Regulating Midwives: Foreclosing Alternatives in the Policymaking Process in West Java, Indonesia

Promotion of “skilled birth attendants” (SBAs) in global maternal health policy has prompted a range of policy responses to “traditional birth attendants” (TBAs). In Indonesia the response has been to develop a national policy of partnership between SBAs (bidan) and TBAs (dukun bayi). This policy aims to ensure the presence of an SBA at every birth yet offers a role for TBAs. In this chapter I examine the development of a district regulation on partnership, promoted within the context of decentralization policies enacted in Indonesia from 1999. The district regulation aimed to strengthen the national policy in a location in West Java where TBAs remain popular. Drawing on 10 months of fieldwork from 2012 to 2013 at a district health office and on observations of its outreach programs, I elucidate how the regulation on partnership was promoted through the policy entrepreneurship of certain key figures in the district health office. They argued that the partnership regulation was the fastest means to improve maternal health. But casting a spotlight on the relationship between SBAs and TBAs diverted attention away from other health system challenges including under-resourced medical facilities and a weak referral system. Three contexts played into this process of bringing the partnership issue to the fore: global policies promoting SBAs and sidelining TBAs; pressure to achieve the Millennium Development Goal (MDG) on maternal mortality; and the limited financial power and decision space afforded to districts under decentralization in Indonesia. In this context, the regulation offered a viable path for demonstrating commitment to improving maternal health outcomes, yet one that failed to address broader constraints in the health system that contribute to persistent high maternal mortality rates.

The Place of Traditional Birth Attendants in Global Maternal Health: Policy Retreat, Ambivalence and Return

In this chapter, I tell the story of the waxing and waning of the status of the traditional birth attendant (TBA) in global maternal health policy from the launch of the Safe Motherhood Initiative in 1987 to the present. Once promoted as part of the solution to reducing maternal mortality, the training and integration of TBAs into formal healthcare systems in the global south was deemed a failure and side-lined in the late 1990s in favour of ‘a skilled attendant at every birth’. This shift in policy has been one of the core debates in the history of the global maternal health movement and TBAs continue to be regarded with deep ambivalence by many health providers, researchers and policymakers at the national and global levels. In this chapter, I take a critical global heath perspective that scrutinises the knowledge, policy and practice of global health in order to make visible the broader social, cultural and political context of its making. In this chapter, I offer a series of critiques of global maternal health policy regarding TBAs: one, that the evidence cited to underpin the policy shift was weak and inconclusive; two, that the original TBA component itself was flawed; three, that the political and economic context of the first decade of the SMI was not taken into account to explain the failure of TBAs to reduce maternal mortality; and four, that the reorganisation of the Safe Motherhood movement at the global level demanded a new humanitarian logic that had no room for the figure of the traditional birth attendant. I close the chapter by looking at the return of TBAs in global level policy, which, I argue, is bolstered by a growing evidence base, and also by the trends towards ‘self-care’ and point-of-use technologies in global health.

The Implementable Needs of Woman With Maternal Near Miss Experience: A Qualitative Study of Healthcare Providers

Introduction: Maternal Near Miss (MNM) case is defined as “a woman who nearly died but survived a life-threatening and failure organ during pregnancy or childbirth complication that the challenges of this group of mothers have not been addressed. Aim: This qualitative study of healthcare providers was conducted to discover the Iranian near miss mother’s (NMM) needs. Design: conventional qualitative content analysis Methods: In this study 37 participants of key informants, health providers, NMM and their husbands were selected using purposive sampling. Semi structured in-depth interviews were conducted for data collection until data saturation was achieved. Data was analyzed using Graneheim and Lundman. MAXQDA 10 software was used for organizing data and managing the process of analysis. Results: The analysis revealed the core category of "the need for comprehensive support". Eight categories included "psychological", "fertility", "information", "improvement of the care quality care", "sociocultural", "financial", "breastfeeding" and "nutritional" needs emerged from 18 sub-categories, were formed from 2112 codes. Conclusions: Maternal health policy makers should call on health provider centers to work on program designed to support NMMs according to standard guidelines designed to assessment needs.

Reproductive and Maternal Health in Anthropology

In anthropology, the subject of maternal health is diffused within the broader areas of the anthropology of reproduction, fertility, and reproductive health. As a topic it is constituted by work at the intersections of anthropology, public health, feminist studies (covering topics on reproductive choice and autonomy, for instance), and development studies (with its focus on the issues of maternal and infant mortality). The citations presented here are grouped into six topic categories as linked to maternal health, each with further subtopics, on childbirth and maternal/reproductive health, fertility and infertility in maternal health, reproductive technologies and maternal health, family planning and maternal health, abortion, and maternal-health policy and human rights. The topics have been selected on the basis of historical work in these areas and in terms of new directions presented by more-recent work. Wherever possible, indigenous anthropological expertise stemming from local authors in the topic areas has been included.

Indigenous methods and knowledge: Maternal health policy and practice in Ethiopia, Africa

This methodological article explores using Indigenous methodologies to elicit, gather, and report Indigenous knowledge as it relates to maternal health and mortality in the North Wollo Zone of Ethiopia. The authors demonstrate how attention to recruitment procedures (i.e. researcher and research assistant familiarity with the zone), data collection (i.e. interviews, visual dialogues, and observations), and data analysis (i.e. Circles and talking pieces) facilitated the elicitation and gathering of Indigenous knowledge. The authors contend using Indigenous methodologies to elicit, gather, and report Indigenous knowledge is essential to developing and implementing effective maternal health and mortality policies and programs in the region.

Maternal Health Policy Priorities in Pakistan: A Content Analysis of Policy Documents

Background: Despite numerous improvements in the health care system of Pakistan in the past few decades, many disparities continue to persist between health care policies and practices in comparison to developed nations, particularly in the area of maternal health. Despite a 181% increase in expenditure, Pakistan did not meet its target to reduce child mortality and improve maternal health by 2015, causing these disparities to further widen. Methods: We sought to investigate the policymaking process of Pakistan by conducting a content analysis of 34 policy documents pertaining to maternal health service delivery. Results: We found a number of gaps, priorities, and determinants for health policymaking. The most commonly discussed themes were the following: Measures of Burden, System and Organizational Capacity, Access and Availability of Health Services, Policy and Planning, Gaps and Needs, and Socioeconomic Factors. Integrated care and opioid use were seldom mentioned in included policy documents. Conclusions: We discuss the reasons that might explain why Pakistan has not observed an improvement in maternal health outcomes despite significant investment. We use path dependency to explain that drawbacks of health care priority-setting processes in Pakistan. We suggest a refocus on identifying and improving health disparities between communities. We also suggest research and policy attention on integrated care and opioid use in Pakistan.

Determinant factors of maternal near miss in selected health facilities of Berak Woreda, Oromia national regional state, Ethiopia

<p class="abstract"><strong>Background:</strong> Maternal near miss is one of the related concepts to maternal mortality where women survive merely by chance, luck, or by good hospital care. The present study was aimed to fill the prevailing knowledge gap on maternal near miss ratio and events and identify factors associated with near miss in selected health facilities of berak woreda. To determine associated factors of maternal near miss in selected health facilities of Berak woreda, Oromia national regional state, Ethiopia. </p><p class="abstract"><strong>Methods:</strong> Institutional based case control study was conducted in selected health facilities of barek woreda to asses determinant factors of maternal near miss among delivered women. Data of 1272 (344 cases and 928 controls) women were included in the analysis registered from 11 September 2014 to 30 March 2018. Cases were women due to severe acute maternal morbidity while controls were women for normal labor. Simple random sampling technique was used in the delivery unit. The data were collected using WHO standard tool. Data were entered using epi data version 3.1 and exported to SPSSV.20 for data analysis. </p><p class="abstract"><strong>Results:</strong> Majority of cases were due to obstructed labor 270 (78.8%) followed by hemorrhage 33 (9.6%), preeclampsia 29 (8.14%), abortion 6 (1.74%), anemia 3 (0.87%), congenital heart disease 2 (0.58%) and gestational infection 1 (0.29%).</p><p><strong>Conclusions:</strong> Independent variables residence, duration of labor, ANC utilization, past obstetrics complication and number of live births were statistically significant with the outcome variable near miss. Maternal health policy needs to be concerned preventing major cause of near miss.</p><strong id="tinymce" class="mceContentBody " dir="ltr"><em></em></strong>

The free maternal health policy: acceptability and satisfaction with quality of maternal health services during pregnancy in rural Northern Ghana

Introduction: Ghana introduced a maternal health policy in July 2008 to provide free of cost health services to women. However, the utilization of services does not depend on affordability alone but acceptability as well. Acceptability includes attitudes and behaviors of providers and satisfaction with the quality of care. The study explored women’s views and perceptions about attitudes and behaviors of providers and satisfaction with the quality of services under the free maternal health policy in Ghana. In addition, the views and perceptions of providers were examined. Methods: A convergent parallel mixed-methods study was conducted. The study was carried out in the Kassena-Nankana Municipality in Ghana. A structured questionnaire was distributed among women (n=406) who utilized health facilities during pregnancy. Further, focus group discussions (FGDs) with women (n=10) and in-depth interviews with midwives and nurses (n=25) were held. Quantitative data were analyzed using descriptive statistics, while the qualitative data were recorded, transcribed, read, and coded thematically. Results: Women perceived facilities to be clean, especially the smaller ones. Ninety-eight percent of women (n=313/320) perceived providers to be respectful or friendly, and this was mostly confirmed in the FGDs. More than two-thirds of the women (74%, n=300) were also very satisfied or satisfied with the quality of care due to the respect accorded them by providers. Equally, midwives and nurses were satisfied with the quality of care they provided. Nonetheless, providers believed that the unavailability of drugs and supplies, laboratory services, accommodation, and transportation for emergencies reduced women’s satisfaction with services and the quality of care they could provide. Conclusion: The services provided to women during pregnancy were acceptable under the free maternal health policy. There remain challenges in addressing a lack of infrastructure and commodities that affects the quality of care.