Maternal morbidity in the first year after childbirth in Mombasa Kenya; a needs assessment

BMC Pregnancy and Childbirth, Volume 9, Year 2009

Interprétation

Background: In sub-Saharan Africa, few services specifically address the needs of women in the first year after childbirth. By assessing the health status of women in this period, key interventions to improve maternal health could be identified. There is an underutilised opportunity to include these interventions within the package of services provided for woman-child pairs attending child-health clinics. Methods: This needs assessment entailed a cross-sectional survey with 500 women attending a child-health clinic at the provincial hospital in Mombasa, Kenya. A structured questionnaire, clinical examination, and collection of blood, urine, cervical swabs and Pap smear were done. Women’s health care needs were compared between the early (four weeks to two months after childbirth), middle (two to six months) and late periods (six to twelve months) since childbirth. Results: More than one third of women had an unmet need for contraception (39%, 187/475). Compared with other time intervals, women in the late period had more general health symptoms such as abdominal pain, fever and depression, but fewer urinary or breast problems. Over 50% of women in each period had anaemia (Hb <11 g/l; 265/489), with even higher levels of anaemia in those who had a caesarean section or had not received iron supplementation during pregnancy. Bacterial vaginosis was present in 32% (141/447) of women, while 1% (5/495) had syphilis, 8% (35/454) Trichomonas vaginalis and 11% (54/496) HIV infection. Conclusion: Throughout the first year after childbirth, women had high levels of morbidity. Interface with health workers at child health clinics should be used for treatment of anaemia, screening and treatment of reproductive tract infections, and provision of family planning counselling and contraception. Providing these services during visits to child health clinics, which have high coverage both early and late in the year after childbirth, could make an important contribution towards improving women's health. © 2009 Chersich et al; licensee BioMed Central Ltd. At Coast Provincial General Hospital in Mombasa, Kenya, 500 women attending an immunization and acute care paediatric clinic participated in a cross-sectional survey to describe the levels of maternal morbidity in the year after childbirth. The survey, held in 2006, also investigated the feasibility of providing HIV testing and counselling, and the levels of HIV-related disease in this population [25,26]. Study activities formed part of a project to improve maternal health services in Coast Province Kenya. From 2002 to 2005 this project focused on strengthening antenatal and intrapartum services; however as it appeared that few women attended postpartum services and their needs were ill defined, this survey was planned to assess women's needs after childbirth and to define a service package that could be provided for women bringing their child for health care. The study was approved by the Kenyatta National Hospital Ethics and Research Committee. The study population consisted of consecutive women who were older than 16 years, biological mothers of the child, and between four weeks and one year after childbirth. After completion of the child-health visit, women were approached and invited to participate in the study. Those willing to participate gave written informed consent and were interviewed using a pre-tested structured questionnaire administered in Swahili, the local language. Besides information on demographic characteristics, data were collected on access to sexual and reproductive health services; family planning needs and sexual health status. Women were screened for mild and major depression (using ICD-10 definitions [27]) and for harmful alcohol use with the AUDIT tool [28]. Thereafter study nurses did a clinical examination and collected blood, urine, a cervical swab and a Pap smear. Full details of test procedures and the sample size calculation are provided elsewhere [26]. Urine dipstick detected nitrites and leucocytes. Blood samples were used for malaria microscopy, RPR test for syphilis and serial rapid HIV testing. Trichomonas vaginalis and candida were detected in a wet mount, and Nugent's criteria used for diagnosing bacterial vaginosis. Participants were advised to return for test results and, if required, received treatment according to local guidelines. For conditions such as syphilis, malaria and severe anaemia, women with positive results were contacted and asked to return to the clinic immediately. All participants were offered HIV counselling and same-day testing; those testing positive were enrolled in an HIV care and treatment clinic at the study site. Data collected during interviews and laboratory investigations were double entered using Statistical Package for Social Science, version 11.5 (Chicago, USA). For analysis, women were divided into three groups according to the time period since childbirth: early (four weeks to two months), middle (two to six months) and late periods(six to twelve months). These categories were selected to be broadly consistent with the local child immunization schedule and the anticipated patterns of illness in women. Sexually-active women not using contraceptive methods were defined as having an unmet need for contraception. Lactational amenorrhea (exclusive breastfeeding and amenorrhea) was classified as a contraceptive method. Haemoglobin levels below 11 g/l were considered anaemia and a mean corpuscular volume below 81fl microcytic [29]. Intercooled Stata 8.0 (Stata Corporation, College Station, Texas, USA) was used to assess the distribution of sexual behaviour, contraceptive need, morbidity and other variables among women presenting in the early, middle and late periods. Also, the demographic and reproductive health characteristics of these three groups were compared to assess whether systematic differences exist which might be explained by differential health-seeking patterns. For example, we assessed whether poorer or multiparous women were less likely to attend visits in the late period. A chi-square test was used for analysis of binary variables and Mantel-Haenszel odds ratios were calculated. For continuous variables, a Student's t test and Wilcoxon's rank-sum test were used for comparing variables with a normal or non-normal distribution respectively. One way analysis of variance was used to compare means of continuous variables in each of the time periods.

Résumé de l’IA

Study Justification:

– The study aimed to assess the health status of women in the first year after childbirth in Mombasa, Kenya.
– By identifying the health needs of women during this period, key interventions to improve maternal health could be identified.
– The study aimed to determine the feasibility of including these interventions within the package of services provided for woman-child pairs attending child-health clinics.

Highlights:

– More than one third of women had an unmet need for contraception.
– Women in the late period after childbirth had more general health symptoms such as abdominal pain, fever, and depression.
– Over 50% of women in each period had anemia, with higher levels in those who had a caesarean section or did not receive iron supplementation during pregnancy.
– Bacterial vaginosis, syphilis, Trichomonas vaginalis, and HIV infection were also prevalent among the women.

Recommendations:

– Treatment of anemia, screening and treatment of reproductive tract infections, and provision of family planning counseling and contraception should be provided during visits to child health clinics.
– These services should be integrated into the existing child health clinics, which have high coverage early and late in the year after childbirth.
– Improving women’s health during the first year after childbirth can make a significant contribution to overall maternal health.

Key Role Players:

– Health workers at child health clinics
– Obstetricians and gynecologists
– Nurses and midwives
– Laboratory technicians
– Public health officials

Cost Items for Planning Recommendations:

– Training and capacity building for health workers
– Equipment and supplies for screening and treatment of reproductive tract infections
– Contraceptive methods and counseling materials
– Laboratory testing and diagnostic tools
– Monitoring and evaluation of the program
– Outreach and awareness campaigns
– Integration of services into existing child health clinics
Please note that the cost items provided are general categories and not specific cost estimates. Actual costs would depend on the local context and implementation plan.

Force de la preuve

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it presents findings from a cross-sectional survey with a large sample size of 500 women. The study collected data through a structured questionnaire, clinical examination, and laboratory tests, which adds to the robustness of the evidence. The study also compares women’s health care needs across different time periods after childbirth, providing valuable insights. To improve the evidence, the abstract could include more details on the methodology, such as the sampling strategy and response rate. Additionally, it would be helpful to mention any limitations of the study, such as potential biases or generalizability issues.

Abstrait

At Coast Provincial General Hospital in Mombasa, Kenya, 500 women attending an immunization and acute care paediatric clinic participated in a cross-sectional survey to describe the levels of maternal morbidity in the year after childbirth. The survey, held in 2006, also investigated the feasibility of providing HIV testing and counselling, and the levels of HIV-related disease in this population [25,26]. Study activities formed part of a project to improve maternal health services in Coast Province Kenya. From 2002 to 2005 this project focused on strengthening antenatal and intrapartum services; however as it appeared that few women attended postpartum services and their needs were ill defined, this survey was planned to assess women's needs after childbirth and to define a service package that could be provided for women bringing their child for health care. The study was approved by the Kenyatta National Hospital Ethics and Research Committee. The study population consisted of consecutive women who were older than 16 years, biological mothers of the child, and between four weeks and one year after childbirth. After completion of the child-health visit, women were approached and invited to participate in the study. Those willing to participate gave written informed consent and were interviewed using a pre-tested structured questionnaire administered in Swahili, the local language. Besides information on demographic characteristics, data were collected on access to sexual and reproductive health services; family planning needs and sexual health status. Women were screened for mild and major depression (using ICD-10 definitions [27]) and for harmful alcohol use with the AUDIT tool [28]. Thereafter study nurses did a clinical examination and collected blood, urine, a cervical swab and a Pap smear. Full details of test procedures and the sample size calculation are provided elsewhere [26]. Urine dipstick detected nitrites and leucocytes. Blood samples were used for malaria microscopy, RPR test for syphilis and serial rapid HIV testing. Trichomonas vaginalis and candida were detected in a wet mount, and Nugent's criteria used for diagnosing bacterial vaginosis. Participants were advised to return for test results and, if required, received treatment according to local guidelines. For conditions such as syphilis, malaria and severe anaemia, women with positive results were contacted and asked to return to the clinic immediately. All participants were offered HIV counselling and same-day testing; those testing positive were enrolled in an HIV care and treatment clinic at the study site. Data collected during interviews and laboratory investigations were double entered using Statistical Package for Social Science, version 11.5 (Chicago, USA). For analysis, women were divided into three groups according to the time period since childbirth: early (four weeks to two months), middle (two to six months) and late periods(six to twelve months). These categories were selected to be broadly consistent with the local child immunization schedule and the anticipated patterns of illness in women. Sexually-active women not using contraceptive methods were defined as having an unmet need for contraception. Lactational amenorrhea (exclusive breastfeeding and amenorrhea) was classified as a contraceptive method. Haemoglobin levels below 11 g/l were considered anaemia and a mean corpuscular volume below 81fl microcytic [29]. Intercooled Stata 8.0 (Stata Corporation, College Station, Texas, USA) was used to assess the distribution of sexual behaviour, contraceptive need, morbidity and other variables among women presenting in the early, middle and late periods. Also, the demographic and reproductive health characteristics of these three groups were compared to assess whether systematic differences exist which might be explained by differential health-seeking patterns. For example, we assessed whether poorer or multiparous women were less likely to attend visits in the late period. A chi-square test was used for analysis of binary variables and Mantel-Haenszel odds ratios were calculated. For continuous variables, a Student's t test and Wilcoxon's rank-sum test were used for comparing variables with a normal or non-normal distribution respectively. One way analysis of variance was used to compare means of continuous variables in each of the time periods.

Matériaux

N/A

Innovations

The study titled “Maternal morbidity in the first year after childbirth in Mombasa Kenya; a needs assessment” conducted at Coast Provincial General Hospital in Mombasa, Kenya aimed to assess the health status of women in the first year after childbirth and identify interventions to improve maternal health. The study included 500 women attending a child-health clinic and collected data on their health needs, including contraception, anaemia, reproductive tract infections, and general health symptoms.

The findings of the study revealed that many women in the first year after childbirth had unmet needs for contraception, anaemia, reproductive tract infections, and general health symptoms. Specifically, more than one-third of women had an unmet need for contraception, over 50% had anaemia, and bacterial vaginosis was present in 32% of women. The study also found that women in the late period after childbirth had more general health symptoms but fewer urinary or breast problems compared to other time intervals.

Based on these findings, the study recommended integrating maternal health services within child health clinics as a way to improve access to maternal health. This approach takes advantage of the existing infrastructure and resources of child health clinics, which have high coverage early and late in the year after childbirth. The recommendation involves training health workers at child health clinics to provide treatment for anaemia, screening and treatment of reproductive tract infections, and family planning counseling and contraception.

Implementing this recommendation would require collaboration between maternal health and child health programs, as well as training and capacity building for health workers. It would also be important to ensure that the necessary equipment and supplies are available at child health clinics to provide these services.

By integrating maternal health services within child health clinics, women would have easier access to the care they need during the first year after childbirth, leading to improved maternal health outcomes.

AI Innovations Description

Based on the information provided, a recommendation to improve access to maternal health would be to integrate maternal health services within child health clinics. This recommendation is based on the findings that many women in the first year after childbirth have unmet needs for contraception, anaemia, reproductive tract infections, and general health symptoms. By providing these services during visits to child health clinics, which have high coverage early and late in the year after childbirth, it could make a significant contribution towards improving women’s health.

This integration of services would involve training health workers at child health clinics to provide treatment for anaemia, screening and treatment of reproductive tract infections, and family planning counseling and contraception. This approach takes advantage of the existing infrastructure and resources of child health clinics to address the maternal health needs of women in the postpartum period.

Implementing this recommendation would require collaboration between maternal health and child health programs, as well as training and capacity building for health workers. It would also be important to ensure that the necessary equipment and supplies are available at child health clinics to provide these services.

By integrating maternal health services within child health clinics, women would have easier access to the care they need during the first year after childbirth, leading to improved maternal health outcomes.

AI Innovations Methodology

To simulate the impact of the main recommendations on improving access to maternal health, the following methodology could be used:

1. Identify the target population: Determine the specific population that would benefit from the integration of maternal health services within child health clinics. This could include women in the first year after childbirth who attend child health clinics at the Coast Provincial General Hospital in Mombasa, Kenya.

2. Define the intervention: Clearly outline the specific interventions that would be implemented, such as training health workers at child health clinics to provide treatment for anaemia, screening and treatment of reproductive tract infections, and family planning counseling and contraception.

3. Develop a control group: Select a comparable group of women who do not receive the integrated services at child health clinics. This group will serve as a control to compare the impact of the intervention.

4. Collect baseline data: Conduct a baseline survey to collect data on the health status, access to maternal health services, and other relevant factors for both the intervention and control groups. This could involve using a structured questionnaire, clinical examinations, and laboratory tests, as described in the abstract.

5. Implement the intervention: Integrate the maternal health services within child health clinics as per the recommendations. This may involve training health workers, ensuring the availability of necessary equipment and supplies, and establishing protocols for providing the services.

6. Monitor and evaluate: Track the implementation of the intervention and collect data on key indicators, such as the uptake of maternal health services, contraceptive use, anaemia prevalence, and reproductive tract infections. This can be done through regular monitoring and evaluation activities, including follow-up surveys and data analysis.

7. Compare outcomes: Compare the outcomes between the intervention and control groups to assess the impact of integrating maternal health services within child health clinics. This could involve statistical analysis, such as chi-square tests, odds ratios, t-tests, and analysis of variance, as described in the abstract.

8. Draw conclusions and make recommendations: Analyze the data and draw conclusions about the impact of the intervention on improving access to maternal health. Based on the findings, make recommendations for scaling up the integrated services or making further improvements.

9. Disseminate findings: Share the results of the simulation study through publications, presentations, and other means to inform policymakers, healthcare providers, and other stakeholders about the potential benefits of integrating maternal health services within child health clinics.

By following this methodology, researchers can simulate the impact of the main recommendations on improving access to maternal health and provide evidence for decision-making and policy development.

Auteur

Dima Health

Statistics:

Citations: 14

Identifiers:

DOI: 10.1186/1471-2393-9-51

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal and Child Health, Mental Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Substance Abuse

Study Countries:

Kenya

Study Design:

Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female

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