WELL-BEING OF MIDWIVES

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CHAPTER 3 LITERATURE REVIEW

INTRODUCTION

Midwives are key persons for the improvement and protection of the health of mothers and children, and for providing prenatal, natal and postpartum health care (Alparslan & Dogane 2009:19). In order to provide quality midwifery care, midwives depend on a conducive environment, including a well-structured labour ward, appropriate and adequate equipment, medical supplies, sufficient human resources as well as a supportive organisation (Pettersson 2007:471). One of the major challenges faced by midwives in developing countries is the difficulty of facing and dealing with maternal death caused by working in a non-conducive environment (Pettersson 2007:471). Maternal death can have adverse effects on the midwives’ health and yet when it occurs, midwives help comfort the bereaved family and they never stop to think about the meaning of it all. It is therefore critical to analyse and describe the effects of work-related exposure to maternal deaths on the well-being of professional midwives in rural Uganda.
The aim of the study was to explore the self-reported stress burden resulting from occupational exposure to maternal death among professional midwives working in rural health units, and the effect of the identified stress burden on their physical and psychological well-being in order to recommend coping mechanisms and support for these midwives.
This chapter presents a review of existing literature relevant to the study. The researcher wished to identify the influence of occupational exposure to maternal deaths on the physical and psychological well-being of professional midwives, as well as what is already known about midwives’ work-related exposure to maternal death in order to assist in identifying a gap or problem that could be addressed by this study.
The researcher identified and discussed various aspects affecting maternal health that influence midwives’ occupational exposure to maternal death. Since there is insufficient information about professional midwives’ exposure to maternal deaths in Uganda and other regions, this review focused on the following main areas:
• The concept of maternal health
• The concept of maternal death
• Occupational exposure to maternal death
• Response to traumatic exposure
• Well-being of professional midwives

MATERNAL HEALTH

Maternal health refers to “the health of women during pregnancy, childbirth, and the postpartum period which encompasses the health care dimensions of family planning, preconception, prenatal and postnatal care in order to reduce maternal morbidity and mortality” (WHO 2011:5).

 The concept of maternal health

Maternal health is important for the survival and health of the mother and the baby (WHO 2011:5; Pollock & King 2009:670). Poor maternal health is measured by high maternal mortality ratio (MMR), and low MMR indicates improving maternal health factors (WHO 2011:5). Globally, MMR was reported at 210 per 100 000 live births in 2010, of which more than half of the deaths occurred in developing countries (WHO UNICEF, UNFPA & World Bank 2012:19; Jabeen, Zaman, Ahmed & Bhatti 2010:679). In many developing countries, maternal deaths among women of reproductive age occur as a result of complications of pregnancy and childbirth, such as postpartum haemorrhage (WHO UNICEF, UNFPA & World Bank 2012:19; Prata et al 2009:132). According to the WHO UNICEF, UNFPA and World Bank (2012:59), the most important intervention in promoting and improving maternal health is the safe motherhood principles which ensure that a trained provider with midwifery skills is present at every birth; transport is available to referral services, and quality emergency obstetric care is available.

Approaches to maternal health

Maternal health is related to both maternal and child health care factors, including preconception and family planning services, prenatal or antenatal care, maternity or delivery care, postnatal care, newborn care, basic essential obstetric care and emergency obstetric care (WHO 2011:5; Prata et al 2010:312; MoH 2010a:4; Pollock & King 2009:670). These factors focus on decreasing maternal morbidity and mortality as follows:
• Preconception emphasises education, health promotion and screening of women to reduce risk factors that might affect future pregnancies, while effective family planning programmes address the largely unmet need for contraception by providing information, counselling and a range of temporary and preventive contraceptive methods (Prata et al 2010: 312; MoH 2010a:4).
• Prenatal care and antenatal care emphasise early detection of any potential complications of pregnancy, so they can be prevented and to direct the woman to appropriate specialist medical services (Prata et al 2010:312).
• Maternity or delivery care emphasises promotion of the use of skilled birth attendants and to ensure that all women have access to life-saving emergency interventions at the time of labour and delivery (Ssengooba et al 2003:3).
• Postnatal care emphasises ensuring that women receive postnatal care after delivery for early diagnosis of postpartum complications.
• Newborn care emphasises an increased awareness of the need to discourage some common practices that are detrimental to newborn health and to promote good practices that contribute to newborn health (Prata et al 2010:314; MoH 2010a:4).
• Basic essential obstetric care includes preventive services as well as medical interventions and procedures that can be provided by skilled birth attendants, such as antenatal care with preventive interventions, early detection and treatment of common problems of pregnancy, the ability to manage simple problems of pregnancy and early management of complications of pregnancy and labour to minimize the need for emergency interventions (Prata et al 2009:134; UNFPA 2003:11).
• Emergency obstetric care specifically covers life-saving interventions of blood transfusion and surgery (Prata et al 2009:134; UNFPA 2003:11).

Main goals of maternal health

The WHO (1999) considers goals as essential in the formulation of rationales for implementing health policies, programmes and services. The goals of maternal health are to improve maternal health by reducing the maternal mortality rate and achieving universal access to reproductive health care (WHO UNICEF, UNFPA & World Bank 2012:19; Prata et al 2010:311). Success is measured by maternal health indicators such as the MMR, the proportion of births attended by skilled health workers, contraceptive prevalence rates, unmet needs for family planning, adolescent birth rates and antenatal care coverage (WHO UNICEF, UNFPA & World Bank 2012:19; Prata et al 2010:311).
The 1994 International Conference on Population and Development in Cairo, Egypt coordinated by the United Nations made a commitment to improve reproductive health with the focus on reducing maternal mortality (WHO et al 2012:19; Prata et al 2010:311). Following the 1994 International Conference on Population and Development, reduction of maternal mortality became the fifth millennium goal with a target of reducing MMR by three quarters (75%) by 2015 (WHO et al 2012:19; Homer et al 2009a:98; Obaid 2009:103). Even though the MMR has nearly halved since 1990 with a decline of 47%, levels are still far below the 2015 target of reducing the MMR by three quarters (75%) (WHO et al 2012:19). According to the WHO et al (2012:19), currently, less than 50% of deliveries are attended by a skilled attendant in low-income countries and 12% of married women aged 15-49 wanting to avoid a pregnancy do not have access to, or are not using an effective method of contraception.

Structure of the maternal health system in Uganda

The maternal health care system in Uganda comprises maternal health policies, maternal health infrastructure, and financing of maternal health services.

Maternal health policies

The National Safe Motherhood Programme is one of the major interventions for the promotion of maternal health in Uganda (MoH Uganda 2009a:13). As part of the Safe Motherhood Programme, a supportive community network of traditional birth attendants has been established as a back-up for a modern maternal health system (MoH Uganda 2009a:13). This intervention is aimed at forecasting high-risk obstetric cases and strengthens referral systems (MoH Uganda 2009a:13). In addition, AbouZahr (2003:14) highlights that the Safe Motherhood Programme has been included as a key element of the Uganda Minimum Health Care Package and is incorporated into the training curriculum of midwives and nurses as an initiative of improving maternal health service delivery.
According to Ssengooba et al (2003:6), the Health Sub-Districts have further adopted a policy strategy for increased decentralisation of service delivery and the expansion of access to essential obstetric care at the community level. In response to a shortage of anaesthetic skills at hospital and health sub-districts level, there is accelerated training of available staff such as nurses and midwives to ensure the functionality of operating theatres (Ssengooba et al 2003:12; Minca 2011). Furthermore, maternal death audits are being conducted as an awareness-raising strategy among health providers and the community. The audit seeks to highlight the factors at the health facility and community level that could help reduce maternal mortality and morbidity (MoH Uganda 2011:15; Ssengooba et al 2003:7).
Other reproductive health policies have also been adopted such as a National Policy that seeks to reduce fertility and maternal morbidity and mortality by promoting informed choice, service accessibility and improved quality of care (MoH Uganda 2009a:13). In addition, due to the lower status of women in many parts of the society, the GoU adopted a National Gender Policy in 1997 with the goal of integrating gender into community and national development (Mugambe 2007:14).

Maternal health infrastructure

The maternal health services in Uganda are delivered through HC IIs, HC IIIs, HC IVs, general hospitals, regional referral hospitals and national referral hospitals. The range of health services delivered varies with the level of care (see table 1.1) (MoH Uganda 2010a:4; MoH Uganda 2010b:5). The government of Uganda committed resources to build 230 HC IVs which provide comprehensive emergency obstetric care to help reduce maternal death, however, only 23% of these health centres IV are fully functioning to provide emergency obstetric care (Minca 2011; MoH Uganda 2010a:4). Modern family planning services are available in 79% of all health care facilities. Normal deliveries can take place in 53% of all health care facilities, while emergency services are not widely available. Approximately two in ten facilities (HC III’s) provide basic emergency obstetric care (17%), while three in ten facilities (HC IV’s & Hospitals) provide comprehensive emergency obstetric care (5%) (MoH Uganda 2011:21). Only 47% of all health care facilities can transport a patient to a referral site for maternal emergencies (UNFPA 2009a:8; Minca 2011).

Financing maternal health services

The Government of Uganda’s priority interventions in the health sector are those that address the burden of disease (Manyire 2010:17). The major contributors to the burden of disease in Uganda include malaria, HIV/AIDS, tuberculosis, diarrhoeal diseases, acute respiratory tract infections, prenatal and maternal conditions attributable to high fertility and poorly spaced births, vaccine preventable childhood illness, malnutrition, injuries and physical and mental disability. Health interventions that address the major causes of the burden of disease constitute the Uganda Minimum Health Care Package, which is the criterion used in determining the allocation of public funds and other essential inputs. Government allocates the greater portion of its budget to the package in such a way that health spending gradually matches the magnitude of priorities within the burden of disease (Manyire 2010:12; MoH Uganda 2010a:23).
Interventions for promoting and achieving maternal health cut across all four clusters of the Uganda Minimum Health Care Package. The clusters are:
• Health promotion, disease prevention and community health initiatives: The central strategy here is the establishment of Village Health Teams and the use of media to mobilize and empower the communities to promote reproductive health and utilise available services. Community empowerment and mobilisation
to utilise contraception would be a significant way of minimising levels of unwanted pregnancies amongst adults and adolescents (Manyire 2010:12; MoH Uganda 2010a:23).
• Maternal and child health: This aims at reducing maternal morbidity and mortality by addressing issues related to sexual health and reproductive rights. It also aims at improving the scope and quality of reproductive health service delivery; building capacity in areas of life saving skills particularly essential new born care, management of malaria in pregnancy, emergency obstetric care, post abortion care and adolescents health (MoH Uganda 2010a:23).
• Prevention and control of communicable diseases: It targets sexually transmitted infections, such as HIV/AIDS, and tuberculosis especially among expectant mothers (Manyire 2010:12; MoH Uganda 2010a:23).
• Prevention and control of non-communicable diseases: this intends to reduce morbidity and mortality attributable to non-communicable diseases, such as injuries, disabilities and rehabilitative health, gender based violence, mental health and control of substance abuse, integrated essential and clinical care, oral health, palliative care, diabetes, cardiovascular diseases, cancers, hypertension, all of which may have implications for safe motherhood (Manyire 2010:12; MoH Uganda 2010a:23).
According to the Health Sector Strategic Plan III, there is no funding to increase the number of health staff, yet it is acknowledged that staffing is low including that of midwives (MoH Uganda 2010a:23). In addition, no funds are allocated for promoting adolescent reproductive health and for facilitating advocacy and lobby work undertaken singularly or in conjunction with civil society organisations, donors and partners to promote safe motherhood (MoH Uganda 2010a:23). Yet, addressing safe motherhood requires multiple approaches and partnerships given its diverse manifestation and consequences (MoH Uganda 2010a:23; Manyire 2010:54). The MoH Uganda and district health services have continued to talk about budgetary allocation for reproductive health, adolescent pregnancy, safe motherhood and gender based violence and yet have done little to oversee the budgetary allocations to these services (MoH Uganda 2010a:23).
Donor support has been biased towards primary health care activities and less has been given to the hospital sector despite the current outstanding role played by hospitals in emergency obstetric care and referral systems (Ssengooba et al 2003:10). Although private-not-for-profit NGO providers charge fees for their services, they only recover about 50% of the total service costs. They charge higher fees for maternal complications and emergencies such as caesarean sections and post abortion care (Ssengooba et al 2003:12).

Maternal health indicators

Health indicators refer to a number, proportion, percentage or rate that helps measure the extent to which planned activities have been conducted and programme achievements completed (WHO 2011:11). According to the WHO et al (2012:19), maternal health indicators are the key determinants of the health status of the population used for monitoring progress towards achieving the maternal health goals. In addition, these indicators also reflect the future directions of maternal health programmes (WHO 2011:11; WHO 1999). When monitoring maternal health progress, one makes a comparison of maternal health indicators, over time and across populations (WHO 2011:11).
Donabedian’s (1988:1743) quality of care framework describes three dimensions, namely input, process, and output indicators. Input indicators in health programmes refer to resources needed for the implementation of an activity or intervention (Donabedian 1988:1743). In maternal health care, input indicators may include maternal health policies, human resources essential for maternal health care, materials, financial resources of maternal health services, equipment and supplies essential for maternal health care, maternal health infrastructure (WHO 2011:11; MoH Uganda 2011:237). The outcome indicators refer more specifically to the objectives of an intervention (Donabedian 1988:1743). In maternal health care, outcome indicators are measured using maternal mortality rate, neonatal mortality rate, total fertility rate and infant mortality rate and these relate to impact or health outcomes of maternal health programmes (WHO et al 2012:19; WHO 2011:11; MoH Uganda 2011:237). Process indicators measure whether planned activities took place successfully to improve service accessibility, utilisation or quality (Donabedian 1988:1743). In maternal health care, process indicators are measured by the proportion of women delivered by skilled attendants, antenatal care coverage, contraception prevalence rate and unmet need for family planning (WHO 2011:16; MoH Uganda 2011:237) (see Table 1.2).

MATERNAL DEATH

Maternal death is defined as “… deaths that occur during pregnancy, within 42 days after pregnancy termination, regardless of pregnancy duration and site, from any cause related to or aggravated by the pregnancy, but not incidental causes » (WHO 2007:4).

The concept of maternal death

Mander (2001:248) states that the death of a mother may be termed us ‘forbidden death’ which means that health care professionals would do everything possible to protect themselves from the unpalatable, even intolerable, reality of a mother’s death. Maternal death is rare in developed countries but is a common experience for developing countries (Pettersson 2007:470). A woman in a developing country has a 97% greater chance of dying as a result of pregnancy and child labour than a woman in a developed country (WHO et al 2012:12; Hunt & Mezquita 2010:4). Therefore maternal death is known to be a major health and social problem in developing countries (WHO et al 2012:12; Cook 2002:107).
Globally, around 80% of maternal deaths are due to obstetric complications; mainly haemorrhage, sepsis, unsafe abortion, pre-eclampsia and eclampsia and prolonged or obstructed labour (Prata et al 2010:314; Homer et al 2009a:98). Timely initiation of medical interventions, such as having a skilled birth attendant caring for the pregnant woman before, during and after childbirth, is essential for reducing maternal deaths (WHO et al 2012:12; Cook 2002:108). If women in developing countries had access to emergency obstetric care, an estimated 74% of maternal deaths could be prevented (Prata et al 2010:314; Homer et al 2009a:98; Hunt & Mezquita 2010:4).

Incidence of maternal death

Maternal death is measured by the maternal mortality ratio (MMR) that predicts the risk of death to pregnant women (WHO et al 2012:13; Cook 2002:108). Maternal mortality is defined as the number of recorded (or estimated) maternal deaths during a given time period per 100 000 live births during the same time period (WHO 2011:11). In addition, the WHO (2011:11) emphasises that maternal mortality is a sensitive measure of health system strength, access to quality care and coverage of effective interventions to prevent maternal deaths. Furthermore, the MMR represents the risks associated with each pregnancy and is also a useful gauge of social and economic conditions such as women’s and girls’ access to education, equality and political commitment to health and development (WHO 2011:11).
The global MMR in 2010 was estimated to be 210 maternal deaths per 100 000 live births, which translates into 287 000 maternal deaths worldwide in 2010, of which developed countries had an estimated MMR of 16 per 100 000 live births (2 200 maternal deaths in 2010) and developing countries had an estimated MMR of 240 per 100 000 live births (284 000 maternal deaths in 2010) (WHO et al 2012:24). In 2008 an estimated 358 000 women died worldwide due to pregnancy-related complications, with low income countries accounting for 99% of these deaths, most of these women delivered alone without a skilled birth attendant (SBA) (Prata et al 2009:132; Homer et al 2009a:98).
The Sub-Saharan African (SSA) region alone accounted for nearly three fifths of the pregnancy-related deaths – 500 per 100 000 live births in 2010 (162 000 maternal deaths) (WHO et al 2012:24). In SSA women have a higher risk of dying (250 times higher) before, during and after pregnancy than other women in industrialised countries (Mavalankar et al 2011:700). For every woman who dies, an estimated 15 to 30 women suffer from chronic illness or injuries as a result of their pregnancies due to fistulas, infertility and incontinence (Homer et al 2009a:98; Prata et al 2009:132). In Uganda the maternal mortality remains high with an estimated MMR of 438 maternal deaths per 100 000 live births, and a life time risk of maternal death of 1 in 10 women (MoH Uganda 2011:14; Orinda, Kakande, Kabarangira, Nanda & Mbonye 2005: 286). Maternal deaths are highest in the most difficult to access areas such as rural areas where women are unable to reach a skilled birth attendant or appropriate health facility in time (Homer et al 2009a:98; Prata et al 2010:314; Jabeen et al 2010:680).

Table of contents
CHAPTER 1 Introduction and orientation to the study
1.1 INTRODUCTION
1.2 BACKGROUND TO THE RESEARCH PROBLEM
1.3 RESEARCH PROBLEM
1.4 AIM OF THE STUDY
1.5 SIGNIFICANCE OF THE STUDY
1.6 THEORETICAL FOUNDATIONS OF THE STUDY
1.7 RESEARCH DESIGN AND METHODOLOGY
1.8 SCOPE AND LIMITATION OF THE STUDY
1.9 DEFINITION OF TERMS
1.10 LAYOUT OF THE STUDY
1.11 CONCLUSION
CHAPTER 2 Theoretical framework
2.1 INTRODUCTION
2.2 THEORETICAL FRAMEWORKS
2.3 CONCLUSION
CHAPTER 3 Literature review
3.1 INTRODUCTION
3.2 MATERNAL HEALTH
3.3 MATERNAL DEATH
3. 4 SKILLED BIRTH ATTENDANTS
3.5 RESPONSE TO TRAUMATIC EXPOSURE
3.6 OCCUPATIONAL EXPOSURE TO MATERNAL DEATH
3.7 WELL-BEING OF MIDWIVES
3.8 CONCLUSION
CHAPTER 4 Research design and methodology
4.1 INTRODUCTION
4.2 RESEARCH DESIGN
4.3 RESEARCH METHODOLOGY
4.4 CONCLUSION
CHAPTER 5 DATA ANALYSIS AND INTERPRETATION, AND FINDINGS
5.1 INTRODUCTION
5.2 RESPONSE RATE
5.3 DATA MANAGEMENT AND ANALYSIS
5.4 RESEARCH RESULTS
5.5 INTEGRATING THE RESULTS INTO THE THEORETICAL FRAMEWORKS
5.6 CONCLUSION
CHAPTER 6 FINDINDS, CONCLUSION AND RECOMMENDATIONS
6.1 INTRODUCTION
6.2 AIM AND OBJECTIVES OF THE STUDY
6.3 FINDINGS
6.4 GENERAL CONCLUSIONS
6.5 RECOMMENDATIONS TO PROMOTE THE COPING MECHANISM AND WELL-BEING OF RURAL MIDWIVES IN VIEW OF OCCUPATIONAL EXPOSURE TO MATERNAL DEATH
6.6 LIMITATIONS OF THE STUDY
6.7 RECOMMENDATIONS FOR FURTHER RESEARCH
6.8 CONCLUSION
LIST OF REFERENCES
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