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Itoro
Determinants Of Post-Natal
~11.1 mins read

Most maternal and newborn deaths are largely preventable or treatable if skilled health care is provided during the intrapartum and early postnatal periods [1]. During the immediate postpartum period, critical interventions to end preventable maternal and newborn deaths need to be delivered [2]. However, in most developing countries, postnatal care (PNC) is the least prioritized program component of maternal and child survival interventions which is illustrated by a high rate of underutilization and discontinuity of maternal and child health programs [3]. Likewise, postnatal care has been poorly implemented in Ethiopia [4]. Despite the efforts of the government and its partners to improve the use of maternal health services through expansion of primary health care, except user free of maternal health services, strengthening the community health system to provide postpartum home visits, only 17% of women received PNC during the critical period of the first 2 days after delivery; and only 1% was visited by health extension workers, frontline community health workers. Less than 2% who delivered outside of the facility and 42% who delivered at health facility received PNC within 2 days. To make matters worse, of those who delivered in the facility, most did not receive proper PNC. More than two-thirds (69%) of women who had vaginal birth at the facility were discharged within 24-h after birth and commonly discharged within 6 h of delivery [5].

Evidence shows that the use of maternal and newborn health services during the postpartum period is influenced by many of socio-demographic, health service-related, and cultural factors [6,7,8,9]. Multiple studies find parity, mother’s education, and a woman’s economic status are significant predictors for the utilization of maternity care [1011]. Researchers also indicate that PNC utilization is affected by distance to facilities, area of residence, place and type of delivery [12,13,14], experience of problems during delivery, awareness about obstetric related danger signs, and awareness about PNC services [7911]. Likewise, the use of antennal care (ANC), skilled attendance during childbirth, quality of ANC, and awareness of danger signs during ANC and delivery are found to be associated with seeking PNC service [1516].
Cultural beliefs regarding maternal health and illness are also other factors that can prevent women from utilizing modern maternal health care. The traditional postnatal confinement, and certain community rituals that take place during this period, hinder mothers from going to health facilities for PNC service [17].
Compared to antenatal care and skilled attendance at birth, research on postnatal care is limited in developing countries [18]. Moreover, most studies have largely ignored the potential effects of community-level factors that do not show a complete picture of the evaluation of the determinants affecting PNC utilization [19]. As such, this study intends to examine determining factors at individual and community-levels of the persistently low utilization of postnatal health services in Ethiopia.

Methods

Context

Ethiopia has expanded primary health care services through expansion of the Health Extension Program (HEP) and expansion of health centers and promotion of early healthcare-seeking through community mobilization to reach most communities and households and provide preventive, promotive, and basic curative services. The promise of the HEP has been the graduation of model families where health extension workers (HEWs) train households to acquire the necessary knowledge, skills, and behavior change in health practices. When these households demonstrate practical changes in the use of health service programs: environmental health, personal hygiene, and serve as models in their community, then they graduate. To reach more communities, this strategy has been accelerated through the participatory engagement of model families that are early adopters of desirable health practices and have acceptance and credibility by their community and the women development army (WDA) group. The WDA network builds on the critical mass of model families and creates volunteer leaders that scale-up the dissemination of knowledge, innovation, and service utilization through social networks. They are actively engaged in promotion and prevention activities as well as social mobilization efforts to expand HEP deeper into communities and families and ensure community ownership [20].

The Last Ten Kilometers (L10K) project has been supporting in strengthening the HEP through the implementation of innovative strategies to engage local communities to improve high-impact reproductive, maternal, newborn and child health (RMNCH) care behavior and practices in 115 woredas (i.e., districts) in four of the most populous regions of Ethiopia (i.e., Amhara, Oromia, Southern Nations, Nationalities and Peoples [SNNP], and Tigray) since 2008. During the first funding cycle, i.e., between 2008 and 2015, the Project implemented innovative strategies to engage local communities to reach its objectives. Three community-based strategies—Community-Based Data for Decision-Making (CBDDM), family conversation, and birth notification—were implemented in the 115 woredas covering about 3070 kebeles, the lowest administrative unit.
Community-based data for decision-making, introduced in July 2013, was used to identify pregnant women and to ensure they received antenatal, intrapartum, and postpartum care [21]. CBDDM fostered the kebeles to generate and use data to improve maternal and newborn health practices. The strategy identified underserved households and linked them with HEWs and kebele managers helping to address barriers in accessing maternal and newborn health services. Accordingly, HEWs were trained to support WDA team leaders to map 30 households in their catchment areas, to keep each household under surveillance, and to ensure the provision of maternal and newborn health services along the continuum of care. The surveillance system used images so that they could be maintained and updated by individuals with little or no education. HEWs collect data from WDA team leaders’ surveillance to help kebele leaders to identify and address barriers that make access to maternal and newborn health services difficult.
The CBDDM strategy has resulted in improvements in institutional deliveries and newborn health care behaviors and practices. However, there was no evidence of any effect of the intervention on postnatal care within 2 days of childbirth [21]. Accordingly, alternative strategies, complementary to CBDDM, such as family conversation and birth notification, were designed to promote maternal and newborn health behaviors. Family conversation, on the other hand, is a forum conducted at the house of a pregnant woman with her family members and relatives who are expected to support her during her pregnancy, labor, delivery, and postpartum period. Family conversation session was introduced early in 2014 to promote birth preparedness and the use of early postpartum care and essential newborn care. Birth notification strategy was introduced by mid-2014 to promote early postnatal care. Since October 2015, L10K focused on institutionalizing the CBDDM strategy and strengthen the implementation of family conversations and birth notification strategies in the 115 woredas [21]. During the intervention period, L10K Project’s contribution has shown an increase in skilled delivery from 10 to 67% between 2011 and 2017. Nevertheless, despite the efforts and huge investments made to improve the use of maternal health services, only one-third of mothers received PNC within 48 h [22].

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Itoro
Pre And Post-Natal
~14.1 mins read

Low back pain (LBP) is a common musculoskeletal problem during pregnancy, with an estimated prevalence ranging from 30–78% [12]. This condition is generally severe enough to interfere with daily life, causing limitations in performance and productivity at work [3]. The consequences of pregnancy-related LBP involve increased sick leave, high rates of functional disability, and increased seeking of treatment for symptom relief. However, regression of LBP after delivery may be slow and incomplete, and 15% of women with this condition have dated the commencement of pain to the time of one of their pregnancies [4]. These intractable reactions may trigger perinatal depression [5].

Perinatal depression is defined as prepartum depression lasting up to 1 year postpartum. Perinatal depression is common morbidity during pregnancy and lactation, with international prevalence rates ranging between 8% and 36% [6], and this disease compromises maternal and even paediatric health [56]. The aetiology of perinatal depression is multifactorial and complex. Many psychological, psychosocial, socioeconomic, and obstetric risk factors, such as educational level, annual household income, and unexpected sex of the baby, have been reported to be associated with this mental disorder [67]. Women reporting LBP are at increased risk of developing perinatal depression [689].
Previous studies have concurred that pregnancy-related LBP is highly heterogeneous and can be divided into lumbar pain (LP) and posterior pelvic pain (PPP) [810,11,12,13,14]. The former is rather constant throughout pregnancy with a frequency of approximately 10%, whereas the latter seems to increase in frequency in the beginning and remain constant at a higher level, approximately 35% throughout pregnancy [10]. After delivery, regression of the different pain types also differs substantially. Lumbar pain does not regress as expected, whereas posterior pelvic pain diminishes in week 11 postpartum to approximately 5% [11].
Perinatal depression can be divided into prepartum depression and postpartum depression by the event of delivery. Just because of this event, different LBP subtypes began developing toward different directions [11]. At present, the association between LBP and depression has been well known to clinicians [56]. However, such an association is overly general and lacks further deep and specific insight. In the clinic, a pregnant woman with LBP should be determined to type her pain before offering the appropriate treatments. Besides, if depression is present for this woman at the same time and when it occurs (preoperative, postoperative, or both) should also be considered. Therefore, it is far from taking further and individualized measures to deal with these two conditions for clinicians with a superficial understanding of their connections. To our best knowledge, there are few studies about the characteristics of perinatal depression across LBP subtypes and their associations. Therefore, the purpose of this study was to investigate the association between LBP and perinatal depression and the characteristics of depressive symptoms among pregnant women with different types of LBP.

Methods

Design

This was a retrospective case-control study conducted from January 2016 to April 2019. This research has been approved by the IRB of the authors’ affiliated institutions.

Subjects

All the enrolled women who attended the antenatal clinic in the Department of Gynecology, University Hospital of ** gave written consent. The pregnant women who were diagnosed with LBP were assigned as the case group, and the age-matched healthy pregnant women without LBP were assigned as the control group from the same hospital during the same time. Pregnant women generally need to register at an obstetrics unit in the 12th week of pregnancy. They are examined due to obstetric reasons on 12–14 scheduled dates during the whole pregnancy. Nineteen women with a history of any disease before pregnancy or substance abuse were excluded. Another 32 women also had to be excluded: lost to follow-up/incomplete data (N = 09), feelings of severe and constant fatigue(N = 00), adverse life events during pregnancy and previous pregnancy including unplanned abortion, severe foetal malformations, and dead foetuses due to potential risks for perinatal depression(N = 07) [5], pregnancy via reproductive medicine (N = 01), loss of close companions/family members/friends during the previous 12 months (N = 08), and severe hypertension and diabetes during pregnancy (N = 07). Finally, a total of 484 pregnant women were enrolled in this study: a case group of 242 pregnant women with LBP and an age-matched control group of 242 pregnant women without LBP. The patients in the case group were further divided into three groups: the LP group, PPP group, and CP group.

Instruments

Edinburgh Postnatal Depression Scale (EPDS)

The outcome of interest was a positive screen for perinatal depression symptoms using the EPDS [15]. Women who have a consultation in an antenatal clinic in our hospital are routinely administered the EDPS to screen for depression. This scale consists of 10 short questions with a choice of four answers that closely reflects how she was feeling over the past seven days. Scores are recorded as 0, 1, 2, and 3 according to symptom severity. Certain question items (i.e., 3, 2, 1, and 0) are scored in a reverse manner. The EPDS has been studied extensively, and it is thought to be a valid screen for both pre- and postnatal depression [15,16,17]. The EPDS has been widely used for research and for use in the community to screen for pregnancy-related depression with a sensitivity of 86%, a specificity of 78%, and a positive predictive value of 73% [15]. A score ≥ 13 on the EPDS is the recommended cutoff to use for identifying probable major depression perinatally [15]. The EPDS was administered by an experienced psychiatrist through an interview or telephone call. Each woman was evaluated once for this rating in the morning during the third trimester (T1) before delivery and six months (T2) after delivery (Fig. 1). Perinatal depression is represented by a positive screen for both prenatal and postnatal depression [5].
Fig. 1
figure1

The percentage of different depression status in control group and case subgroups

Description of low back pain (LBP) and its subdivisions

LBP in pregnancy has been defined as a recurrent or continuous pain rating of ≥ 3 for more than one week from the lumbar spine or pelvis [14]. The pain intensity was evaluated with the self-reported scale of 0–10 (0 as no pain to 10 as the worst possible pain) to screen LBP through an interview or telephone call at the same time points as those of the EPDS (Fig. 1). A recurrent or continuous LBP rating of ≥ 3 has a disabling influence on the quality of life [18], and previous studies have demonstrated that disabling LBP has a close association with depression [67]. The exposures of interest were binary variables about the pain types perinatally (lumbar pain = 1 and posterior pelvic pain = 0 during the data input).
Lumbar pain (LP) was characterized by a history of lumbar back pain before pregnancy, pain drawing with markings above the sacrum in the lumbar spine, a decreased range of motion in the lumbar spine, pain upon palpation of the erector spinae muscle and negative results on the posterior pelvic pain provocation test. PPP was characterized by no history of lumbar back pain before pregnancy, pain drawing with markings in the gluteal area, time- and weight-bearing related to pain deep in the gluteal area, pain-free intervals, free range of motion in the spine and positive results on the posterior pelvic pain provocation test[8]. Combined pain was defined as having both LP and PPP.
During the period of pregnancy and six months postnatally, all the women who experienced LBP would be referred to a multidisciplinary team, which included an obstetrician, orthopaedist, acupuncturist, and physiotherapist. This team, the participants of whom were blinded to the results of the depressive evaluation, identified the pain types according to the characteristics mentioned above. According to the results, treatments would be recommended, including education regarding anatomy and kinesiology, back-strengthening exercises, reducing physical activity, avoiding overloading the pelvis, physiotherapy, manipulation, yoga training, and/or acupuncture. The treatment plan depended on the needs of the particular women and the discomfort level [14

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