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Introduction: Between 2006 and 2017, antenatal care (ANC) coverage in Benin declined, potentially exacerbating inequalities and substantiating the need for health inequality monitoring. This study examines inequalities in ANC attendance in Benin, disaggregated by women's age, educational level, economic status, place of residence, region of residence, and the extent to which they have changed over time. Methods: Three rounds of the Benin Demographic and Health Surveys (2006, 2011–12, and 2017–18) were analyzed to examine inequalities in ANC coverage. An exploratory descriptive approach was adopted for the analysis. Simple [difference (D) and ratio (R)] and complex [population attributable risk (PAR) and population attributable fraction (PAF)] measures of inequalities were computed using the World Health Organization's Health Equity Assessment Toolkit (WHO's HEAT) online platform. The measures were computed separately for each of the three surveys, and their estimates were compared. Results: The findings revealed an 8.4% decline in at least four ANC visits between 2006 and 2017–18. The decline occurred irrespective of age, educational status, economic status, place of residence, and region. Region-related inequalities were the largest and increased slightly between 2006 (D = 54.6; R = 2.6; PAF = 47.8, PAR = 29.0) and 2017–18 (D = 55.8; R = 3.1; PAF = 57.2, PAR = 29.8). Education (2006: D = 31.3, R = 1.6, PAF = 40.5, PAR = 24.5; 2017–18: D = 25.2, R = 1.6, PAF = 34.9, PAR = 18.1) and rural-urban (2006: D = 16.8, R = 1.3, PAF = 17.8, PAR = 10.8; 2017–18: D = 11.2, R = 1.2, PAF = 13.1, PAR = 6.8) inequalities reduced while economic status inequalities did not improve (2006: D = 48, R = 2.2, PAF = 44.5, PAR = 26.9; 2017–18: D = 43.9, R = 2.4, PAF = 45.0, PAR = 23.4). Age inequalities were very minimal. Conclusion: ANC inequalities remain deeply ingrained in Benin. Addressing their varying levels requires comprehensive strategies that encompass both supply—and demand-side interventions, focusing on reaching uneducated women in the poorest households and those residing in rural areas and Atacora. [ABSTRACT FROM AUTHOR]

Background: In the quest for quality antenatal care (ANC) and positive pregnancy experience, the value of comprehensive woman hand-held case notes cannot be emphasised enough. However, the woman's health passport book in Malawi presents gaps which hinder provision of quality care, especially during pregnancy. We aimed to develop a compressive updated woman hand-held case notes tool (health passport book) which reflects WHO 2016 ANC guidelines in Malawi. Methods: From July 2022 to August 2022, we applied a co-creative participatory approach in 3 workshops with key stakeholders to compare the current ANC tool contents to the WHO 2016 ANC guidelines, decide on key elements to be changed to improve adherence and change in practice, and redesign the woman's health passport tool to reflect the changes. Within-group discussions led to whole-group discussions and consensus, guided by a modified nominal group technique. Facilitators guided the discussions while ensuring autonomy of the group members in their deliberations. Discussions were recorded and transcribed. Data was analysed through thematic analysis, and reduction and summaries in affinity diagrams. The developed tool was endorsed for implementation within Malawi's healthcare system by the national safe motherhood technical working group (TWG) in July 2023. Results: Five themes were identified in the analysis. These were (i) critical components in the current tool missed, (ii) reimagining the current ANC tool, (iii) opportunity for ultrasound scanning conduct and documentation, (iv) anticipated barriers related to implementation of the newly developed tool and (v) cultivating successful implementation. Participants further recommended strengthening of already existing policies and investments in health, strengthening public private partnerships, and continued capacity building of healthcare providers to ensure that their skill sets are up to date. Conclusion: Achieving goals of quality ANC and universality of healthcare are possible if tools in practice reflect the guidelines set out. Our efforts reflect a pioneering attempt in Malawi to improve women's hand-held case notes, which we know help in enhancing quality of care and improve overall women's satisfaction with their healthcare system. [ABSTRACT FROM AUTHOR]

Background: QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania.Methods: This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider's perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios.Results: Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes.Conclusions: Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system.Trial Registration: Registered clinical trial at www.clinicaltrials.gov ( NCT01409824 ). Registered May 2009. [ABSTRACT FROM AUTHOR]

Background: Sustainable Development Goal (SDG) 3.7 aims to ensure universal access to sexual and reproductive healthcare services, where antenatal care (ANC) is a core component. This study aimed to examine the influence of health facility availability and readiness on the uptake of four or more ANC visits in Bangladesh. Methods: The 2017/18 Bangladesh Demographic and Health Survey data were linked with the 2017 Health Facility Survey and analyzed in this study. The associations of health facility-level factors with the recommended number of ANC uptakes were determined. A multilevel mixed-effect logistic regression model was used to determine the association, adjusting for potential confounders. Results: Nearly 44% of mothers reported four or more ANC uptakes, with significant variations across several areas in Bangladesh. The average distance of mothers' homes from the nearest health facilities was 6.36 km, higher in Sylhet division (8.25 km) and lower in Dhaka division (4.45 km). The overall uptake of the recommended number of ANC visits was positively associated with higher scores for the management (adjusted odds ratio (aOR) 1.85; 95% CI, 1.16–2.82) and infrastructure (aOR, 1.59; 95% CI, 1.09–2.19) of health facilities closest to mothers' homes. The odds of using the recommended number of ANC in mothers increased by 3.02 (95% CI, 2.01–4.19) and 2.36 (95% CI, 2.09–3.16) folds for each unit increase in the availability and readiness scores to provide ANC services at the closest health facilities, respectively. Every kilometer increase in the average regional-level distance between mothers' homes and the nearest health facilities reduced the likelihood of receiving the recommended number of ANC visits by nearly 42% (aOR, 0.58, 95% CI, 0.42–0.74). Conclusion: The availability of healthcare facilities close to residence, as well as their improved management, infrastructure, and readiness to provide ANC, plays a crucial role in increasing ANC services uptake. Policies and programs should prioritize increasing the availability, accessibility, and readiness of health facilities to provide ANC services. [ABSTRACT FROM AUTHOR]

Background: Ghana is attracting global attention for efforts to provide health insurance to all citizens through the National Health Insurance Scheme (NHIS). With the program's strong emphasis on maternal and child health, an expectation of the program is that members will have increased use of relevant services. Methods: This paper uses qualitative and quantitative data from a baseline assessment for the Maternal and Newborn errals Evaluation from the Northern and Central Regions to describe women's experiences with the NHIS and to study associations between insurance and skilled facility delivery, antenatal care and early care-seeking for sick children. The assessment included a quantitative household survey (n = 1267 women), a quantitative community leader survey (n = 62), qualitative birth narratives with mothers (n = 20) and fathers (n = 18), key informant interviews with health care workers (n = 5) and focus groups (n = 3) with community leaders and stakeholders. The key independent variables for the quantitative analyses were health insurance coverage during the past three years (categorized as all three years, 1-2 years or no coverage) and health insurance during the exact time of pregnancy. Results: Quantitative findings indicate that insurance coverage during the past three years and insurance during pregnancy were associated with greater use of facility delivery but not ANC. Respondents with insurance were also significantly more likely to indicate that an illness need not be severe for them to take a sick child for care. The NHIS does appear to enable pregnant women to access services and allow caregivers to seek care early for sick children, but both the quantitative and qualitative assessments also indicated that the poor and least educated were less likely to have insurance than their wealthier and more educated counterparts. Findings from the qualitative interviews uncovered specific challenges women faced regarding registration for the NHIS and other barriers such lack of understanding of who and what services were covered for free. Conclusion: Efforts should be undertaken so all individuals understand the NHIS policy including who is eligible for free services and what services are covered. Increasing access to health insurance will enable Ghana to further improve maternal and child health outcomes. [ABSTRACT FROM AUTHOR]

Background The levels and origins of socio-economic inequalities in health-seeking behaviours in Egypt are poorly understood. This paper assesses the levels of health-seeking behaviours related to maternal care (antenatal care [ANC] and facility delivery) and their accumulation during pregnancy and childbirth. Secondly, it explores the mechanisms underlying the association between socio-economic position (SEP) and maternal health-seeking behaviours. Thirdly, it examines the effectiveness of targeting of free public ANC and delivery care. Methods Data from the 2008 Demographic and Health Survey were used to capture two latent constructs of SEP: individual socio-cultural capital and household-level economic capital. These variables were entered into an adjusted mediation model, predicting twelve dimensions of maternal health-seeking; including any ANC, private ANC, first ANC visit in first trimester, regular ANC (four or more visits during pregnancy), facility delivery, and private delivery. ANC and delivery care costs were examined separately by provider type (public or private). Results While 74.2% of women with a birth in the 5-year recall period obtained any ANC and 72.4% delivered in a facility, only 48.8% obtained the complete maternal care package (timely and regular facility-based ANC as well as facility delivery) for their most recent live birth. Both socio-cultural capital and economic capital were independently positively associated with receiving any ANC and delivering in a facility. The strongest direct effect of socio-cultural capital was seen in models predicting private provider use of both ANC and delivery. Despite substantial proportions of women using public providers reporting receipt of free care (ANC: 38%, delivery: 24%), this free-of-charge public care was not effectively targeted to women with lowest economic resources. Conclusions Socio-cultural capital is the primary mechanism leading to inequalities in maternal healthseeking in Egypt. Future studies should therefore examine the objective and perceived quality of care from different types of providers. Improvements in the targeting of free public care could help reduce the existing SEP-based inequalities in maternal care coverage in the short term. [ABSTRACT FROM AUTHOR]

Background: Evidence on healthcare managers' experience on operational feasibility of malaria intermittent preventive treatment for malaria during pregnancy (IPTp) using sulphadoxine-pyrimethamine (SP) in Africa is systematically inadequate. This paper elucidates the perspectives of District Council Health Management Team (CHMT)s regarding the feasibility of IPTp with SP strategy, including its acceptability and ability of district health care systems to cope with the contemporary and potential challenges. Methods: The study was conducted in Mkuranga and Mufindi districts. Data were collected between November 2005 and December 2007, involving focus group discussion (FGD) with Mufindi CHMT and in-depth interviews were conducted with few CHMT members in Mkuranga where it was difficult to summon all members for FGD. Results: Participants in both districts acknowledged the IPTp strategy, considering the seriousness of malaria in pregnancy problem; government allocation of funds to support healthcare staff training programmes in focused antenatal care (fANC) issues, procuring essential drugs distributed to districts, staff remuneration, distribution of fANC guidelines, and administrative activities performed by CHMTs. The identified weaknesses include late arrival of funds from central level weakening CHMT's performance in health supervision, organising outreach clinics, distributing essential supplies, and delivery of IPTp services. Participants anticipated the public losing confidence in SP for IPTp after government announced artemither-lumefantrine (ALu) as the new first-line drug for uncomplicated malaria replacing SP. Role of private healthcare staff in IPTp services was acknowledged cautiously because CHMTs rarely supplied private clinics with SP for free delivery in fear that clients would be required to pay for the SP contrary to government policy. In Mufindi, the District Council showed a strong political support by supplementing ANC clinics with bottled water; in Mkuranga such support was not experienced. A combination of health facility understaffing, water scarcity and staff non-adherence to directly observed therapy instructions forced healthcare staff to allow clients to take SP at home. Need for investigating in improving adherence to IPTp administration was emphasised.Conclusion: High acceptability of the IPTp strategy at district level is meaningless unless necessary support is assured in terms of number, skills and motivation of caregivers and availability of essential supplies. [ABSTRACT FROM AUTHOR]

Background: Despite growing interest in monitoring improvements in quality of care, data on service quality in low-income and middle-income countries (LMICs) is limited. While health systems researchers have hypothesized the relationship between facility readiness and provision of care, there have been few attempts to quantify this relationship in LMICs. This study assesses the association between facility readiness and provision of care for antenatal care at the client level and facility level. Methods: To assess the association between provision of care and various facility readiness indices for antenatal care, we used multilevel, multivariable random-effects linear regression models. We tested an inflection point on readiness scores by fitting linear spline models. To compare the coefficients between models, we used a bootstrapping approach and calculated the mean difference between all pairwise comparisons. Analyses were conducted at client and facility levels. Results: Our results showed a small, but significant association between facility readiness and provision of care across countries and most index constructions. The association was most evident in the client-level analyses that had a larger sample size and were adjusted for factors at the facility, health worker, and individual levels. In addition, spline models at a facility readiness score of 50 better fit the data, indicating a plausible threshold effect. Conclusions: The results of this study suggest that facility readiness is not a proxy for provision of care, but that there is an important association between facility readiness and provision of care. Data on facility readiness is necessary for understanding the foundations of health systems particularly in countries with the lowest levels of service quality. However, a comprehensive view of quality of care should include both facility readiness and provision of care measures. [ABSTRACT FROM AUTHOR]

Background: We performed an economic analysis of a new technology used in antenatal care (ANC) clinics, the ANC panel. Introduced in 2019–2020 in five Rwandan districts, the ANC panel screens for four infections [hepatitis B virus (HBV), human immunodeficiency virus (HIV), malaria, and syphilis] using blood from a single fingerstick. It increases the scope and sensitivity of screening over conventional testing. Methods: We developed and applied an Excel-based economic and epidemiologic model to perform cost-effectiveness and cost-benefit analyses of this technology in Kenya, Rwanda, and Uganda. Costs include the ANC panel itself, its administration, and follow-up treatment. Effectiveness models predicted impacts on maternal and infant mortality and other outcomes. Key parameters are the baseline prevalence of each infection and the effectiveness of early treatment using observations from the Rwanda pilot, national and international literature, and expert opinion. For each parameter, we found the best estimate (with 95% confidence bound). Results: The ANC panel averted 92 (69–115) disability-adjusted life years (DALYs) per 1,000 pregnant women in ANC in Kenya, 54 (52–57) in Rwanda, and 258 (156–360) in Uganda. Net healthcare costs per woman ranged from $0.53 ($0.02-$4.21) in Kenya, $1.77 ($1.23-$5.60) in Rwanda, and negative $5.01 (-$6.45 to $0.48) in Uganda. Incremental cost-effectiveness ratios (ICERs) in dollars per DALY averted were $5.76 (-$3.50-$11.13) in Kenya, $32.62 ($17.54-$46.70) in Rwanda, and negative $19.40 (-$24.18 to -$15.42) in Uganda. Benefit-cost ratios were $17.48 ($15.90-$23.71) in Kenya, $6.20 ($5.91-$6.45) in Rwanda, and $25.36 ($16.88-$33.14) in Uganda. All results appear very favorable and cost-saving in Uganda. Conclusion: Though subject to uncertainty, even our lowest estimates were still favorable. By combining field data and literature, the ANC model could be applied to other countries. [ABSTRACT FROM AUTHOR]

Background: Women from ethnic minority backgrounds are at greater risk of adverse maternal outcomes. Antenatal care plays a crucial role in reducing risks of poor outcomes. The aim of this study was to identify, appraise, and synthesise the recent qualitative evidence on ethnic minority women's experiences of accessing antenatal care in high-income European countries, and to develop a novel conceptual framework for access based on women's perspectives. Methods: We conducted a comprehensive search of seven electronic databases in addition to manual searches to identify all qualitative studies published between January 2010 and May 2021. Identified articles were screened in two stages against the inclusion criteria with titles and abstracts screened first followed by full-text screening. Included studies were quality appraised using the Critical Appraisal Skills Programme checklist and extracted data were synthesised using a 'best fit' framework, based on an existing theoretical model of health care access. Results: A total of 30 studies were included in this review. Women's experiences covered two overarching themes: 'provision of antenatal care' and 'women's uptake of antenatal care'. The 'provision of antenatal care' theme included five sub-themes: promotion of antenatal care importance, making contact and getting to antenatal care, costs of antenatal care, interactions with antenatal care providers and models of antenatal care provision. The 'women's uptake of antenatal care' theme included seven sub-themes: delaying initiation of antenatal care, seeking antenatal care, help from others in accessing antenatal care, engaging with antenatal care, previous experiences of interacting with maternity services, ability to communicate, and immigration status. A novel conceptual model was developed from these themes. Conclusion: The findings demonstrated the multifaceted and cyclical nature of initial and ongoing access to antenatal care for ethnic minority women. Structural and organisational factors played a significant role in women's ability to access antenatal care. Participants in majority of the included studies were women newly arrived in the host country, highlighting the need for research to be conducted across different generations of ethnic minority women taking into account the duration of stay in the host country where they accessed antenatal care. Protocol and registration: The review protocol was registered on PROSPERO (reference number CRD42021238115). [ABSTRACT FROM AUTHOR]

Background: Over the last decade, progress in reducing maternal mortality in Rwanda has been slow, from 210 deaths per 100,000 live births in 2015 to 203 deaths per 100,000 live births in 2020. Access to quality antenatal care (ANC) can substantially reduce maternal and newborn mortality. Several studies have investigated factors that influence the use of ANC, but information on its quality is limited. Therefore, this study aimed to identify the determinants of quality antenatal care among pregnant women in Rwanda using a nationally representative sample.Methods: We analyzed secondary data of 6,302 women aged 15-49 years who had given birth five years prior the survey from the Rwanda Demographic and Health Survey (RDHS) of 2020 data. Multistage sampling was used to select RDHS participants. Good quality was considered as having utilized all the ANC components. Multivariable logistic regression was conducted to explore the associated factors using SPSS version 25.Results: Out of the 6,302 women, 825 (13.1%, 95% CI: 12.4-14.1) utilized all the ANC indicators of good quality ANC); 3,696 (60%, 95% CI: 58.6-61.1) initiated ANC within the first trimester, 2,975 (47.2%, 95% CI: 46.1-48.6) had 4 or more ANC contacts, 16 (0.3%, 95% CI: 0.1-0.4) had 8 or more ANC contacts. Exposure to newspapers/magazines at least once a week (aOR 1.48, 95% CI: 1.09-2.02), lower parity (para1: aOR 6.04, 95% CI: 3.82-9.57) and having been visited by a field worker (aOR 1.47, 95% CI: 1.23-1.76) were associated with more odds of receiving all ANC components. In addition, belonging to smaller households (aOR 1.34, 95% CI: 1.10-1.63), initiating ANC in the first trimester (aOR 1.45, 95% CI: 1.18-1.79) and having had 4 or more ANC contacts (aOR 1.52, 95% CI: 1.25-1.85) were associated with more odds of receiving all ANC components. Working women had lower odds of receiving all ANC components (aOR 0.79, 95% CI: 0.66-0.95).Conclusion: The utilization of ANC components (13.1%) is low with components such as having at least two tetanus injections (33.6%) and receiving drugs for intestinal parasites (43%) being highly underutilized. Therefore, programs aimed at increasing utilization of ANC components need to prioritize high parity and working women residing in larger households. Promoting use of field health workers, timely initiation and increased frequency of ANC might enhance the quality of care. [ABSTRACT FROM AUTHOR]

Background: Migration has increased the number of immigrant women in western countries, which has led to a need to adapt sexual and reproductive health (SRH) care to a larger variety of experiences. Examples of problems are poor access/utilization of SRH services among migrants and a comparatively higher rate of mortality and morbidity in relation to pregnancy, especially among those from low- and middle-income settings. Attempts to improve SHR care must consider the complexity of both the problem and the system. A national program to improve women's health in Sweden provided opportunities to study interventions aimed at immigrant women, using a complexity theory lens. The purpose was to explore the characteristics and complexity of regional interventions aiming to improve care and health of immigrant women before, during and after childbirth, and provide knowledge on how regional healthcare actors perceive and address problems in these areas.Methods: This archival research study is based on qualitative data from detailed yearly reports of all regional program interventions (n = 21 regions) performed between January 2017 and January 2019. The archival data consists of the regional actors' answers to an extensive questionnaire-like template, where the same questions were to be filled in for each reported intervention. Data analyses were performed in several steps, combining classic and directive content analysis.Results: Six problem categories were addressed by 54 regional interventions, 26 directed at immigrant women and their families, 11 at healthcare staff, and 17 at the organizational system. The simple level interventions (n = 23) were more unilateral and contained information campaigns, information material and translation, education, mapping e.g., of genital mutilation, and providing staff and/or financial resources. The complicated interventions (n = 10) concerned increasing communication diversity e.g., by adding iPads and out-reach visits. The complex interventions (n = 21), e.g., health schools, integration of care, contained development, adaptions, and flexibility with regards to the immigrant women's situation, and more interaction among a diversity of actors, also from the wider welfare system.Conclusions: It is important that complex problems, such as ensuring equal care and health among a diverse population, are addressed with a mix of simple, complicated, and complex interventions. To enhance intended change, we suggest that pre-requisites e.g., communication channels and knowledge on behalf of immigrant women and staff, are ensured before the launch of complex interventions. Alternatively, that simple level interventions are embedded in complex interventions. [ABSTRACT FROM AUTHOR]

Background: Late antenatal care initiation is linked to a higher risk of maternal death. Women who do not start ANC at an early stage may experience the effects of pregnancy-related health difficulties, as well as long-term health issues and pregnancy complications. Therefore, our study aimed to determine the prevalence of late initiation of antenatal care and associated factors among pregnant women in Jimma Zone public Hospitals.Methods: A facility-based cross-sectional study design was employed in Jimma zone public hospitals from February 1 up to 30 March 2020 and 409 pregnant women were participated in the study by using a systematic random sampling method. Structured questionnaire was used to collect data that contain socio demographic variables, socio cultural variables, pregnancy related factors and predisposing factor related variables. The data was entered into EPI data version 3.1 and exported to SPSS version 20 for statistical analysis. Binary and multivariable logistic regression analysis were performed by using 95%CI and significance was declared at P < 0.05.Result: Forty-eight percent of pregnant women were initiated their first ANC late. Primary education (AOR = 0.242; 95% CI, 0.071-0.828) and college diploma and above was (AOR = 0.142; 95% CI, 0.040- 0.511), mothers with an unplanned pregnancy (AOR = 11.290; 95%CI, 4.109-31.023), time taken to arrive the health facility greater than sixty (60) minutes (AOR = 8.285; 95% CI, 2.794-24.564) and inadequate knowledge about ANC service (AOR = 4.181; 95%CI, 1.693-10.348) were associated with late first Antenatal care initiating.Conclusion: The prevalence of late initiation of ANC still remains a major public health concern in the study area. Level of education, unplanned pregnancy, distance from house to health facility, and lack of understanding about ANC services were all found to be significant variables in late ANC starting. As a result, healthcare workers can provide ongoing health education on the need of starting antenatal care visits early to avoid unfavorable pregnancy outcomes by considering all identified factors. [ABSTRACT FROM AUTHOR]

Background: Antenatal care (ANC) provides healthcare services to pregnant women in an attempt to ensure, the best possible pregnancy outcome for women and their babies. Healthcare providers' understanding of their patient's behaviour and reasons for engagement in care and their response to this insight can influence patient-provider interactions and patient demand for ANC early in pregnancy. We examined the insight of healthcare providers into women's reasons for starting ANC later than the South African National Department of Health's recommended 20 weeks gestation. We also looked at the impact of late ANC presentation on overall healthcare providers' work experiences and their response in their interactions with patients.Methods: In-depth interviews were conducted with 10 healthcare providers at Maternal Obstetrics Units (MOU) and Primary Healthcare Centres (PHC) in Gauteng, South Africa. Healthcare providers were selected with the assistance of the facility managers. Data analysis was conducted using the qualitative analysis software NVivo 11, using a thematic approach of pinpointing, examining, and recording patterns within the data.Results: Healthcare providers were aware of patients need for secrecy in the early stages of pregnancy because of fears of miscarriage and women's preference for traditional care. Women with prior pregnancies presumed to know about stages of pregnancy and neglected to initiate ANC early. Barriers to early ANC initiation also include, women's need to balance income generating activities; travel cost to the clinic and refusal of care for coming after the daily patient limit has been reached. Healthcare providers encounter negative attitudes from un-booked patients. This has a reciprocal effect whereby this experience impacts on whether healthcare providers will react with empathy or frustration.Conclusions: Timing of ANC is influenced by the complex decisions women make during pregnancy, starting from accepting the pregnancy itself to acknowledging the need for ANC. To positively influence this decision making for the benefit of early ANC, barriers such as lack of knowledge should be addressed prior to pregnancy through awareness programmes. The relationship between healthcare providers and women should be emphasized when training healthcare providers and considered as an important factor that can affect the timing of ANC. [ABSTRACT FROM AUTHOR]

Abstract Background QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania. Methods This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider’s perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios. Results Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes. Conclusions Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system. Trial registration Registered clinical trial at www.clinicaltrials.gov ( NCT01409824 ). Registered May 2009.

Background: Most previous studies on healthcare service utilization in low-income countries have not used a multilevel study design to address the importance of community-level women's autonomy. We assessed whether women's autonomy, measured at both individual and community levels, is associated with maternal healthcare service utilization in Ethiopia.Methods: We analyzed data from the 2005 and 2011 Ethiopia Demographic and Health Surveys (N = 6058 and 7043, respectively) for measuring women's decision-making power and permissive gender norms associated with wife beating. We used Spearman's correlation and the chi-squared test for bivariate analyses and constructed generalized estimating equation logistic regression models to analyze the associations between women's autonomy indicators and maternal healthcare service utilization with control for other socioeconomic characteristics.Results: Our multivariate analysis showed that women living in communities with a higher percentage of opposing attitudes toward wife beating were more likely to use all three types of maternal healthcare services in 2011 (adjusted odds ratios = 1.21, 1.23, and 1.18 for four or more antenatal care visits, health facility delivery, and postnatal care visits, respectively). In 2005, the adjusted odds ratios were 1.16 and 1.17 for four or more antenatal care visits and health facility delivery, respectively. In 2011, the percentage of women in the community with high decision-making power was positively associated with the likelihood of four or more antenatal care visits (adjusted odds ratio = 1.14). The association of individual-level autonomy on maternal healthcare service utilization was less profound after we controlled for other individual-level and community-level characteristics.Conclusions: Our study shows that women's autonomy was positively associated with maternal healthcare service utilization in Ethiopia. We suggest addressing woman empowerment in national policies and programs would be the optimal solution. [ABSTRACT FROM AUTHOR]

Background: Intimate partner violence (IPV) during or before pregnancy is associated with many adverse health outcomes. Pregnancy-related complications or poor infant health outcomes can arise from direct trauma as well as physiological effects of stress, both of which impact maternal health and fetal growth and development. Antenatal care can be a key entry point within the health system for many women, particularly in low-resource settings. Interventions to identify violence during pregnancy and offer women support and counselling may reduce the occurrence of violence and mitigate its consequences. Methods: Following a formative research phase, a randomized controlled trial will be conducted to test a nurse-led empowerment counselling intervention, originally developed for high-income settings and adapted for urban South Africa. The primary outcome is reduction of partner violence, and secondary outcomes include improvement in women's mental health, safety and self-efficacy. The study aims to recruit 504 pregnant women from three antenatal clinics in Johannesburg who will be randomized to the nurse-led empowerment arm (two 30-min counselling sessions) or enhanced control condition (a referral list) to determine whether participants in the intervention arm have better outcomes as compared to the those in the control arm. Discussion: This research will provide much needed evidence on whether a short counselling intervention delivered by nurses is efficacious and feasible in low resource settings that have high prevalence of IPV and HIV. [ABSTRACT FROM AUTHOR]