Skirting the issue: women and international health in historical perspective.
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Over the last decades women have become central to international health efforts, but most international health agencies continue to focus narrowly on the maternal and reproductive aspects of women's health. This article explores the origins of this paradigm as demonstrated in the emergence of women's health in the Rockefeller Foundation's public health programs in Mexico in the 1920s and 1930s. These efforts bore a significant reproductive imprint; women dispensed and received services oriented to maternal and childbearing roles. Women's health and social advocacy movements in Mexico and the United States partially shaped this interest. Even more important, the emphasis on women in the Rockefeller programs proved an expedient approach to the Foundation's underlying goals: promoting bacteriologically based public health to the government, medical personnel, business interests, and peasants; helping legitimize the Mexican state; and transforming Mexico into a good political and commercial neighbor. The article concludes by showing the limits to the maternal and reproductive health model currently advocated by most donor agencies, which continue to skirt--or sidestep--major concerns that are integral to the health of women. (+info)
Adherence by midwives to the Dutch national guidelines on threatened miscarriage in general practice: a prospective study.
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OBJECTIVE: To determine the feasibility for midwives to adhere to Dutch national guidelines on threatened miscarriage in general practice. DESIGN: Prospective recording of appointments by midwives who agreed to adhere to the guidelines on threatened miscarriage. Interviews with the midwives after they had recorded appointments for one year. SETTING: Midwifery practices in The Netherlands. SUBJECTS: 56 midwives who agreed to adhere to the guidelines; 43 midwives actually made records from 156 clients during a period of 12 months. MAIN OUTCOME MEASURES: Adherence to each recommendation and reasons for non-adherence. RESULTS: The recommendation that a physical examination should take place on the first and also on the follow up appointment was not always adhered to. Reasons for non-adherence were the midwives' criticism of this recommendation, their lack of knowledge or skills, and the specific client situation. Adherence to a follow up appointment after 10 days, a counselling consultation after six weeks, and not performing an ultrasound scan was low. Reasons for non-adherence were mainly based on the midwives' criticism of these recommendations and reluctance on the part of the client. Furthermore, many midwives did not give information and instructions to the client. It is noteworthy that in 13% of the cases the midwife's policy was overridden by the obstetrician taking control of the situation after the midwife had requested an ultrasound scan. CONCLUSIONS: Those recommendations in the guidelines on threatened miscarriage that are most often not adhered to should be reviewed. To reduce conflicts about ultrasound scans and referrals, agreement on the policy on threatened miscarriage should be mutually established between midwives and obstetricians. (+info)
Characteristics of nurse-midwife patients and visits, 1991.
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OBJECTIVES: This study describes the patient populations served by and visits made to certified nurse-midwives (CNMs) in the United States. METHODS: Prospective data on 16,729 visits were collected from 369 CNMs randomly selected from a 1991 population survey. Population estimates were derived from a multistage survey design with probability sampling. RESULTS: We estimated that approximately 5.4 million visits were made to nearly 3000 CNMs nationwide in 1991. Most visits involved maternity care, although fully 20% were for care outside the maternity cycle. Patients considered vulnerable to poor access or outcomes made 7 of every 10 visits. CONCLUSIONS: Nurse-midwives substantially contribute to the health care of women nationwide, especially for vulnerable populations. (+info)
Clinical interventions and outcomes of One-to-One midwifery practice.
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BACKGROUND: Changing Childbirth became policy for the maternity services in England in 1994 and remains policy. One-to-One midwifery was implemented to achieve the targets set. It was the first time such a service had been implemented in the Health Service. An evaluation was undertaken to compare its performance with conventional maternity care. METHODS: This was a prospective comparative study of women receiving One-to-One care and women receiving the system of care that One-to-One replaced (conventional care) to compare achievement of continuity of carer and clinical outcomes. The evaluation took place in The Hammersmith Hospitals NHS Trust, the Queen Charlotte's and Hammersmith Hospitals. This was part of a larger study, which included the evaluation of women's responses, cost implications, and clinical standards and staff reactions. The participants were all those receiving One-to-One midwifery practice (728 women), which was confined to two postal districts, and all women receiving care in the system that One-to-One replaced, in two adjacent postal districts (675 women), and expecting to give birth between 15 August 1994 and 14 August 1995. Main outcome measures were achievement of continuity of care, rates of interventions in labour, length of labour, maternal and infant morbidity, and breastfeeding rates. RESULTS: A high degree of continuity was achieved through the whole process of maternity care. One-to-One women saw fewer staff at each stage of their care, knew more of the staff who they did see, and had a high level of constant support in labour. One-to-One practice was associated with a significant reduction in the use of epidural anaesthesia (odds ratio (OR) 95 per cent confidence interval (CI) = 0.59 (0.44, 0.80)), with lower rates of episiotomy and perineal lacerations (OR 95 per cent CI = 0.70 (0.50, 0.98)), and with shorter second stage labour (median 40 min vs 48 min). There were no statistically significant differences in operative and assisted delivery or breastfeeding rates. CONCLUSIONS: This study confirms that One-to-One midwifery practice can provide a high degree of continuity of carer, and is associated with a reduction in the rate of a number of interventions, without compromising safety of care. It should be extended locally and replicated in other services under continuing evaluation. (+info)
Costs and benefits of community postnatal support workers: a randomised controlled trial.
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OBJECTIVES: This study aimed to measure the effect and the total cost per woman of providing postnatal support at home, based on a Dutch model. The research hypothesis was furnished by some existing evidence that postnatal support could reduce the risk of postnatal depression and encourage breastfeeding. DESIGN: The randomised controlled trial aimed to measure differences in health status in a group of women who were offered postnatal support from a community midwifery support worker (SW) compared with a control group of women who were not offered this support. Women were followed-up by postal questionnaire at 6 weeks and 6 months postnatally. SETTING AND SUBJECTS: All women who delivered a baby at the recruiting hospital were eligible to take part in the trial if they lived within the study area, were aged 17 years or over, and could understand English. INTERVENTION: The intervention consisted of the SW offering practical and emotional support and to help women rest and recover after childbirth. The SW offered ten visits in the first 28 days postnatally, for up to 3 hours per day. The SW's activities included housework, talking with the mother, and care for the baby or other siblings. The service was provided in addition to routine visits by the community midwife. MAIN OUTCOME MEASURES: The primary outcome was the general health perception domain of the Short Form-36 at 6 weeks. Secondary outcomes were mean Edinburgh Postnatal Depression Scale (EPDS), Duke Functional Social Support (DUFSS) scores and breastfeeding rates. RESULTS: The 623 randomised women were well-matched by group with a good response to follow-up. At 6 weeks there was no evidence of a significant difference between the two groups for the primary outcome. There was a non-significant trend for the control group to have better mean DUFSS and EPDS scores at 6 weeks. Breastfeeding rates were not significantly different at follow-up. At 6 months, both groups had similar health status. Satisfaction with the service was higher than for all other services received. The incremental cost of introducing the service comprised setting up and running the service. There were no differences between the groups in other resource use (general practitioner contacts, hospital services, prescriptions or medicines bought for mothers and babies) to 6-month follow-up. The total mean NHS cost to 6-month follow-up for the intervention group was pound180 per woman greater than for the control group (confidence interval, pound79.60, pound272.40). CONCLUSIONS: Although women valued the service, there was no evidence of any health benefit at the 6-week or 6-month follow-up, no difference in use of NHS services, and the additional cost of the service provision would be around pound 180 per woman. (+info)
Costs and effectiveness of community postnatal support workers: randomised controlled trial.
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OBJECTIVES: To establish the relative cost effectiveness of postnatal support in the community in addition to the usual care provided by community midwives. DESIGN: Randomised controlled trial with six month follow up. SETTING: Recruitment in a university teaching hospital and care provided in women's homes. PARTICIPANTS: 623 postnatal women allocated at random to intervention (311) or control (312) group. INTERVENTION: Up to 10 home visits in the first postnatal month of up to three hours duration by a community postnatal support worker. MAIN OUTCOME MEASURE: General health status as measured by the SF-36 and risk of postnatal depression. Breast feeding rates, satisfaction with care, use of services, and personal costs. RESULTS: At six weeks there was no significant improvement in health status among the women in the intervention group. At six weeks the mean total NHS costs were pound 635 for the intervention group and pound 456 for the control group (P=0.001). At six months figures were pound 815 and pound 639 (P=0.001). There were no differences between the groups in use of social services or personal costs. The women in the intervention group were very satisfied with the support worker visits. CONCLUSIONS: There was no health benefit of additional home visits by community postnatal support workers compared with traditional community midwifery visiting as measured by the SF-36. There were no savings to the NHS over six months after the introduction of the community postnatal support worker service. (+info)
Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth.
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OBJECTIVE: To assess the effectiveness of a midwife led debriefing session during the postpartum hospital stay in reducing the prevalence of maternal depression at six months postpartum among women giving birth by caesarean section, forceps, or vacuum extraction. DESIGN: Randomised controlled trial. SETTING: Large maternity teaching hospital in Melbourne, Australia. PARTICIPANTS: 1041 women who had given birth by caesarean section (n= 624) or with the use of forceps (n= 353) or vacuum extraction (n= 64). MAIN OUTCOME MEASURES: Maternal depression (score >/=13 on the Edinburgh postnatal depression scale) and overall health status (comparison of mean scores on SF-36 subscales) measured by postal questionnaire at six months postpartum. RESULTS: 917 (88%) of the women recruited responded to the outcome questionnaire. More women allocated to debriefing scored as depressed six months after birth than women allocated to usual postpartum care (81 (17%) v 65 (14%)), although this difference was not significant (odds ratio=1.24, 95% confidence interval 0.87 to 1.77). They were also more likely to report that depression had been a problem for them since the birth, but the difference was not significant (123 (28%) v 94 (22%); odds ratio=1. 37, 1.00 to 1.86). Women allocated to debriefing had poorer health status on seven of the eight SF-36 subscales, although the difference was significant only for role functioning (emotional): mean scores 73.32 v 78.98, t= -2.31, 95% confidence interval -10.48 to -0.84). CONCLUSIONS: Midwife led debriefing after operative birth is ineffective in reducing maternal morbidity at six months postpartum. The possibility that debriefing contributed to emotional health problems for some women cannot be excluded. (+info)
Process measures in an antenatal smoking cessation trial: another part of the picture.
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Data on provider and patient compliance can be crucial in understanding the degree of a health education program's effectiveness, as well as in identifying areas where the program requires modification. However, such data are rarely systematically reported in randomized trials. This report assesses the degree to which doctors and midwives complied with intervention protocols in a hospital antenatal smoking cessation trial, and also examines the program's acceptability to patients. Provider compliance was assessed principally via consultation audiotapes and provider-completed checklists. The audiotape analysis identified substantial compliance problems. For example, in relation to six specific smoking-related pregnancy risks, the proportions of Experimental Women informed about each individual risk ranged from 26 to 38% and the proportions receiving counselling items ranged from 52 to 79%. Doctors only informed a minority of Experimental Women of the increased risk of Sudden Infant Death Syndrome (28%) and of the presence of toxic chemicals in tobacco (21%). Comparison of compliance data from audiotapes and provider checklists revealed there was no significant agreement in three of four cases tested. Experimental Patients completed questionnaires to assess recall of smoking advice and to rate 12 program features. Of specific Experimental Program elements, the videotape (85%) received the highest level of positive patient ratings and the lottery (42%) the lowest. The process evaluation indicated that the Experimental Program needed some modification to increase its suitability for routine application. The findings also support the value of including an objective measure of provider compliance. (+info)