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‘How good is good?’: Studies of facility-based childbirth care in southern Mozambique, from the perspectives of women and health providers
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (Obstetrics and Reproductive Health Research)ORCID iD: 0000-0002-2475-2560
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Despite the large shift toward facility-based childbirths occurred during the last 15 years in several low resource settings, including in Mozambique, the burden of maternal mortality and morbidity remain considerable. Obstetric fistula is one of the most devastating of all maternal morbidities which still prevalent and is entirely avoidable.

The aim of this thesis was to evaluate and explore the provision of childbirth care, focusing on obstetric fistula as one of its complications, in a rural Mozambican setting of high facility delivery rate.

The four studies constituting this thesis were implemented in Maputo and Gaza provinces, southern Mozambique, between April 2016 and March 2017. We included 4385 women having given birth up to 12 months the study identified from a cohort of women of reproductive age (12-49 years). We identified women with constant urine leakage, assess them clinically, confirm the diagnosis and estimate the incidence of obstetric fistula. In-depth interviews with selected women with and without fistula (n=28), were used to describe the women’s experiences of maternal care and pinpoint those experiences that are unique to women with fistula. During the same cross-sectional survey (n=4385) we also assessed the women’s experiences of care and satisfaction with care during childbirth. We complemented the women’s survey with a survey among 175 health workers of the study area to assess their perception of their work context.

The incidence of fistulae was 1.1 per recently pregnant women (95% CI 0.14-2.16). Delays in receiving definite care at referral hospitals despite having reached the primary health facility in time, were reported by the women who had fistulae. Women without fistula, blamed the fistula condition on women’s physiological and behavioural characteristics. Most (92.5%) of the 4358 women interviewed reported to be satisfied with care during childbirth and would recommend a family member to deliver in the same facility. Women who gave birth in primary level facilities tended to be more satisfied than those gave birth in hospitals, and presence of a companion had a positive influence on the satisfaction, irrespective of age, education and socio-economic background. Health workers rated highly the items on all dimensions of context when asked to evaluate their work context using the Context Assessment for Community Health (COACH) tool, although still above the scale midpoint, the organizational resources dimension had the lowest score.

This thesis demonstrates a high incidence of obstetric fistula despite a high coverage of facility-based childbirths in a rural context where services are generally perceived as adequate by childbearing women and health providers. To reduce maternal morbidity by fistula, major interventions are needed to improve the quality of childbirth care, including complication recognition and decision-making for referral, health facility preparedness as well as to improve the health providers’ work environment.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2019. , p. 84
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1561
Keywords [en]
Facility-based childbirth, Obstetric fistula, Satisfaction with care, Health providers, Context assessment, Mozambique
National Category
Medical and Health Sciences
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-380580ISBN: 978-91-513-0619-3 (print)OAI: oai:DiVA.org:uu-380580DiVA, id: diva2:1300582
Public defence
2019-05-20, Rudbecksalen, Rudbeck entréplan C11, Dag Hammarskjölds väg 20, Uppsala, 09:00 (English)
Opponent
Supervisors
Available from: 2019-04-26 Created: 2019-03-29 Last updated: 2019-06-18
List of papers
1. Obstetric fistulae in southern Mozambique: incidence, obstetric characteristics and treatment
Open this publication in new window or tab >>Obstetric fistulae in southern Mozambique: incidence, obstetric characteristics and treatment
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2017 (English)In: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 14, article id 147Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Obstetric fistula is one of the most devastating consequences of unmet needs in obstetric services. Systematic reviews suggest that the pooled incidence of fistulae in community-based studies is 0.09 per 1000 recently pregnant women; however, as facility delivery is increasing, for the most part, in Africa, incidence of fistula should decrease. Few population-based studies on fistulae have been undertaken in Sub-Saharan Africa, including Mozambique. This study aimed to estimate the incidence of obstetric fistulae in recently delivered mothers, and to describe the clinical characteristics and care, as well as the outcome, after surgical repair.

METHODS: We selected women who had delivered up to 12 months before the start of the study (June, 1st 2016). They were part of a cohort of women of reproductive age (12-49 years), recruited from selected clusters in rural areas of Maputo and Gaza provinces, Southern Mozambique, who were participating in an intervention trial (the Community Level Interventions for Pre-eclampsia trial or CLIP trial). Case identification was completed by self-reported constant urine leakage and was confirmed by clinical assessment. Women who had confirmed obstetric fistulae were referred for surgical repair. Data were entered into a REDCap database and analysed using R software.

RESULTS: Five women with obstetric fistulae were detected among 4358 interviewed, giving an incidence of 1.1 per 1000 recently pregnant women (95% CI 2.16-0.14). All but one had Caesarean section and all of the babies died. Four were stillborn, and one died very soon after birth. All of the patients identified and reached the primary health facility in reasonable time. Delays occurred in the care: in diagnosis of obstructed labour, and in the decision to refer to the secondary or third-level hospital. All but one of the women were referred to surgical repair and the fistulae successfully closed.

CONCLUSION: This population-based study reports a high incidence of obstetric fistulae in an area with high numbers of facility births. Few first and second delays in reaching care, but many third delays in receiving care, were identified. This raises concerns for quality of care.

Keywords
Obstetric fistula, Caesarean, Incidence, Population-based, Sub-Saharan Africa
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-341929 (URN)10.1186/s12978-017-0408-0 (DOI)000414870000001 ()29126412 (PubMedID)
Available from: 2018-02-26 Created: 2018-02-26 Last updated: 2019-03-29Bibliographically approved
2. Obstetric fistula in southern Mozambique: a qualitative study on women’s experiences and perspectives
Open this publication in new window or tab >>Obstetric fistula in southern Mozambique: a qualitative study on women’s experiences and perspectives
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Obstetric fistula is still common in low- and middle-income countries (LMIC) despite the on-going shift to increased facility deliveries in the same settings.  The social behavioural circumstances in which fistula, as well as its consequences, still occur are poorly documented, particularly from the perspective of the experiences of women with obstetric fistula. This study sought to describe women’s experiences of antenatal, partum and post-partum care in southern Mozambique, and to pinpoint those experiences that are unique to women with fistula in order to understand the care-seeking and care provision circumstances which could have been modified to avoid or mitigate the onset or consequences of fistula. 

Methods: This study took place in Maputo and Gaza provinces, southern Mozambique, in 2016-2017.  Qualitative data were collected through in-depth interviews conducted with 14 women with positive diagnoses of fistula and an equal number of women without fistula. All interviews were audio-recorded and transcribed verbatim prior to thematic analysis using NVivo11.

Results: Study participants had all attended antenatal care (ANC) visits and had prepared for a birth facility. Prolonged or obstructed labour, untimely multiple referrals, and delays in receiving secondary and tertiary health care were common among the discourses of women with fistula. The term “fistula” was rarely known among participants, but the condition (referred to as “loss of water” or “illness of spillage”) was recognised after being prompted on its signs and symptoms. Women with fistula were invariably aware of the links between fistula and poor birth assistance, in contrast with those without fistula, who blamed the condition on women’s physiological and behavioural characteristics.

Conclusion: Although women sought antenatal and childbirth care in health facilities, delays and deficiencies in the provision of the most appropriate care possible, such as referral and caesarean section, were evident in their discourses. While women with fistula were minimally aware of the causes of their condition, those without fistula cited discriminatory attributions, reflecting the outsider’s perspectives of fistula. There is a need to increase awareness and reinforce preventive obstetric measures, early detection and prompt management of obstetric fistula.

Keywords
obstetric fistula, women’s experiences, quality of care, Mozambique.
National Category
Medical and Health Sciences
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-380579 (URN)
Available from: 2019-03-29 Created: 2019-03-29 Last updated: 2019-03-29
3. Mothers' satisfaction with care during facility-based childbirth: a cross-sectional survey in southern Mozambique
Open this publication in new window or tab >>Mothers' satisfaction with care during facility-based childbirth: a cross-sectional survey in southern Mozambique
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Client satisfaction is an essential component of quality of care. Health system factors, processes of care as well as mothers’ characteristics influence the extent to which care meets the expectations of mothers and families. In our study, we specifically aimed to address the mother’s experiences of, and satisfaction with, care during childbirth.

Methods: A population-based cross-sectional study, using structured interviews with published sequences of questions assessing satisfaction, included 4358 mothers who gave birth during the 12 months before June 2016 to estimate satisfaction with childbirth care. Regression analysis was used to determine the predictors of client satisfaction.

Results: Most mothers (92.5%) reported being satisfied with care during childbirth and would recommend a family member to deliver at the same facility. Specifically, 94.7% were satisfied with the cleanliness of the facility, 92% reported being satisfied with the interaction with the healthcare providers, but only 49.8% felt satisfied with the assistance to feed their baby. Mothers who had negative experiences during the process of care, such as abandoned when needed help, disrespect, humiliation, or physical abuse, reported low levels of satisfaction when compared to those who had not had such experiences (68.5% vs 93.5%). Additionally, they reported higher levels of dissatisfaction (20.1% vs 2.1%). Regression analysis revealed that mothers who gave birth in primary level facilities tended to be more satisfied than those gave birth in hospitals, and having a companion, increased, on average, the overall satisfaction score, with 0.06 in type II health centres (CI 0.03 – 0.10) and with 0.05 in type I health centres (CI -0.02 – 0.13), compared to -0.01(CI -0.08 – 0.07) in the hospitals, irrespective of age, education and socio-economic background.

Conclusion: Childbirth at the primary facilities contributes to the level of satisfaction. The provision of childbirth care should consider women’s preferences and needs, including having a companion of choice. We highlight the challenge in balancing safety of care versus satisfaction with care and for policies on health care organizations for deliveries to be conducted in fully equipped hospitals rather than primary facilities. Interventions to improve the interaction with providers and the provision of respectful care are recommended.

Keywords
Satisfaction with care, experiences of care, facility-based childbirth
National Category
Medical and Health Sciences
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-380577 (URN)
Available from: 2019-03-29 Created: 2019-03-29 Last updated: 2019-03-29
4. Ready to deliver maternal and newborn care?: Health providers' perceptions of their work context in rural Mozambique
Open this publication in new window or tab >>Ready to deliver maternal and newborn care?: Health providers' perceptions of their work context in rural Mozambique
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2018 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1532631Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Deficiencies in the provision of evidence-based obstetric care are common in low-income countries, including Mozambique. Constraints relate to lack of human and financial resources and weak health systems, however limited resources alone do not explain the variance. Understanding the healthcare context ahead of implementing new interventions can inform the choice of strategies to achieve a successful implementation. The Context Assessment for Community Health (COACH) tool was developed to assess modifiable aspects of the healthcare context that theoretically influence the implementation of evidence.

OBJECTIVES: To investigate the comprehensibility and the internal reliability of COACH and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique.

METHODS: A response process evaluation was completed with six purposively selected health providers to uncover difficulties in understanding the tool. Internal reliability was tested using Cronbach's α. Subsequently, a cross-sectional survey using COACH, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique.

RESULTS: The content of COACH was clear and most items were understood. All dimensions were near to or exceeded the commonly accepted standard for satisfactory internal reliability (0.70). Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the Work culture, Leadership, and Informal payment dimensions. Responses to many items had low variance and were left-skewed.

CONCLUSIONS: COACH was comprehensible and demonstrated good reliability, although biases may have influenced participants' responses. The study suggests that COACH has the potential to evaluate the healthcare context to identify shortcomings and enable the tailoring of strategies ahead of implementation. Supplementing the tool with qualitative approaches will provide an in-depth understanding of the healthcare context.

Keywords
Context assessment, health personnel, implementation science, maternal and neonatal care, validity
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-365816 (URN)10.1080/16549716.2018.1532631 (DOI)000449336300001 ()30387378 (PubMedID)
Available from: 2018-11-14 Created: 2018-11-14 Last updated: 2019-06-26Bibliographically approved

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