic minority communities, among other sources of MCH information (social networks, health literacy mediators, and health professionals) [ 4 ], but in our study, health workers were the main source. Most women (about 80%) had received information on MCH from health providers, either at the health facility or during health campaigns in their village, while less than half had received MCH information from media (smart phone, TV and or radio) and social networks (relative, friend, and or neighbor). We did not separately assess for different sources of information, but most of the information came from health workers, and the mothers reported having trouble appraising and applying all MCH information they received, regardless of the source.
However, getting information does not necessarily lead to improved MHL. It appears that health providers are able to reach the target group, but their communication of health messages may not be very effective. Our previous studies on ANC focusing on information and education demonstrated that very little health information was actually provided by health workers to the pregnant women. Health workers often neglected giving MCH information and when they did, their communication skills were poor. Another issue was that MCH information materials are not well developed in Laos and were seldom available or used during ANC visits [ 22 , 23 , 32 ]. When we combine the reported poor communication performance of the health workers and the lack of health literacy among the mothers, we believe that strategies and activities to strengthen health workers’ communication skills could help to improve mothers’ health literacy.
Different results have been reported in other contexts. For example, in Iran, health education of mothers was significantly associated with MHL [ 24 ] and in Texas (USA), education, family/household income, and English language were significantly associated with better MHL [ 25 ], while in our case it was the mother’s own income that was significantly positively correlated with greater MHL. A study in Mali demonstrated that own income of mothers was associated with child nutrition status [ 38 ].
In addition, our results suggest that making four or more ANC visits was significantly associated with adequate MHL. This is consistent with similar results in Nigeria [ 11 ]. Although we cannot make inferences about causal relations and/or directions, these associations do suggest that increased literacy is significantly related to positive practices. Most notably visits to ANC and immunization completion were positively correlated with increased health literacy. However, other practices, such as hotbed stay, food restrictions, and drinking alcohol were not related with maternal health literacy level, although they do pose serious health risks. Hotbed stays have been significantly associated with newborns’ skin infection and even septicemia [ 46 ]. Food taboos/restrictions during the postpartum period have been associated with infantile beri-beri (vitamin B1 deficiency) and death [ 47 – 51 ]. These practices are probably hard to change despite high literacy scores, because hotbed stay and traditional food restrictions are known to be deeply embedded in Lao culture [ 22 ].
Strengths and limitations
The strengths of this study are the large sample size representing both urban and rural mothers, which could be sufficient to identify significant differences, strengthened by the sampling method, using cluster sampling at the village level, and proportional to size for the household level.
However, the study also had limitations. Cross-sectional data cannot provide causal inferences as longitudinal studies might. Furthermore, not all potentially important influencing factors were included, for example, we did not investigate social support, parenting self-efficacy, and early parenting practices [ 25 ]. Food restriction was considered a negative factor here, but in other settings the same practice may mean low intake of unhealthy foods such as sugar, white bread, processed meat, and considered a positive factor for fetal development [ 52 ]. We did not look at food restriction in detail, but another study revealed that women avoided eating vegetables, fruits, and some types of meat, as well as sauces, sugar and spices [ 22 ]. Because we did not use information on the age of the child, we do not know how long ago the birth took place and therefore cannot say whether recall bias might be less among mothers who gave birth more recently. Information on ANC visits, place of delivery, and child immunization was checked on the appropriate record cards, but we could not check in the same way for information received about breastfeeding, so there could be recall bias for that topic among mothers whose children were older.
The findings of this study reflect the Lao context, where the health personnel seem to be the main source of information for mothers, the deficiencies in providing maternal and child health information identified in earlier studies may explain why mothers still had low levels of maternal health literacy. If mothers’ knowledge and practice are to improve, the quality of information and communication skills is as important as the fact of providing information. Therefore, the quality of delivering comprehensive information by health care providers has to be improved as well.
Although the study may not be representative of the whole country, we think that the sample can be representative of at least the population in Southern Laos, because the two provinces of our study site had been randomly selected from the five provinces in the southern region in previous studies [ 16 , 17 ]. Nevertheless, we do have the impression that in many other areas of Laos similar results will be found. Women largely utilize similar public health services, staffed by providers that were educated in one of the few training facilities available. Also women largely utilize similar media. However, social networks and customs, which are critical for health literacy, may differ between regions.
Overall, the maternal health literacy level of Lao mothers found in this study was very poor in both urban and rural areas. Health personnel were reported to be the main source of MCH information but were apparently not very effective in that aspect of their work. Socio-demographic characteristics and key practices of mothers were significantly associated with levels of MHL. To improve the level of MHL in Laos, developing better information, education and communication materials and strengthening communication skills of health workers are strongly recommended.
Acknowledgments
We would like to give special thanks to Dr. Phouthone Vangkonevilay, Dr. Chanthanom Manithip, Dr. Bouthom Samontry, Dr. Sengchanh Kounnavong, Dr. Vanphanom Sychareune, Dr. Vongsinh Phothisansack, Dr. Kongmany Chalearnvong, Dr. Visanou Hansana, Dr. Alongkone Phengsavanh, Mr. Ian Bromage, Mr. Stephen Himley, Ms. Suzanna Lipscombe, and Dr. Leonie Venroij and our family members for their kind support and encouragement. In addition, we would like to thank our research assistants from the University of Health Sciences and health facilities, Laos, who contributed their best efforts to collect data. We also would like to express our sincere thanks to Salavane and Attapeu provincial and district health departments for their excellent collaboration in the fieldwork. Finally we would like to give our heartfelt thanks to all participants at the community levels for sharing their valuable time and information to participate in this study.
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- Published: 15 March 2023
Maternal Health Concerns for Pregnant Labor-Trafficked People: A Scoping Review
- Jaya Prakash ORCID: orcid.org/0000-0002-5845-6647 1 ,
- Tahireh Markert 1 , 2 ,
- Paul A. Bain 1 , 3 &
- Hanni Stoklosa 1 , 4 , 5
Journal of Immigrant and Minority Health ( 2023 ) Cite this article
Metrics details
We set out to map the (1) living/occupational hazards, (2) health outcomes, and (3) barriers to care that exist for pregnant labor-trafficked people. Eight databases were systematically searched based on inclusion criteria. Five papers were eligible for inclusion. Data on study characteristics, social determinants, hazardous exposures, health outcomes, and barriers to care were extracted and synthesized. Common risk factors and occupational/living hazards were identified. Both were thematically connected with barriers to care and a host of adverse health outcomes. More importantly, a significant gap was discovered with no disaggregated quantitative data on the experience of pregnancy among labor-trafficked people. The interaction of risk factors, occupational/living hazards, and barriers to care experienced by pregnant labor-trafficked people may influence their susceptibility to adverse health outcomes. We need population-based studies, informed by those with lived experience of labor trafficking to examine the experience of pregnancy for labor-trafficked people to improve intervention and support efforts for this population.
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This project is/was partially supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant T76MC00001 and entitled Training Grant in Maternal and Child Health.
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JP and HS conceived the study. PB designed and executed the search. JP and TM reviewed studies, selected sources, and extracted data. JP, TM, and HS finalized qualitative analysis and thematic selection. HS oversaw and guided the study. All authors were involved in the revision of the draft manuscript and have agreed to the final content.
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Prakash, J., Markert, T., Bain, P.A. et al. Maternal Health Concerns for Pregnant Labor-Trafficked People: A Scoping Review. J Immigrant Minority Health (2023). https://doi.org/10.1007/s10903-023-01466-5
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Systematic Review of Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries
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Page Contents
This protocol was amended on September 12, 2017. To view the changes, go to " Summary of Protocol Amendments ."
I. Background and Objectives for the Systematic Review
Breast milk is the natural nutrition for all infants; evidence supports the association between breastfeeding and better health outcomes for both infants and mothers. 1-3 Multiple clinical guidelines and health-related organizations recommend exclusive breastfeeding up to (or around) 6 months, including the American Academy of Pediatrics, 4 the American Congress of Obstetrics and Gynecology, 5 the World Health Organization, 6,7 and others. 8,9 After 6 months, these organizations recommend continued breastfeeding through the first year of life and beyond.
A 2007 Agency for Healthcare Research and Quality (AHRQ) review by Ip and colleagues evaluated the evidence on the association between breastfeeding and infant and maternal health outcomes. 2 For maternal health outcomes, they concluded that a history of breastfeeding (compared with no breastfeeding or a shorter duration of breastfeeding) was associated with a reduced risk of type 2 diabetes and breast and ovarian cancer. 2 No benefit was found for risk of fracture; for other outcomes (e.g., postpartum depression) the relationship between breastfeeding and improved maternal health was unclear. Since 2007, several new studies have reported on outcomes not addressed in the 2007 AHRQ review, including hypertension, rates of myocardial infarction and other cardiovascular outcomes. 10-13
Despite evidence supporting the association between breastfeeding and better health outcomes (for infants and mothers), 45 percent of U.S. women who initiate breastfeeding report early, undesired weaning. 14 The estimates for any breastfeeding for infants born in 2013 in the United States were 81.1 percent for initiation, 51.8 percent for infants breastfed at 6 months, and 30.7 percent for infants breastfed at 12 months. 15 Each decade, the US Department of Health and Human Services releases and monitors a list of "Healthy People" objectives to guide the nation's 10-year health promotion and disease prevention efforts; these objectives include several targets related to breastfeeding. 16 Healthy People 2020 targets for initiating breastfeeding, breastfeeding to 6 months, and breastfeeding to 12 months are 81.9 percent, 66.6 percent, and 34.1 percent, respectively. 17 There are racial and ethnic differences in breastfeeding initiation (starting) and duration (continuing) rates. From 2000–2013, the percentage of women who initiated breastfeeding went up from 47.4 percent to 66.3 percent for blacks, 71.8 percent to 84.3 percent for whites, and 77.6 percent to 83.0 percent for Hispanics. 18,19 Sociodemographic factors associated with an increased likelihood of breastfeeding initiation and continuation include older maternal age, being married, Asian or white race, Hispanic ethnicity, higher maternal education, and access to private insurance. 19-22
Community, workplace and health care system-based programs and policies are seen as promising strategies to support initiation and increase duration breastfeeding. In addition to setting targets for breastfeeding initiation rates and duration of breastfeeding, other Healthy People 2020 objectives related to breastfeeding include increasing the proportion of employers that have worksite lactation support programs and increasing the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies. 17
Health care system-based interventions include implementation of the Baby-Friendly Hospital Initiative (BFHI). The BFHI is a global program sponsored by the World Health Organization and UNICEF to encourage and recognize hospitals and birth centers that create an environment that supports breastfeeding; the "10 Steps to Successful Breastfeeding for Hospitals" are listed in Table 1. For U.S. hospitals, Baby-Friendly accreditation is awarded to facilities that successfully implement the 10 steps and the International Code of Marketing of Breast-Milk Substitutes 7 and pass an intensive site visit. 23 Site visits and certification are adjudicated by Baby Friendly USA, a 501c3 non-profit organization. 24 In addition to certification by Baby Friendly USA, state departments of public health have encouraged implementation of the 10 Steps through local programs such as the Texas Ten Step Program, 25 the North Carolina Maternity Center Breastfeeding-Friendly Designation Program, 26 and others. On a national level, the Centers for Disease Control and Prevention has audited maternity care practices during the past 10 years with a biannual maternity practice survey, results of which are distributed to each maternity center. 27
In terms of health care policy interventions beyond hospital policies, costs associated with breastfeeding support (e.g., comprehensive lactation support and counseling and breastfeeding equipment) are currently covered by health insurance marketplace plans and private nongrandfathered health plans under the 2010 Patient Protection and Affordable Care Act (ACA). 29 It is not clear whether certain lactation benefit packages (e.g., type of breastfeeding supplies offered, number of visits provided, or qualifications of intervention delivery personnel) are more or less effective in increasing breastfeeding initiation and duration.
Workplace interventions have been proposed as a way to increase duration and exclusivity of breastfeeding for mothers participating in paid work. If not supported by their employers, employed mothers may have difficulty expressing and storing milk and thus not be able to maintain breastfeeding. A prior systematic review in 2012 found no controlled trials evaluating the effectiveness of workplace programs. 30 The ACA included a provision aimed at workplace breastfeeding policies by amending section 7 of the Fair Labor Standards Act to require employers to provide reasonable break time and a private space (other than a bathroom) for breastfeeding women to express breast milk for at least 1 year after the child's birth. 31
Programs and policies to support breastfeeding are quite diverse and often complex. 32-34 The purpose of this review is to conduct an evidence report that summarizes the effectiveness of community, workplace and health care system-based programs and policies aimed at supporting and promoting breastfeeding. This review will describe whether certain programs or policies are more or less effective than other approaches in supporting breastfeeding, and whether effectiveness varies for subgroups of women defined by important sociodemographic factors (e.g., maternal age, education, and income; family and social support). This review will not address the effectiveness of individual-level primary care interventions to support and promote breastfeeding; this evidence was recently summarized in a systematic review 35 to support the U.S. Preventive Services Task Force in updating its recommendation on counseling to promote and support breastfeeding. 36
In addition, this review will also address the association between breastfeeding and maternal health. Substantial time has elapsed since the last AHRQ review on this topic in 2007, and the body of literature focused on the maternal health benefits of breastfeeding has grown. 1,37-39 This review will conduct a partial update of the 2007 AHRQ review focused on the relationship of breastfeeding and various maternal health outcomes.
II. The Key Questions
Key question (kq) 1a.
What is the effectiveness and harms of programs and policies on initiation, duration, and exclusivity of breastfeeding?
To what extent do the effectiveness and harms of programs and policies on initiation, duration, and exclusivity of breastfeeding differ for subpopulations of women defined by sociodemographic factors (e.g., age, race, ethnicity, socioeconomic status)?
To what extent do intervention-related characteristics (e.g., type of breast pump provided—manual or electric; delivery personnel) influence the initiation, duration, and exclusivity of breast feeding?
What are the comparative benefits and harms for maternal health outcomes among women who breastfeed for different intensities and durations?
To what extent do benefits and harms for maternal health outcomes differ for subpopulations of women defined by age, race, ethnicity, and comorbidity?
For the above KQs, the following population, intervention, comparator, outcomes, timing, setting (PICOTS) criteria apply:
Population(s)
KQs 1, 2: Childbearing women and adolescents; we will also search for evidence on subgroups of women defined by age, race, ethnicity, comorbidity, and socioeconomic status (including insurance status and payer type).
Interventions/Exposure
- KQ 1: Community, workplace, and health care system-based interventions aimed at promoting and supporting breastfeeding, including the following: health plan benefits, state and federal policies or programs (e.g., WIC programs), hospital implementation of the BFHI, workplace or school-based programs, and others. For studies assessing the effectiveness of BFHI, we will include studies evaluating full and partial implementation (at least 3 steps) of the 10 steps (see Table 1).
- KQ 2: Exposure to breastfeeding
Comparators
- KQ 1: No intervention (or usual practice); comparisons of two interventions that differ in content or intensity.
- KQ 2: No breastfeeding; shorter duration of breastfeeding (e.g., breastfeeding for 1 month vs. 12 months) and/or less intensive breastfeeding (e.g., exclusive breastfeeding vs. mixed feeding or formula feeding)
- KQ 1: Rates of breastfeeding initiation; duration and exclusivity of breastfeeding, adverse effects of interventions (e.g., guilt about not breastfeeding, workplace discrimination, and other reported harms)
- KQ 2: Postpartum depression, breast cancer, ovarian cancer, osteoporosis, cardiovascular outcomes (e.g., stroke, myocardial infarction), postpartum weight change, type 2 diabetes, hypertension
KQs 1, 2: We will have no minimum study duration or length of followup.
KQs 1, 2: Studies conducted in a developed country ["very high" (KQs 1, 2) and "high" (KQ 1) human development index per the United Nations Development Programme] 40
Study Design
- KQ 1: Randomized and non-randomized controlled clinical trials; prospective cohort studies with concurrent control groups; systematic reviews; for studies assessing policy or system-level interventions, we will also include pre-post studies with repeated outcome measures before and after the intervention
- KQ 2: Randomized and non-randomized controlled clinical trials; cohort studies; case-control studies; systematic reviews
III. Analytic Framework
IV. Methods
Criteria for inclusion/exclusion of studies in the review.
The criteria for inclusion and exclusion of studies are designed to identify studies that can answer the Key Questions (KQs) and are based on the population, intervention/exposure, comparator, outcomes, time frames, country settings, study design (PICOTs) are show in Table 2 and described in Section II above.
Searching for the Evidence: Literature Search Strategies for Identification of Relevant Studies to Answer the Key Questions
We will systematically search, review, and analyze the scientific evidence for each KQ. The steps that we will take to accomplish the literature review are described below.
To identify relevant published literature, we will search the following databases: PubMed/MEDLINE, the Cochrane Library, CINAHL and trial registries. We will conduct two separate search strategies, one for KQ1 and a second for KQ2. The preliminary search strategies formatted for MEDLINE are shown in the Appendix and are comprised of medical subject heading (MeSH) terms and natural language terms reflective of breastfeeding interventions and outcomes of interest. The search strategy will be adapted for the other databases as needed. An experienced librarian familiar with systematic reviews will design and conduct all searches in consultation with the review team. We will ask the Technical Expert Panel for feedback on the search terms and strategy.
For KQ 1, our literature searches will include articles published since 1980 to ensure that evidence is applicable to current breastfeeding policies and practices. For KQ 2, our literature searches will include articles published after November 1, 2005 (6 months prior to the date of the 2007 AHRQ review searches); we will also check reference lists of the included studies and systematic reviews to confirm that earlier studies were not missed. The literature search will be updated concurrent with the peer review process.
We will search the "gray literature" for unpublished studies relevant to this review and will include studies that meet all the inclusion criteria and contain enough methodological information to assess risk of bias. Gray literature sources will include ClinicalTrials.gov and any scientific information packages received from Federal register notices or informational requests.
Data Abstraction and Data Management
To ensure accuracy, all titles and abstracts will be reviewed independently by two reviewers. We will retrieve the full text for all citations deemed appropriate for inclusion by at least one of the reviewers. Each full-text article, including any articles that peer reviewers suggest or that may arise from the public posting process, will be independently reviewed for eligibility by two team members. Any disagreements will be resolved by consensus. We will maintain a record of studies excluded at the full-text level with reasons for exclusion and will include this list in our final report.
After we select studies for inclusion, we will abstract data into categories that include (but are not limited to) the following: study design, year of publication, setting (including geographic location), sample size, eligibility criteria, population characteristics, intervention characteristics, and outcomes relevant to each KQ as outlined in the previous PICOTs section. Relevant information that we will abstract for assessing applicability will include the characteristics of the population (e.g., demographic factors) and geographic setting. A second team member will verify abstracted study data for accuracy and completeness.
Assessment of Methodological Risk of Bias of Individual Studies
To assess the risk of bias (i.e., internal validity) of studies, we will adapt existing tools (ROBIS-I 42 for observational studies, and the Cochrane tool 43 for trials) and use predefined criteria based on the AHRQ Methods Guide for Comparative Effectiveness Reviews . These include questions to assess selection bias, confounding, performance bias, detection bias, and attrition bias; concepts covered include those about adequacy of randomization, similarity of groups at baseline, masking, attrition, whether intention-to-treat analysis was used, method of handling dropouts and missing data, validity and reliability of outcome measures, and treatment fidelity). 44
In general terms, results from a study assessed as having low risk of bias are considered to be valid. A study with moderate risk of bias is susceptible to some risk of bias but probably not enough to invalidate its results. A study assessed as high risk of bias has significant risk of bias (e.g., stemming from serious issues in design, conduct, or analysis) that may invalidate its results.
Two independent reviewers will assess risk of bias for each study. Disagreements between the two reviewers will be resolved by discussion and consensus or by consulting a third member of the team.
Data Synthesis
We will summarize all included studies in narrative form and in summary tables that tabulate the important features of the study populations, design, intervention, outcomes, setting (including geographic location) and results.
For both KQs, we will capitalize on the availability of existing systematic reviews and meta-analyses; these will be captured in our database searches and identified during the literature review. KQ 2 is a partial update of the 2007 AHRQ review by Ip and colleagues; we plan to synthesize evidence from that review with newly identified evidence. For eligible outcomes that have previously been systematically reviewed, we will summarize the findings of recent (published within the past 5 years) relevant systematic reviews rated low or medium risk of bias using the ROBIS tool 45 ; we will also summarize data from primary studies published after the latest search date of those reviews, Conclusions from systematic reviews rated as high risk of bias may not be valid due to bias stemming from uncertain study eligibility criteria, lack of dual-review during identification and selection of studies, and other factors. We may use reviews rated as high risk of bias to identify primary studies our database searches may have missed. For outcomes for which we do not identify previous systematic reviews, we will synthesize primary studies that meet our inclusion criteria published after the last search date of the 2007 review.
When recent, relevant existing systematic reviews are identified for a particular outcome, we will assess whether newly identified primary studies are likely to change judgments about conclusions made in existing reviews using a SOE framework (i.e., assessment of study limitations, consistency, precision, directness, and reporting bias). If the new studies are likely to change the conclusions, we will conduct a new quantitative synthesis if appropriate (i.e., if conclusions made in existing reviews are based on a pooled analysis of studies). If the new studies are consistent with prior syntheses and will not to change the conclusion of the review, we will present the results of the existing review along with an updated qualitative synthesis including the newly identified studies and an explanation of how they are consistent with the prior findings. In order to maintain a consistent approach, we will conduct a new SOE for each outcome and not use SOE grading from existing reviews.
We will consider performing meta-analyses where we have at least three unique studies of low or medium risk of bias that we deem to be sufficiently similar (in population, interventions, comparators, and outcomes). We are aware of the potential biases of meta-analyses that include a small number of studies; 46 before routinely calculating a pooled summary estimate in a meta-analysis, we will carefully consider the heterogeneity across studies. As described above, in cases where we identify a recent eligible meta-analysis for an eligible outcome, we will assess whether to update the analysis by considering how the results of recently published primary studies would change the conclusions of the meta-analyses using a SOE framework.
If meta-analysis seems appropriate in these circumstances, we will perform only random-effects model meta-analyses. We will look across trials to identify heterogeneity qualitatively any potential effect-modifying factors, such as age, race, setting (e.g., highly versus very highly developed countries), and components of the included intervention (for KQ 1). If clinical heterogeneity can be narrowed down to a small number of promising factors, we will consider these for subgroup analyses or meta-regression. For KQ 2, we expect to find heterogeneity in terms of the definition of "breastfeeding" and extent to which studies distinguish between exclusive and less intense breastfeeding (i.e., mixed feeding with breastmilk and formula supplementation). Similar to the 2007 review, we will accept all definitions of "exclusive breastfeeding" as provided by the different study authors, but will qualify our conclusions (and perform subgroups analyses if feasible) with respect to those specific definitions.
We plan to exclude studies deemed high risk of bias from our main data synthesis and main analyses; we will include them only in sensitivity analyses. We will show forest plots for all meta-analyses performed, either in the main report or in appendices.
Grading the Strength of Evidence (SOE) for Major Comparisons and Outcomes
We will grade the strength of evidence based on the guidance established for the Evidence-based Practice Center Program. Developed to grade the overall strength of a body of evidence, this approach now incorporates five key domains: risk of bias (including study design and aggregate risk of bias), consistency, directness, and precision of the evidence, and reporting bias. It also considers other optional domains that may be relevant for some scenarios, such as plausible confounding that would decrease the observed effect and strength of association (i.e., magnitude of effect) or factors that would increase the strength of association (i.e., dose-response effect).
Table 3 describes the grades of evidence that can be assigned. Grades reflect the strength of the body of evidence to answer the KQs on the comparative effectiveness, efficacy, and harms of the interventions in this review. Two reviewers will assess each domain for each key outcome, and differences will be resolved by consensus. We will grade the strength of evidence for all included outcomes.
Assessing Applicability
We will assess the applicability of individual studies as well as the applicability of a body of evidence following guidance from the Methods Guide for Effectiveness and Comparative Effectiveness Reviews . 48 For individual studies, we will examine conditions that may limit applicability based on the PICOTS structure. Some factors identified a priori that may limit the applicability of evidence include the following: race or ethnicity of enrolled populations, setting of enrolled populations, geographic setting, and availability of health insurance and other health-related employment benefits. We will pay close to attention to secular trends when interpreting the evidence. Such trends are of concern, in that breastfeeding rates in the United States have changed dramatically in the past 40 years, from a nadir of less than 25 percent in 1971 49 to more than 80 percent in 2013. 50 This is important because the time period between exposure to breastfeeding and some outcomes of interest (e.g., cancer, cardiovascular disease) may be decades, and secular trends in social determinants of infant feeding may confound observed associations. Findings linking breastfeeding to maternal health among women feeding their infants decades ago may not be generalizable to contemporary women.
V. References
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- Ip S; Chung M; Raman G; Chew P; Magula N; DeVine D; Trikalinos T; Lau J. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries Evidence Report/Technology Assessment No. 153 (Prepared by Tufts-New England Medical Center Evidence-based Practice Center, under Contract No. 290-02-0022). AHRQ Publication No. 07-E007. Rockville, MD: Agency for Healthcare Research and Quality; April 2007.
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- World Health Organization. International Code of Marketing Breast-milk Substitutes. Geneva: World Health Organization; 1981.
- World Health Organization, UNICEF. Protecting, promoting and supporting breast-feeding: the special role of maternity services. Geneva: World Health Organization; 1989.
- American Academy of Family Physicians. Breastfeeding (policy statement): American Academy of Family Physicians [serial on the Internet]; 2012.
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VI. Definition of Terms
We will define important terms in the full report.
VII. Summary of Protocol Amendments
Viii. technical experts.
Technical Experts constitute a multi-disciplinary group of clinical, content, and methodological experts who provide input in defining populations, interventions, comparisons, or outcomes and identify particular studies or databases to search. They are selected to provide broad expertise and perspectives specific to the topic under development. Divergent and conflicting opinions are common and perceived as healthy scientific discourse that results in a thoughtful, relevant systematic review. Therefore, study questions, design, and methodological approaches do not necessarily represent the views of individual technical and content experts. Technical Experts provide information to the EPC to identify literature search strategies and suggest approaches to specific issues as requested by the EPC. Technical Experts do not do analysis of any kind nor do they contribute to the writing of the report. They have not reviewed the report, except as given the opportunity to do so through the peer or public review mechanism.
Technical Experts must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Because of their unique clinical or content expertise, individuals are invited to serve as Technical Experts and those who present with potential conflicts may be retained. The AHRQ TOO and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified.
IX. Peer Reviewers
Peer reviewers are invited to provide written comments on the draft report based on their clinical, content, or methodological expertise. The EPC considers all peer review comments on the draft report in preparation of the final report. Peer reviewers do not participate in writing or editing of the final report or other products. The final report does not necessarily represent the views of individual reviewers. The EPC will complete a disposition of all peer review comments. The disposition of comments for systematic reviews and technical briefs will be published three months after the publication of the evidence report.
Potential Peer Reviewers must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Invited Peer Reviewers may not have any financial conflict of interest greater than $10,000. Peer reviewers who disclose potential business or professional conflicts of interest may submit comments on draft reports through the public comment mechanism.
X. EPC Team Disclosures
No team members have financial conflicts of interest. Dr. Stuebe, as a practicing OBGYN and member of the ACOG, follows clinical practice guidelines in supporting breastfeeding. In the event that her published studies on the relationship between breastfeeding and outcomes are eligible for the review, Drs. Feltner and Viswanathan will review them for inclusion and exclusion, full-text, risk of bias, and any strength of evidence grading that arise from their inclusion. Dr. Stuebe will not be involved in any review activities related to her studies.
XII. Role of the Funder
This project was funded under Contract No. HHSA290201500011I_HHSA29032008T from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. The AHRQ Task Order Officer reviewed contract deliverables for adherence to contract requirements and quality. The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
XIII. Registration
This protocol will be registered in the international prospective register of systematic reviews (PROSPERO).
Project Timeline
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Internet Citation: Research Protocol: Systematic Review of Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries. Content last reviewed October 2019. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD. https://effectivehealthcare.ahrq.gov/products/breastfeeding/research-protocol
- Open Access
- Published: 14 March 2023
Interventions addressing maternal and child health among the urban poor and homeless: an overview of systematic reviews
- Devaki Nambiar 1 ,
- Bincy Mathew 2 ,
- Shubhankar Dubey 3 &
- Sandeep Moola 4
BMC Public Health volume 23 , Article number: 492 ( 2023 ) Cite this article
23 Accesses
Metrics details
Inequalities in access to and utilization of maternal and child health (MCH) care are hampering progress on the path to achieving the Sustainable Development Goals. In a number of Low- and Middle-Income Countries (LMICs) population subgroups at disproportionate risk of being left behind are the urban poor. Within this neglected group is the further neglected group of the homeless. Concomitantly, a number of interventions from the antenatal period onward have been piloted, tested, and scaled in these contexts. We carried out an overview of systematic reviews (SRs) to characterize the evidence around maternal and child health interventions relevant to urban poor homeless populations in LMICs.
We searched Medline, Cochrane Library, Health Systems Evidence and EBSCOhost databases for SRs published between January 2009 and 2020 (with an updated search through November 2021). Our population of interest was women or children from urban poor settings in LMICs; interventions and outcomes corresponded with the World Health Organization’s (WHO) guidance document. Each SR was assessed by two reviewers using established standard critical appraisal checklists. The overview was registered in PROSPERO (ID: CRD42021229107).
In a sample of 33 high quality SRs, we found no direct relevant evidence for pregnant and lactating homeless women (and children) in the reviewed literature. There was a lack of emphasis on evidence related to family planning, safe abortion care, and postpartum care of mothers. There was mixed quality evidence that the range of nutritional interventions had little, unclear or no effect on several child mortality and development outcomes. Interventions related to water, sanitation, and hygiene, ensuring acceptability of community health services and health promotion type programs could be regarded as beneficial, although location seemed to matter. Importantly, the risk of bias reporting in different reviews did not match, suggesting that greater attention to rigour in their conduct is needed.
The generalizability of existing systematic reviews to our population of interest was poor. There is a clear need for rigorous primary research on MCH interventions among urban poor, and particularly homeless populations in LMICs, as it is as yet unclear whether the same, augmented, or altogether different interventions would be required.
Peer Review reports
Inequality in access to maternal healthcare services has consequences for Sustainable Development Goals (SDG) target 3.1 and 3.2, which relate to reduction of the global maternal mortality ratio, neonatal mortality and under-5 mortality, respectively [ 1 ]. Globally, 42 countries in the Sahel (above the Sahara desert through to the West African coast), Sub Saharan, South Asian, South East-Asian and parts of South American regions are unlikely to attain SDG targets for maternal and child mortality [ 2 ].
By the last year of SDG, i.e. 2030, it is estimated that 60 per cent of people will live in cities [ 3 ]. Moreover, with the global expansion of towns and cities, there has for some time been a trend of urbanization of poverty [ 4 ]. The convenience of living in cities (shorter distances, accessibility of services, social networks) benefits a small percentage of population with millions of urban-dwellers being excluded [ 3 ]; which in turn has implications for maternal [ 5 ] and child health [ 6 ]. A study drawing from Demographic and Health Surveys in Least Developed Countries showed significant inequalities in children’s nutritional outcomes, with higher inequalities in the most rapidly urbanizing countries [ 7 ].
Despite inequalities in health outcomes among the urban poor, issues relating to access persist. A study of 22 African cities showed disruptions in the maternal continuum of care, characterized drop offs in antenatal care, childbirth and postpartum care, with varying reliance on public and private sector use, and use of hospitals across cities [ 8 ]. Another study, drawing on data from seven cities in LMICs highlighted issues relating to availability, accessibility, quality of MCH services as well as delayed care-seeking [ 5 ]. In a study on 30 developing countries, it was noted that the urban poor did not have better access to maternal healthcare despite proximity to healthcare services [ 9 ]. Among the urban poor, people living on the streets are at the highest risk of being left behind, because they are hard to reach and often are not covered by social welfare systems [ 10 ]. Thus, homeless people have disproportionately higher levels of morbidity and mortality compared to the general population, [ 11 , 12 ] and the homelessness of pregnant women is associated with poor health outcomes of children [ 13 , 14 ].
Interventions introduced from the antenatal period to the later childhood period can bring about a decrease in neonatal and later mortality [ 15 ]. Interventions relating to the health sector including those outside it are needed to bring countries on track for achieving SDG goals 3.1 and 3.2. These include scaling up of integrated packages of reproductive health, maternal and newborn health, and child health as well as those beyond it such as access to clean water and sanitation [ 2 ].
Maternal and child health interventions have been a major focus of public health research for decades and are in a sense core to the discipline itself. Drawing on this evidence base, a multitude of systematic reviews have assessed a broad range of interventions, with varying primary aims and outcomes recognize the potential of interventions to improve maternal and child health outcomes [ 16 , 17 , 18 ]. We sought to compile an overview of SRs to examine and consolidate evidence on the interventions relating to clinical, public health or community-based health or health promotion services in context of maternal and child health in LMICs, with focus on homeless populations.
An overview of SRs was conducted based on a pre-defined protocol, which was registered in PROSPERO (ID: CRD42021229107, the full protocol may be downloaded at this link).
Inclusion criteria
Systematic reviews involving women and children from urban poor settings in LMICs, including the homeless were included. Populations of interest were women (pregnant or lactating women, if any) or children from urban poor settings in LMICs. We were looking for any interventions (clinical or public health or community-based health or health promotion, etc.) addressing MCH were considered, guided by the WHO guidance document on packages of interventions for family planning, safe abortion care, maternal, newborn and child health [ 19 ]. Comparator interventions included usual or standard care, no intervention, or another intervention. Outcome indicators were also aligned with the WHO guidance document [ 19 ] pertaining to family planning, safe abortion care, pregnancy care, childbirth care, postpartum care of the mother, care of the newborn, and care during infancy and childhood were considered. Some of the outcome indicators included unmet need for family planning, percentage of health providers trained to provide safe abortion, percentage of pregnant women receiving antenatal care at least once/four times during pregnancy, percentage of births in facilities, percentage of women receiving postpartum care within seven days after childbirth, neonatal and early neonatal mortality rates, and percentage of infants under six months exclusively breastfed.
All the SRs with or without meta-analysis of any study design were included. Non-English language reviews were considered for inclusion where English translated reviews were available. However, the overview did not find any SRs published in non-English languages. All the available SRs published from January 2009 till January 2020 were considered. An updated search was conducted from February 2020 till November 2021, utilising the same search strategies. Reviews that incorporated theoretical studies or text or opinion as the primary source of evidence were excluded. Reviews that included interventions conducted only in high-income countries (HICs) and those that had interventions in general women and child populations (i.e., non-urban) conducted in LMICs were excluded.
Search methods and review selection process
A comprehensive literature search was conducted in databases such as Medline (PubMed), Cochrane, Health System Evidence (HSE) and EBSCOhost platform. The search strategies are available in Supplementary File 1. Two reviewers (SD, BM) independently performed preliminary screening of titles and abstracts of the records with support from SM. Full-text screening of the selected records was done independently by SD and BM. Conflicts were resolved with mutual consensus and consultation with a third reviewer (DN). The review selection process is presented in the flow diagram adapted from the Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines (see Fig. 1 ) [ 20 ].
PRISMA Flow diagram
Assessment of methodological quality of included reviews
The methodological quality of each included SR was assessed in duplicate by SD and BM using A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) checklist [ 21 ] and Joanna Briggs Institute (JBI) critical appraisal checklist [ 22 ]. The quality rating in the included SRs was classified as high, moderate, low depending on the scores for individual items in the tools as decided with consensus (High: if Yes > 81%; Moderate: between 81% and 56%, Low: if Yes < 60%). Resolution of any disagreements was resolved through consensus with the help of a third reviewer (DN).
Data extraction and synthesis
The data were independently extracted by SD and BM using a predesigned data extraction template. The following data were extracted: author/year, objectives, review characteristics, description of interventions and comparators, outcomes, and results. Extracted findings were summarised narratively by population and intervention type. Where SRs assessed certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) [ 23 ] and GRADE-CERQual approaches, [ 24 ] for quantitative and qualitative reviews, respectively, we reported the findings accordingly. The GRADE approach is used in individual SRs to assess the quality of evidence or the confidence in the effect estimates [ 25 ].
Based on a comprehensive search performed, 203 reviews were identified. After removing duplicates, 177 records underwent title and abstract screening, of which 87 were excluded. Of the 93 records remaining, 54 records were excluded during the full-text screening of the articles. Thirty-three high-quality reviews were finally included for this review (see Fig. 1 for PRISMA flow diagram). This included three new SRs identified in the updated searches [ 26 , 27 , 28 ].
Most of the reviews included infants and children from urban poor settings. Other participants included pregnant and lactating women. The reviews addressed family planning, pregnancy care, postpartum care of the mother and care of the newborn, childbirth care, And care during infancy and childhood. None of the reviews addressed abortion care.
Based on the eligibility criteria, among the 39 reviews, two were of low quality, [ 29 , 30 ] four were of moderate quality, [ 15 , 31 , 32 , 33 ] and the remaining 33 were of high quality. We included only high-quality reviews (N = 33) as adjudged during critical appraisal. Of the 33 SRs, 29 used meta-analysis, mainly comprising randomized controlled trials (RCTs) and non-randomized and quasi-experimental designs. Three reviews did not conduct a meta-analysis, and one review was a qualitative synthesis. The three new SRs identified in the updated searches examined hand washing promotion, education of family members to support weaning, and targeted client communication via mobile devices [ 26 , 27 , 28 ].
Summary of key findings
Interventions relevant to specific urban poor populations (i.e., the homeless, slum dwellers).
Overall, six reviews included studies relevant to urban slum settings; however, most of the evidence was based on single studies from the reviews; hence the findings should be interpreted with caution [ 34 , 35 , 36 , 37 , 38 , 39 ]. In the Turley et al. (2013) review, there was low quality, but consistent body of evidence to indicate that slum upgrading – defined as “improving the physical environment, for example the water supply, sanitation, waste collection, electricity, drainage, road paving and street lighting” (p.3) may reduce the incidence of diarrheal diseases [ 34 ]. Moderate quality evidence was found for that supplementary feeding improving the physical growth of middle income children as compared to slum-dwelling children in India; authors opine that the differential effects may have been due to poor environmental conditions for slum-dwelling children that in turn decreased the effectiveness of the intervention [ 35 ]. Moderate quality evidence showed that the Sanitation Hygiene Education and Water Supply in Bangladesh (SHEWA-B) programme resulted in little to no difference on diarrhea prevalence among children (aged < five years) living in urban slums [ 37 ].
Moderate quality evidence indicated beneficial effect of nutritional interventions on length at birth and low birth weight (LBW); however, low quality evidence indicated that the interventions may reduce stunting in infants and children below five years of age in locations outside slum areas [ 39 ]. The review by Lassi et al. (2016) found that there was low quality evidence that zinc supplementation may reduce the incidence and prevalence of pneumonia among children under five years in low-income urban areas in LMIC contexts, including slums in India [ 36 ].
A qualitative review of factors influencing antenatal care (ANC) visits found that pregnancy was seen as a healthy condition by women in a slum in Dhaka that rendered ANC visits unnecessary, and this finding was based on high confidence in the evidence [ 38 ].
Interventions relevant to urban poor populations in general
Among the included SRs, 14 reviews were on nutritional interventions, 15 on community health services (e.g., immunization) and health promotion, while three reviews were on water sanitation and hygiene (WASH) and one on slum upgrading. Findings from these reviews are summarized below.
Nutritional interventions
Most reviews reported on nutrient supplementation for improving MCH. Some interventions assessed supplementation (lipid-based nutrients, vitamin A, vitamin D), others looked at fortification, and the remaining examined supplementary feeding.
Child growth
Moderate quality evidence indicated that lipid-based nutrient supplements (LNS) (given to pregnant women) might be of slight benefit to babies who are born small, as well as on newborn weight and length compared to iron-folic acid (IFA) [ 40 ]. In another review, low quality evidence indicated that multiple micronutrient (MMN) fortification may improve child growth, measured as a weight for age and height/length [ 41 ]. Low quality evidence showed that micronutrient or macronutrient supplementation of children (birth to 59 months) had little to no effect on height for age (HFA) and on length. There was no evidence of an effect of zinc supplementation given to pregnant women on LBW and length [ 39 ]. Low quality evidence from another review suggested that supplementary feeding had little to no effect on child growth in children under five years [ 42 ].
Very low quality evidence indicated that providing additional food to children aged three months to five years may lead to small gains in weight (0.24 kg a year) and height (0.54 cm a year) [ 35 ]. Specifically, this review indicated that “Supplementary feeding young children has a small effect on gain in weight and weight-for-age z-scores (WAZ) in low- and middle-income countries… Supplementary feeding for young children has a small effect on linear growth in low- and middle-income countries… Supplementary feeding may have a moderate positive effect on psychomotor development in low- and middle-income countries… The evidence of effects on cognitive development in low- and middle-income countries is sparse and mixed….” [ 35 ] Limited evidence suggested little to no effect of animal-source food compared to cereal products or no intervention on growth outcomes of children [ 43 ]. Another SR showed that compared to specially formulated fortified foods, LNS might be slightly more effective in aiding recovery from MAM and effective in weight gain among children aged 6 to 59 months [ 44 ]. Low to moderate quality evidence showed that nutrition education to families about appropriate feeding practices during weaning may slightly improve weight and height at 12 months of age [ 27 ].
Anemia and vitamin deficiency
Moderate quality evidence suggested that IFA and MMN likely resulted in a decrease in maternal anemia compared to LNS [ 40 ]. Low quality evidence indicated that fortified rice with only iron or in conjunction with other micronutrients might make little to no difference to the risk of having anemia. However, the intervention might decrease the risk of iron deficiency in children, non-pregnant and non-lactating women [ 45 ]. Low quality evidence from another review indicated that MMN fortification may reduce anemia, iron deficiency anemia, and other micronutrient deficiencies slightly in infants, children, pregnant women [ 41 ]. Fortifying staple foods with vitamin A alone may have little to no difference to the risk of having subclinical vitamin A deficiency, but the evidence is very uncertain [ 46 ]. Compared with the provision of unfortified foods, the provision of staple foods fortified with vitamin A plus other micronutrients may decrease the risk of subclinical vitamin A deficiency, but the evidence is very uncertain. Similarly, there is very uncertain evidence that staple foods fortified with vitamin A plus other micronutrients may reduce the risk of subclinical vitamin A deficiency compared with no intervention [ 46 ].
Malnutrition and infections
Moderate quality evidence indicated that LNS likely led to a clinically significant benefit in the number of children recovering from malnutrition compared with blended foods [ 47 ]. Kramer and Kakuma (2012) reported that exclusive breastfeeding (EBF) for six months led to a decreased risk of gastrointestinal infection, and there were no deficits in growth among infants; however, this was based on low quality evidence [ 17 ]. Low to moderate quality evidence suggested that children (between six months of age and five years) with moderate acute malnutrition were found to recover from moderate acute malnutrition when given specially formulated foods such as both LNS and blended foods when compared to standard care (medical care and counselling without food) [ 47 ]. Low to very low quality evidence indicated that vitamin D supplementation did not reduce the incidence of pneumonia and diarrhea among children under five years of age [ 48 ].
Morbidity and mortality
Moderate quality evidence suggested that vitamin A supplementation (VAS) given to infants in the 1–6 months age group likely did not reduce mortality or morbidity [ 49 ]. In a review that included neonates at birth, high quality evidence suggested that VAS did not reduce mortality at 12 months of age. However, as per region-specific analyses, there was a significant decrease in the risk of death at six months among children in Asia, compared to no impact to a 21% rise in mortality risk in Africa [ 50 ]. For the outcome of diarrhea-related death, there was a high quality evidence that VAS significantly reduced (12%) mortality risk in the 6–59 month age group when compared to placebo or usual care [ 51 ]. Moderate quality evidence indicated that LNS likely did not decrease mortality or progression to severe acute malnutrition when compared with blended foods [ 47 ].
Community health services and health promotion
Community health services and health promotion interventions carried out in a wide range of contexts have shown some impact on a range of disease conditions.
Moderate quality evidence indicated that the administration of anthelminthic (or co-interventions) for soil-transmitted Helminth (STH) infections during the second or third trimester of pregnancy likely resulted in little to no difference on preterm births or perinatal deaths [ 52 ]. Moderate to high quality evidence indicated that neither single nor combined interventions reduced maternal deaths even as the latter strategy increased antenatal visits [ 53 ].
Low quality evidence showed that Integrated Management of Childhood Illness (IMCI) strategies including post-natal home visits may lead to lower neonatal and infant mortality [ 54 ]. Low quality evidence indicated that community-based delivery of antibiotics may slightly reduce neonatal mortality by treating neonatal Possible Severe Bacterial Infections (PSBI) as compared to standard care [ 55 ]. Community health educational interventions had a significant impact on decreasing overall neonatal mortality, early neonatal mortality, late neonatal mortality, and perinatal mortality; however, the quality of evidence varied from very low to low [ 56 ]. A systematic review examined community-based interventions (media campaigns, education, financial incentives for pregnant women to attend ANC care) and health systems interventions (including home visits for pregnant women by community health workers (CHWs). Low to moderate quality evidence indicated that single or combined interventions did not reduce the rates of perinatal or neonatal deaths [ 53 ].
High quality evidence showed that single community-based interventions and health systems interventions (including home visits for pregnant women by CHWs) did not reduce LBW [ 53 ]. Although, more women who got combined interventions had one or more antenatal visits, there were fewer LBW babies associated with combined interventions [ 53 ].
Low quality evidence suggested that nutritional education interventions given to pregnant women may slightly improve LBW compared to standard care or no intervention [ 39 ]. Another review reported that nutrition education given to pregnant women was found to slightly increase head circumference at birth. While birth weight among undernourished women improved, it did not significantly increase in the case of adequately nourished women [ 18 ]. Low to moderate quality evidence indicated that educational interventions improved complementary feeding and hygiene practices. However, it was reported that education improved the duration of EBF with community-based interventions but not with health facilities-based community-based interventions. The evidence was uncertain on the effect education on children’s’ growth [ 16 ]. Targeted client communication via mobile devices (TCCMD) may increase exclusive breastfeeding in settings where rates of exclusive breastfeeding are less common but have little or no effect in settings where almost all women breastfeed (low certainty in evidence). Low quality evidence showed that TCCMD may slightly increase EBF in settings where rates of EBF are less common but have little or no effect in settings where almost all women breastfeed [ 28 ].
Vaccination status and uptake
Moderate quality evidence showed that IMCI strategies including post-natal home visits had little to no impact on measles vaccine coverage [ 54 ]. In another review, moderate quality evidence indicated that the use of LHWs was found to promote immunization uptake among children [ 57 ]. Low to moderate quality evidence suggested that face-to-face education may slightly improve the vaccination status of children and parents’ knowledge and their intention to vaccinate [ 58 ]. Limited and low quality evidence indicated that health education at home/village meetings probably led to an uptake of three doses of Diphtheria-Tetanus-Pertussis (DTP3) vaccines by more children [ 59 ]. There was evidence that providing information regarding the significance of vaccinations to parents during visits to the clinics and redesigned reminder cards on vaccination may enhance the uptake of three doses of the DTP3 vaccine [ 59 ].
Anemia and Infectious diseases
Low quality evidence suggested that monthly administration of sulphadoxine-pyrimethamine (SP) was found to decrease maternal parasitemia and placental parasitemia at the time of delivery in HIV-positive pregnant women in their first or second pregnancy, living in malaria-endemic areas [ 60 ]. Low quality evidence showed that the administration of antihelminthics (or co-interventions) for STH infections during the second or third trimester of pregnancy on maternal anemia and pregnancy outcomes had little to no effect on maternal anemia in the third trimester [ 52 ].
Integration of HIV/AIDS and MNCHN-FP (Maternal, Neonatal and Child Health, Nutrition, and Family Planning) services likely had positive effects on contraceptive use, HIV testing, initiation of antiretroviral therapy in pregnancy; however, the quality of the evidence was low [ 61 ]. Low to moderate quality evidence indicated that educational programmes as single interventions probably had little to no effect on HIV, STI, and pregnancies among adolescents [ 62 ].
WASH (Water Sanitation and Hygiene) and Health Promotion
Diarrhoea incidence and prevalence.
Low to very low quality evidence indicated that education and hygiene promotion interventions with messages on disposal of child faeces might decrease diarrhea incidence by nearly 30% but did not affect diarrhea prevalence [ 37 ]. Evidence from interventions that addressed child faeces as part of a broader intervention directed at ending open defecation by all household members did not find an effect on diarrhea prevalence or STH infection [ 37 ]. Further, evidence showed that sanitation hardware (such as potties) and interventions relating to behavior change had mixed results on diarrhea prevalence, although no effect was seen [ 37 ]. Findings from the updated SR also reported that hand-washing promotion probably reduced diarrhea episodes by about 30% among communities living in LMICs [ 26 ]. Low quality evidence found that handwashing promotion may prevent almost 30% of diarrhea episodes in schools and about 28% of diarrhea episodes in communities in LMIC s [ 63 ].
Low quality evidence based on short-term studies indicated that WASH interventions (particularly provision of soap, solar disinfection of water, and improvement of water quality) showed a marginal benefit on linear growth of children aged under five years [ 64 ]. It was further reported that WASH interventions (specifically solar disinfection of water, provision of soap, and improvement of water quality) were shown to slightly improve height-for-age z-scores in children under five years of age [ 64 ]. Limited and low quality evidence showed no effect of slum upgrading on infant mortality but found that multicomponent slum upgrading led to a marginal reduction in the proportion of underweight children [ 34 ].
This overview examined interventions addressing MCH among urban poor populations, including homeless people in LMICs. It must first be mentioned that given the variation in definition and operationalization of populations, interventions and outcomes of interest, direct comparisons are likely to be misleading. We found no direct relevant evidence for pregnant and lactating homeless women (and children) in the reviewed literature. Most SRs that evaluated interventions relating to pregnant and lactating homeless women were conducted in HICs, which indicates a need to conduct more research in this domain in LMICs.
The results showed that there was mixed evidence of effect of slum upgrade, sanitation education and nutritional interventions on improving outcomes in urban poor pregnant and lactating women (and children) in LMICs [ 34 , 36 , 37 , 39 ]. The range of nutritional interventions and outcomes varied across the SRs, making comparisons difficult. Mixed quality evidence showed that the range of nutritional interventions had little to no effect on child growth [ 35 , 39 , 40 , 41 , 42 , 43 ]. Evidence indicated that MAM was treated effectively with LNS and blended foods [ 47 ]. However, evidence from Africa suggested that LNS compared to specially formulated fortified foods might be slightly more effective in aiding recovery from MAM and in weight gain among children aged 6 to 59 months [ 44 ]. There could be a host of reasons or confounders for this including the geographic context, the (base nutritional) content of blended foods and nutritional status of mothers during pregnancy. Supplementation combined with vitamins and minerals would help improve maternal and infant health rather than specific nutrients alone; however, outcomes varied by population, as a reduction in LBW rates was reported among adolescent pregnant women [ 65 ].
Supplementary feeding had little or negligible impact on the growth of children under five years of age [ 35 , 42 , 66 ]. However, supplementary feeding was found to be effective in terms of height and weight gain in children younger than two years old and more effective among poorer and less well-nourished children [ 66 ]. Evidence regarding the impact of MMN on anemia was mixed [ 40 , 41 , 45 ]. Other SRs found no significant benefit or differential impact of MMN compared to iron folate on third-trimester maternal anemia [ 67 , 68 ]. Evidence indicated that child-feeding interventions were underperforming, with responsiveness to supplementary feeding being more among poorer and undernourished children. Supplementary feeding would be more effective if it is provided under supervision in a feeding centre, day care centre, or preschool. Children at day care centers or preschools had more benefit from the supplement [ 35 ].
There was no evidence of a reduced risk of mortality due to neonatal VAS on children less than one-year-old [ 49 , 50 , 68 ]. Similar findings were reported from another SR, with data from developed countries that showed that VAS had no effect in decreasing all-cause mortality in infants 1–6 months of age [ 69 ]. Based on data from developing countries, it was found that VAS reduced all-cause mortality (by 25 per cent) as well as diarrhea specific mortality (by 30 per cent) among children in the 6 to 59 months age group [ 70 ]. Another SR based on data from Asia, Africa and Latin America) showed that in children under 5 years old, VAS was associated with a decrease in diarrhea-related mortality (28 per cent) and a decrease in all-cause mortality (24 per cent) [ 71 ]. Further, the benefits of supplementation on mortality were seen to be greater in Asia compared to Africa and Latin America [ 71 ].
Vitamin D supplementation had no benefit on the incidence of pneumonia, [ 48 ] and in children under five with acute pneumonia [ 72 ]. Evidence from studies conducted in developing countries reported that factors such as accessibility (location, distance and transport), affordability (financial constraints) and cultural barriers constrained the uptake of ANC services [ 73 ]. Two SRs, one with evidence from Ethiopia [ 74 ] and another SR based on evidence from Sub Saharan Africa [ 75 ] found that urban residence, and women’s and husband’s education were associated with uptake of ANC services.
Three or more doses of sulphadoxine-pyrimethamine given to HIV positive women may have a marginal effect on the prevalence of maternal anemia and the number of LBW babies, [ 60 ] and IPT with three or more doses of SP was associated with higher birth weight and lower risk of LBW compared to standard 2-dose regimens among both HIV infected and uninfected women in sub-Saharan Africa [ 76 ]. Lindegren et al. (2012) reported a positive impact of integrating HIV/AIDS and MNCHN-FP services across settings [ 61 ]. This overview did not find any other literature on similar models of integrated services, but the included SRs showed that the integration of services may be feasible [ 77 , 78 ]. Evidence from LMICs in Africa, the Caribbean, Europe, Asia that looked at strengthening linkages between FP and HIV interventions found that interventions that included a community component were feasible and effective [ 78 ].
There was mixed evidence on the effect of mass media campaigns and education on the uptake of ANC services [ 53 ]. Similar to the findings from Lewin et al.’s (2010) review [ 57 ], two other SRs, one based on studies from LMICs in Asia, Africa, and North America [ 79 ] and another based on findings from Brazil [ 80 ] found that CHW interventions were effective in improving breastfeeding [ 79 , 80 ] as well as in reducing neonatal mortality in South Asian countries [ 81 ]. Continued uptake of ANC services depends on the positive experience of pregnant women with the health system, such as providing good quality, culturally sensitive services; however, barriers may include the indirect cost of services such as transport to the facility, cultural barriers relating to restrictions on movement, and lack of privacy [ 38 ].
The evidence on the impact of educational interventions on growth outcomes was mixed and generally of low quality, which indicated that educational interventions slightly improved immunization uptake and that redesigned reminder cards may enhance immunization uptake. In comparison, an SR suggested that educational interventions significantly increased childhood immunization uptake in LMICs, compared to HICs where the intervention was not consistently effective [ 82 ]. Evidence from both LMICs and developed countries indicated a positive impact of reminder strategies on immunization [ 82 , 83 ]. Another SR found that breastfeeding education increased EBF rates, resulting primarily from community-based interventions, with those from LMICs showing a greater impact compared to HICs [ 84 ].
The effect of handwashing on diarrheal episodes differed based on location (school/community), specifically incidence. Evidence from less developed countries showed that handwashing reduced diarrhea illness [ 85 ], another SR conducted in HICs and LMICs found that handwashing promotion resulted in higher reduction of diarrhea than broader hygiene education [ 86 ]. Evidence from LMICs showed a significant association between WASH interventions and child growth [ 87 ] while another SR based on LMICs indicated that WASH interventions resulted in some reduction to no change in mortality [ 88 ].
The varying reportage of risk of bias for overlapping studies in different SRs was noted in this overview. It highlighted the need for greater rigour and consistency in the quality appraisal of reviews. The main limitation of our overview was the non-use of search terms related to individual LMIC countries. This may have resulted in the omission of some SRs. Further, given the relative dearth of literature, we are now persuaded to attempt a review rather than an overview for our population of interest, urban poor women and children as the literature is not as deep as we had anticipated when we began the overview. We had constraints of time in this exercise and moreover, were interested in the diversity of populations covered in existing reviews of MCH interventions (which we found to be quite poor!) [ 89 ].
There are some key policy implications of these findings. For one, the review suggests that even as MCH interventions have been the mainstay of public health interventions for decades; rather little is known about their impact on urban poor and homeless populations. Even as there remains work to be done with MCH interventions overall - in neglected areas like family planning, safe abortion care, and postpartum care of mothers- there is a need to generate primary evidence on what interventions work for urban poor and particularly homeless families.
This review cast a wide net to try to see what interventions work for the MCH needs of the urban poor and homeless. Overall, the review did not find directly relevant information for the homeless. As regards the general urban poor population, there was a lack of emphasis on evidence related to family planning, safe abortion care, and postpartum care of mothers. There was mixed quality evidence that the range of nutritional interventions had little, unclear or no effect on several child mortality and development outcomes. From a policy perspective, this suggests that more research would be needed before promoting such interventions for urban homeless people. Interventions such as WASH, ensuring acceptability of community health services and health promotion type programs could be regarded as beneficial, although location seemed to matter. Overall, the generalizability of findings was poor, and there is a clear need for rigorous primary research on MCH interventions among the urban poor and homeless.
Data availability
All relevant data analysed during this review are included in this published article. Other relevant information extracted and analysed (such as data extraction tables) during the current review are available from the corresponding author on reasonable request.
Abbreviations
A Measurement Tool to Assess Systematic Reviews
Antenatal Care
Community Health Workers
Diphtheria-Tetanus-Pertussis
Exclusive Breastfeeding
Grading of Recommendations, Assessment, Development and Evaluations
Height for Age
Height-for-Age Z scores
High-Income Countries
Iron-Folic Acid
Integrated Management of Childhood Illness
Joanna Briggs Institute
Length-for-Age Z scores
Lipid-based Nutrient Supplements
- Low- and Middle-Income Countries
Low Birth Weight
Maternal and Child Health
Maternal, Neonatal And Child Health, Nutrition, and Family Planning
Multiple Micronutrient
Possible Severe Bacterial Infection
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Randomized Controlled Trials
Sustainable Development Goals
Sanitation Hygiene Education and Water Supply in Bangladesh
Systematic Reviews
Soil-Transmitted Helminth
Targeted Client Communication via Mobile Devices
Vitamin A Supplementation
Water Sanitation and Hygiene
Weight-for-Age Z scores
World Health Organization
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Devaki Nambiar
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Nambiar, D., Mathew, B., Dubey, S. et al. Interventions addressing maternal and child health among the urban poor and homeless: an overview of systematic reviews. BMC Public Health 23 , 492 (2023). https://doi.org/10.1186/s12889-023-15410-7
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Maternal depression during pregnancy and postpartum period among the association of southeast asian nations (asean) countries: a scoping review.
1. Introduction
2. methods and materials, 3.1. literature search, 3.2. characteristics, measurement, and prevalence of ad, 3.3. characteristics, measurement, and prevalence of pd, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.
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Share and Cite
Hong, S.A.; Buntup, D. Maternal Depression during Pregnancy and Postpartum Period among the Association of Southeast Asian Nations (ASEAN) Countries: A Scoping Review. Int. J. Environ. Res. Public Health 2023 , 20 , 5023. https://doi.org/10.3390/ijerph20065023
Hong SA, Buntup D. Maternal Depression during Pregnancy and Postpartum Period among the Association of Southeast Asian Nations (ASEAN) Countries: A Scoping Review. International Journal of Environmental Research and Public Health . 2023; 20(6):5023. https://doi.org/10.3390/ijerph20065023
Hong, Seo Ah, and Doungjai Buntup. 2023. "Maternal Depression during Pregnancy and Postpartum Period among the Association of Southeast Asian Nations (ASEAN) Countries: A Scoping Review" International Journal of Environmental Research and Public Health 20, no. 6: 5023. https://doi.org/10.3390/ijerph20065023
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Women’s empowerment related to pregnancy and childbirth: introduction to special issue
- Ndola Prata 1 , 2 ,
- Paula Tavrow 1 , 3 &
- Ushma Upadhyay 1 , 4
BMC Pregnancy and Childbirth volume 17 , Article number: 352 ( 2017 ) Cite this article
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Empowerment is widely acknowledged as a process by which those who have been disempowered are able to increase their self-efficacy, make life-enhancing decisions, and obtain control over resources [ 1 , 2 , 3 ]. In addition, empowerment is multi-dimensional – a woman may be empowered in one dimension or sphere (such as financial) but not in another (such as in sexual and reproductive decision-making). Most countries now recognize the importance for girls and women to become more empowered, both as a goal in itself, as well as to achieve a more gender equitable society [ 4 ]. More recently, researchers have been assessing the contexts and mechanisms by which empowerment directly or indirectly affects various aspects of women’s health [ 5 , 6 , 7 ]. A better understanding of the situations where greater empowerment is associated with improved health outcomes can assist policymakers in planning and prioritizing their investments.
Although associations between women’s empowerment and some aspects of their health, such as fertility and contraception, have been studied fairly extensively and seem to be mostly positive [ 6 , 8 , 9 ], the relationship between women’s empowerment and pregnancy or childbirth, including abortion, has not received sufficient attention. Moreover, empowerment measures still need to be critically evaluated [ 10 , 11 ] and to encompass a range of potential empowerment domains – psychological, social, political, economic and legal [ 8 , 9 , 12 , 13 ]. The purpose of this special issue in BMC Pregnancy and Childbirth is to bring a multidisciplinary lens and varied methodologies to the central question of how women’s empowerment relates to pregnancy and childbirth. By highlighting women’s health concerns, rights, and empowerment, this special issue aims to catalyze societal-level changes that will yield sustainable improvements in health and well-being for women on a global scale.
This special issue is sponsored by the Women’s Health, Gender, and Empowerment Center of Expertise (COE), a part of the University of California Global Health Institute. The COE is comprised of faculty, staff and students from across the campuses of the University of California, along with practitioners and international partners. The COE promotes research, education, and community engagement at the intersection of health and empowerment in the US and globally. Collectively, it represents a wide variety of disciplines and approaches to improving women’s health and empowerment.
In the fall of 2015, the COE put out an open call for long abstracts from multiple disciplines on the role of women’s empowerment on pregnancy and childbirth. We received a total of 52 submissions, which were evaluated by all managing editors using several criteria, including strength of the empowerment construct, methodology, clarity, significance, innovation, and suitability for the supplement. The top 16 submissions were invited to submit full papers. All selected articles included a construct that is conceptualized as women’s empowerment, defined broadly. To further develop and share ideas concerning the articles for this issue, the COE conducted a one-day research workshop, which was partially funded by the National Institutes of Health, National Center for Advancing Translational Sciences, University of California, Los Angeles, Clinical and Translational Science Institute (NIH NCATS UCLA CTSI Grant Number UL1TR000124). Members of the COE submitting full papers had the opportunity to give an oral presentation presenting their study’s aims and methods, receive feedback and guidance on how to improve their study’s conceptualization, hear about other scholars’ work for this special issue, and network with others interested in these topics. A total of 12 papers successfully went through peer review and were accepted for this special issue [ 14 ].
The 12 studies included in this special issue apply methodologies from different disciplines – anthropology, sociology, law, demography, and public health – to provide empirical data on an aspect of women’s empowerment during a critical period of the reproductive life-course. The authors were also asked to discuss how their research results could affect future policies and programs. We have grouped the articles into three main subject areas, namely (1) fertility, family planning, and abortion; (2) antenatal care, delivery, and the perinatal period; and (3) maternal health and mortality.
Empowerment and fertility, family planning, and abortion
Gipson and Upchurch [ 15 ] tried to understand intergenerational transmission of women’s empowerment by examining the influence of maternal status on the reproductive health outcomes of their daughters in the Philippines. They found that maternal empowerment was an important determinant of daughters’ timing of sexual debut, where greater empowerment led to delayed sex, regardless of whether contraception was used. However, maternal empowerment was not predictive of daughters' reports of unintended pregnancy. The authors concluded that more research is needed to better understand the intervening mechanisms between onset of sexual activity and unintended pregnancy.
While most researchers examine the impact of women’s empowerment on reproductive outcomes, Samari [ 16 ] flipped the question and innovatively investigated the impact of childbearing on women’s empowerment trajectories in Egypt. She discovered that, for a young woman, giving birth is associated with increased empowerment; the first birth and each subsequent birth predicted improvements in all measures of empowerment (individual household decision-making, joint household decision-making, and mobility), except one (financial autonomy). She also found that empowerment earlier in a woman’s life is a predictor of subsequent empowerment in life.
In her paper, McReynolds-Pérez [ 17 ] focused on Argentina, where abortion is legally restricted. Using ethnographic methods, she described the strategies used by activist healthcare providers to apply the health exception to extend the range of legal abortion. She showed how the providers conceptualized their work as opening opportunities for women to exercise their reproductive autonomy.
Mandal et al. [ 18 ] make a methodological contribution in their review of the measures of empowerment and gender-related constructs used to evaluate family planning and maternal health programs in low- and middle-income countries. Their review covered 16 program evaluations, of which only a minority used a validated measure of a gender construct. The authors recommended that future evaluations test for a clear causal pathway from program participation to an intermediary measure of gender, to the ultimate family planning or maternal health outcome that the intervention intends to improve.
Empowerment and antenatal care, delivery, and the perinatal period
In many countries, during childbirth, women experience some form of mistreatment such as abuse, neglect, rudeness, or discrimination. Diamond-Smith et al. [ 19 ] were interested in assessing whether women in the slums of Lucknow, India, who held more gender equitable views were less likely to be mistreated. They hypothesized that empowerment could be a protective mechanism. Using the Gender Equitable Men (GEM) Scale to measure women’s views of gender equality, they found that women who had more equitable views about the role of women were less likely to report experiencing mistreatment during childbirth. Interestingly, they also discovered that the wealthiest slum women reported more mistreatment and had lower GEM scores. It is not known whether wealthier women were more likely to have higher expectations of quality, perceive slights, or experience more mistreatment. Those with higher GEM scores may be more assertive in obtaining proper treatment during childbirth.
Hoffkling et al. [ 20 ] present a rare look at the experience of transgender men in the United States who retained their uteruses, became pregnant, and gave birth. Based on in-depth interviews with 10 transgender men, the authors noted that becoming pregnant was at times an empowering act, but the experience was often difficult and alienating due to the lack of role models, transphobia and violence, insufficient training among providers, and lack of research on testosterone and pregnancy. The authors described how patient strategies and healthcare provider behaviors affected their sense of empowerment. In the end, the authors provided specific recommendations for how providers and clinics can deliver appropriate care to transgender men during the pre-transition, pre-conception, prenatal, and postpartum periods.
The objective of McGowan et al.’s [ 21 ] paper was to test the effect of the Centering Pregnancy model of group antenatal care on women’s empowerment, compared to standard individual antenatal care. The Centering Pregnancy model encompasses interactive learning and community-building, along with short individual consultations four times during a pregnancy. To assess the impact on empowerment in Malawi and Tanzania, the authors used the Pregnancy-Related Empowerment Scale, which evaluates the connectedness women feel with their caregivers, their participation in decision-making, and whether they engage in pregnancy-related healthy behaviors. They found that Centering Pregnancy seems to be empowering in Malawi, but not in neighboring Tanzania, suggesting that the model is context-dependent and may be empowering in situations where women have less access to other forms of communication, including cell phones.
Garcia and Yim [ 22 ] conducted a systematic review of studies on empowerment and interventions aimed at improving empowerment in the perinatal period. They described findings from 27 articles focusing on perinatal depressive symptoms or premature birth. All of the observational studies found significant associations between empowerment and depressive symptoms. The interventions were predominantly based on introducing the Centering Pregnancy model and most were successful in reducing preterm birth or low birthweight, but only interventions that provided women with coping skills for future stressors reduced women’s perinatal depressive symptoms.
In their literature review, Afulani et al. [ 23 ] examined the links between women’s empowerment and prematurity. Although they did not find evidence supporting a direct link between women’s empowerment and prematurity, they did identify some studies that linked empowerment to factors known to be associated with prematurity and outcomes for premature babies, namely (1) preventing early marriage and promoting family planning, which will delay first pregnancy and increase inter-pregnancy intervals; (2) improving women’s nutritional status; (3) reducing domestic violence and other factors associated with stress; and (4) promoting use of recommended health services during pregnancy and delivery to help prevent prematurity and improve survival of their babies. Thus, improving women’s empowerment could potentially prevent prematurity, but definitive proof is still lacking.
Empowerment and maternal health and mortality
In their article, Shimamoto and Gipson [ 24 ] examined the mechanisms by which women’s status and empowerment affect skilled birth attendant use in West Africa. They found the structural equation modeling approach to be useful in examining the complex and multidimensional constructs of women’s empowerment and their effects. Despite variations across measures, many of the women’s status and empowerment variables were positively associated with skilled birth attendance. In particular, women’s education demonstrated a substantial indirect effect, and higher education was related to older age at first marriage, which in turn was associated with higher levels of empowerment and the use of skilled birth attendants. Interestingly, the authors did not find significant associations between household decision-making and the use of skilled birth attendance.
It is commonly believed that greater women’s empowerment will lead to improvements in their health, particularly in areas where disparities are highest such as maternal mortality. To test this assumption, Lan and Tavrow [ 25 ] sought to assess various gender composite measures to determine if they were associated with reduced mortality at the national level, after controlling for other macro-level and direct determinants. They used data from 44 low-income countries, half of which are in Africa. After controlling for all measures, they found that none of the composite measures of gender equality were significantly linked to maternal mortality in these countries. Rather, skilled birth attendance was the main factor associated with maternal mortality in non-African countries, and perceptions of corruption were most linked to mortality in African countries, where mortality is highest. They concluded that improving gender equality and even skilled birth attendance is unlikely to reduce maternal mortality in Africa unless corruption is addressed.
Laws and social norms can interact to disempower women, or they can be used to empower them. In addition, laws often have a norm-setting function. In their paper, Dunn et al. [ 26 ] analyzed the impact of international and domestic decisions on access to high quality reproductive healthcare, showing that human rights litigation can support other efforts to achieve better care for women. They discussed several case studies in which national courts in countries such as Uganda, as well as international treaty bodies, have challenged traditional structures that discriminate against women. They argued that human rights litigation is a women’s empowerment strategy that needs greater attention, because they found that cases like Alyne v. Brazil brought public awareness about discrimination against poor or marginalized women in the health system and provided leverage to civil society to make changes. Indeed, human rights litigation often complements political and social movements and provides momentum to bring change.
Through an overview of the collection of articles as a whole, the key findings were:
Fertility, pregnancy and abortion
Fertility decline does seem to be linked to better well-being for women, but patriarchal gender norms can inhibit its impact. Just as empowerment seems to affect health, women who start childbearing later are more likely to show more gender equitable attitudes. When mothers are empowered, their daughters are less likely to have sex at a young age, but they still have the same rates of unintended pregnancies. Among slum women, higher rates of expressed empowerment are correlated with lower levels of mistreatment by health providers during delivery. Providers who are themselves empowered can actively expand women’s access to abortion, even in countries where it is legally restricted. Overall, gender-integrated interventions related to family planning and maternal health are not evaluated with sufficiently consistent and validated measures of women’s empowerment to know if they are having the intended impact.
Antenatal care, delivery, and the perinatal period
In some contexts, group antenatal care can be more empowering to women than the standard of care, possibly because it increases communication and learning among a peer group. Pregnant women who feel empowered through better coping skills prior to birth seem less likely to suffer from postpartum depression. For transgender men who give birth, culturally competent and caring providers can help to make the experience more empowering, although transphobia in society can make these men feel alienated and anxious. While a direct link cannot be found between disempowerment and low birthweight or premature births, the same programs that empower women (such as programs to reduce intimate partner violence) can also be expected to reduce prematurity.
Maternal health and mortality
Women who are more empowered are more likely to use skilled birth attendants, which could be expected to lower maternal mortality. However, in Africa, women’s empowerment may not lead to changes in maternal mortality rates if health systems remain corrupt. Litigation can be an empowering strategy globally if it reframes maternal mortality as discriminatory and changes public norms.
In summary, this special issue provides a platform for examining the relevance of empowerment to various features of women’s (and transgender men’s) experiences of pregnancy and childbirth across the globe. While women’s empowerment itself still needs further conceptualization, this special issue broadens the range of health outcomes that are often associated with empowerment, provides insights into the current state of knowledge and research, and points to the importance of considering and measuring empowerment when designing and implementing programs.
We express our deepest gratitude to Chiao-Wen Lan for managing all steps of the editorial process and ensuring that the authors received constructive, impartial reviews. We are also grateful for the time and invaluable comments provided by the peer reviewers of this special issue (those reviewers with an asterisk are also members of the COE):
Onyema Afulukwe, Center for Reproductive Rights
Koki Agarwal, Jhpiego – an affiliate of Johns Hopkins University
Saifuddin Ahmed, Johns Hopkins University
Meg Autry,* University of California, San Francisco
Sarah Baum, Ibis Reproductive Health
Joelle Brown,* University of California, San Francisco
Julianna Deardorff, University of California, Berkeley
Teresa DePineres, Fundación Oriéntame/ESAR
Shari Dworkin,* University of California, San Francisco
Linda Franck,* University of California, San Francisco
Caitlin Gerdts, Ibis Reproductive Health
Sarah Jane Holcombe,* University of California, Berkeley
Rana Marie Jaleel,* University of California, Davis
Randall Kuhn, University of California, Los Angeles
Andrzej Kulczycki, University of Alabama, Birmingham
Susan Meffert,* University of California, San Francisco
Deborah Mindry,* University of California, Los Angeles
Corrina Moucheraud,* University of California, Los Angeles
Kavita Singh Ongechi, University of North Carolina at Chapel Hill
Bhavya Reddy, Public Health Foundation of India
Lara Stemple,* University of California, Los Angeles
Kirsten Stoebenau, American University
Dallas Swendeman,* University of California, Los Angeles
Charlotte Warren, Population Council
Sheri Weiser,* University of California, San Francisco
Mellissa Withers,* University of Southern California
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This article is part of a special issue on women’s health, gender and empowerment, led and sponsored by the University of California Global Health Institute, Center of Expertise on Women’s Health, Gender, and Empowerment.
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Maternal deaths in the U.S. spiked in 2021, CDC reports
In 2021, the U.S. had one of the worst rates of maternal mortality in the country's history, according to a new report from the Centers for Disease Control and Prevention. The report found that 1,205 people died of maternal causes in the U.S. in 2021. That represents a 40% increase from the previous year.
These are deaths that take place during pregnancy or within 42 days following delivery, according to the World Health Organization .
The U.S. rate for 2021 was 32.9 maternal deaths per 100,000 live births, which is more than ten times the estimated rates of some other high income countries , including Australia, Austria, Israel, Japan and Spain which all hovered between 2 and 3 deaths per 100,000 in 2020.
According to data from the World Health Organizatio n, the maternal mortality rate in high-income nations overall was 12 per 100,000 live births in 2020, while in low-income countries it was 430 per 100,000.
International comparisons of maternal deaths are difficult because of differences in methodology in tracking the data, warns the author of the new U.S. report, Donna Hoyert, a health scientist at the National Center for Health Statistics, at the CDC. But, she notes, the U.S. is "usually not faring all that well" on maternal mortality.
"There is just no reason for a rich country to have poor maternal mortality," says Eileen Crimmins , professor of gerontology at the University of Southern California. The CDC's latest compilation of data from state committees that review these deaths found that 84% of pregnancy-related deaths in the U.S. were preventable.
The increase in maternal mortality in 2021 was "seen broadly across different age groups and race and Hispanic-origin groups," says Hoyert.
She connects the increase in maternal deaths to the COVID-19 pandemic.
"We had some forewarning with the increase between 2019 and 2020 that it looked like maternal mortality rates were increasing during this pandemic period," she says. "With the overall COVID deaths that occurred in 2021, there was a shift towards younger people, so those would be in the age groups where people would be more likely to be pregnant or recently pregnant."
She says provisional data suggest the deaths peaked in 2021 and started to go down last year. "So hopefully that's the apex," Hoyert says.
Yet some experts worry that other trends around the country could make these figures worse, not better, including abortion restrictions that c an delay care for pregnancy complications , and staffing problems at hospitals and closures of rural maternity wards.
The maternal death rate among Black Americans is much higher than other racial groups; in 2021 it was 69.9 per 100,000, which is 2.6 times higher than the rate for White women.
Dr. Veronica Gillispie-Bell , an OB-GYN at Ochsner Health in Louisiana who works with the state's health department to investigate maternal deaths, says social factors, not biological ones, fuel the racial gap. "We have to address the social factors that either are barriers to accessing care or that make your medical conditions worse coming into the pregnancy," she says. "This is not just about doctors in the hospital."
Louisiana is among a group of states working with the Centers for Disease Control and Prevention to improve processes in the health care system to prevent maternal deaths and reduce racial disparities. Gillispie-Bell says she's optimistic the efforts will pay off, but "it's not something that happens overnight. It's going to be a while before we see the benefits of that change."
Change can't come soon enough for families whose lives are affected. Wanda Irving's daughter died from complications of high blood pressure just three weeks after giving birth to a baby girl in 2017. Irving, who has spoken to NPR in the past about her daughter, now runs an organization called Dr. Shalon's Maternal Action Project to raise awareness of the risks for Black mothers in particular.
Irving's daughter, Shalon Irving , was an accomplished scientist, working as an epidemiologist at the CDC in Atlanta.
Wanda Irving tears up talking about her daughter's final weeks. "She had gained 9 pounds in that last week. She was having headaches. One leg was bigger than the other and she said, 'There's something dreadfully wrong, can you please check.' "
But she kept getting sent home from the hospital even though she was insistent that she needed medical attention. About three weeks after she gave birth, she collapsed at home, and never woke up.
Wanda Irving says her daughter's death was preventable – she attributes it to racism within the health care system, to doctors ignoring her daughter's symptoms and health risks.
Irving now lives in her daughter's house and is raising her granddaughter, who's now 6 years old, and bright, but struggles with her loss.
"There are days where she totally loses it and she breaks down and she's in tears," Irving says, saying her granddaughter will explain why she's crying by saying, 'I want my mommy. Can I die to go see my mommy?' "
Irving is working to raise awareness of the toll of maternal mortality, she says, because she doesn't want another little girl or a little boy to grow up without their mother's love.
"People need to understand the tremendous devastation that is caused by maternal mortality and the loss to society as well as to the families," she says.
Copyright 2023 NPR. To see more, visit https://www.npr.org.
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Health care for women and children has been an important focus of the Sustainable Development Goals (SDGs). This focus is encapsulated in goal number 3: "Ensure healthy lives and promote well-being for all at all ages." 1 The goal outlines specific targets including, to reduce maternal, neonatal, and child mortality (by 2030), to ensure universal access to sexual and reproductive health ...
Cultural Barriers to Seeking Maternal Health Care in Ethiopia: A Review of the Literature 1 Introduction and Background Ethiopia has one of the highest maternal mortality ratios (MMRs) in the world (676 maternal deaths per 100,000 live births in the 2011 Ethiopian Demographic Health Survey) (UNDP 2010;
2.2. LITERATURE REVIEW: EFFECT OF MATERNAL AND CHILD HEALTH INTERVENTIONS ON CHILD MORTALITY AND HEALTH EQUITY IN RESOURCE POOR SETTINGS Backgraound Low- and middle income countries failed to achieve MGD4 to reduce child mortality by two thirds in 2015. And inequality in intervention coverage and health outcome remained high (WHO, 2015). As we discussed in the first chapter, child health and ...
Introduction. Continuity of maternal care is a model that was first used in 1970 according to Liebowitz and Brody (1970), revealing that no patient was lost to follow-up or separated from care. 1 This continuity model is supportive and useful for increasing service coverage and satisfaction for mothers, families, the wider community, midwives, and nurses.
Maternal health literacy refers to the ability of mothers to access, understand, appraise, and apply information on mother and child health care during pregnancy, at childbirth and in the postpartum period with emphasis on specific attention was paid to key practices of ANC visits, childbirth, and postpartum care at health facilities, nutrition, …
Given the nascent stage of the literature, a scoping review rather than a systematic review, was deemed warranted. The objective of this scoping review was to map out the research regarding pregnant people at the time of labor exploitation and examine 1) hazardous exposures, 2) health outcomes, and 3) barriers to care that exist for this ...
Substantial time has elapsed since the last AHRQ review on this topic in 2007, and the body of literature focused on the maternal health benefits of breastfeeding has grown. 1,37-39 This review will conduct a partial update of the 2007 AHRQ review focused on the relationship of breastfeeding and various maternal health outcomes. II. The Key ...
Methods: A thorough literature review relies on a well-developed search strategy. This resulted in a total of 20 papers that were included in this review. ... It is therefore unsurprising that safety was identified as a prominent barrier to couplet care in this review. Maternal well-being and mother and infant safety were major concerns ...
Background Inequalities in access to and utilization of maternal and child health (MCH) care are hampering progress on the path to achieving the Sustainable Development Goals. In a number of Low- and Middle-Income Countries (LMICs) population subgroups at disproportionate risk of being left behind are the urban poor. Within this neglected group is the further neglected group of the homeless ...
Identification of mothers with depression is important because untreated perinatal depression can have both short- and long-term consequences for the mother, the child, and the family. This review attempts to identify the prevalence of antenatal and postnatal depression (AD and PD, respectively) of mothers among the ASEAN member countries. A literature review was conducted using PubMed, Scopus ...
Gipson and Upchurch [] tried to understand intergenerational transmission of women's empowerment by examining the influence of maternal status on the reproductive health outcomes of their daughters in the Philippines.They found that maternal empowerment was an important determinant of daughters' timing of sexual debut, where greater empowerment led to delayed sex, regardless of whether ...
The report found that 1,205 people died of maternal causes in the U.S. in 2021. That represents a 40% increase from the previous year. These are deaths that take place during pregnancy or within 42 days following delivery, according to the World Health Organization . The U.S. rate for 2021 was 32.9 maternal deaths per 100,000 live births, which ...