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Background Although antenatal care coverage in Ghana is high, there exist gaps in the continued use of maternity care, especially utilization of skilled assistance during delivery. Many pregnant women seek care from different sources aside the formal health sector. This is due to negative perceptions resulting from poor service quality experiences in health facilities. Moreover, the socio-cultural environment plays a major role for this care-seeking behavior, as this paper seeks to understand. To examine beliefs, knowledge and, perceptions about pregnancy and delivery and care-seeking behavior among pregnant women in urban Accra, Ghana. Methods A qualitative study with 6 focus group discussions and 13 in-depth interviews were conducted at Taifa-Kwabenya and Madina sub-districts, Accra. Participants included mothers who had delivered within the past 12 months, pregnant women, community members, religious and community leaders, orthodox and non-orthodox healthcare providers. Interviews and discussions were audio-taped, transcribed and coded into larger themes and categories. Results Evidence showed perceived threats, which are often given socio-cultural interpretations, increased women's anxieties, driving them to seek multiple sources of care. Crucially, careseeking behavior among pregnant women indicated sequential or concurrent use of biomedical care and other forms of care including herbalists, traditional birth attendants, and spiritual care. Use of multiple sources of care in some cases disrupted continued use of skilled provider care. Furthermore, use of multiple forms of care is encouraged by a perception that facility-based care is useful only for antenatal services and emergencies. It also highlights the belief among some participants that care from multiple sources are complementary to each other. Conclusions Socio-cultural interpretations of threats to pregnancy mediate pregnant women's use of available healthcare services. Efforts to encourage continued use of maternity care, especially skilled birth assistance at delivery, should focus on addressing generally perceived dangers to pregnancy. Also, the attractiveness of facility-based care offers important opportunities for building collaborations between orthodox and alternative care providers with the aim of increasing use of skilled obstetric care. Conventional antenatal care should be packaged to provide psychosocial support that helps women deal with pregnancy-related fear. [ABSTRACT FROM AUTHOR]

Background: Adolescent mothers aged 15-19 years are known to have greater risks of maternal morbidity and mortality compared with women aged 20-24 years, mostly due to their unique biological, sociological and economic status. Nowhere Is the burden of disease greater than in low-and middle-income countries (LMICs). Understanding factors that influence adolescent utilisation of essential maternal health services (MHS) would be critical in improving their outcomes.Methods: We systematically reviewed the literature for articles published until December 2015 to understand how adolescent MHS utilisation has been assessed in LMICs and factors affecting service utilisation by adolescent mothers. Following data extraction, we reported on the geographical distribution and characteristics of the included studies and used thematic summaries to summarise our key findings across three key themes: factors affecting MHS utilisation considered by researcher(s), factors assessed as statistically significant, and other findings on MHS utilisation.Results: Our findings show that there has been minimal research in this study area. 14 studies, adjudged as medium to high quality met our inclusion criteria. Studies have been published in many LMICs, with the first published in 2006. Thirteen studies used secondary data for assessment, data which was more than 5 years old at time of analysis. Ten studies included only married adolescent mothers. While factors such as wealth quintile, media exposure and rural/urban residence were commonly adjudged as significant, education of the adolescent mother and her partner were the commonest significant factors that influenced MHS utilisation. Use of antenatal care also predicted use of skilled birth attendance and use of both predicted use of postnatal care. However, there may be some context-specific factors that need to be considered.Conclusions: Our findings strengthen the need to lay emphasis on improving girl child education and removing financial barriers to their access to MHS. Opportunities that have adolescents engaging with health providers also need to be seized. These will be critical in improving adolescent MHS utilisation. However, policy and programmatic choices need to be based on recent, relevant and robust datasets. Innovative approaches that leverage new media to generate context-specific dis-aggregated data may provide a way forward. [ABSTRACT FROM AUTHOR]

Background: Over the last decade, a trend towards high utilisation of primary maternity care was observed in high-income countries. There is limited research with contradictory results regarding frequent attendance (FA) and perinatal outcomes in midwifery care. Therefore, this study examined possible associations between FA in midwifery care and obstetric interventions and perinatal outcomes.Methods: A retrospective cohort study was performed in a medium-sized midwifery-led care practice in an urban region in the Netherlands. Frequent attenders (FAs) were categorised using the Kotelchuck-Index Revised. Regression analyses were executed to examine the relationship between FAs and perinatal outcomes, stratified by antenatal referral to an obstetrician. Main outcomes of interest were Apgar score ≤ 7 and perinatal death, birth weight, mode of delivery, haemorrhage, place of birth, transfer during labour, and a requirement for pain relief.Results: The study included 1015 women, 239 (24%) FAs and 776 (76%) non-FAs, 538 (53%) were not referred and 447 (47%) were referred to an obstetrician. In the non-referred group, FA was significantly associated with a requirement for pain relief (OR 1.98, 95% CI 1.24-3.17) and duration of dilatation (OR 1.20, 95% CI 1.04-1.38). In the referred group, FA was significantly associated with induction of labour (OR 1.86, 95% CI 1.17-2.95), ruptured perineum (OR 0.50, 95% CI 0.27-0.95) and episiotomy (OR 0.48, 95% CI 0.24-0.95). In the non-referred and the referred group, FA was not associated with the other obstetric and neonatal outcomes. Due to small numbers, we could not measure possible associations of FA with an Apgar score ≤ 7 and perinatal death.Conclusion: In our study, perinatal outcomes differed by FA and antenatal referral to an obstetrician. In the non-referred group, FA was significantly associated with medical pain relief and duration of dilatation. In the referred group, FA was significantly associated with induction of labour, ruptured perineum, and episiotomy. Further research with a larger study population is needed to look for a possible association between FA and primary adverse birth outcomes such as perinatal mortality. [ABSTRACT FROM AUTHOR]

Background: The major causes of maternal and neonatal mortality in the Philippines are hemorrhages and obstructed labor due to placental implantation abnormalities (PIAs), twin pregnancies and fetal malpresentations. All of which are all easily detected by ultrasound. However, women in rural areas and low-income groups do not have access to ultrasound during their prenatal care. We aimed to provide additional evidence on the benefits of handheld ultrasound (HU) for screening pregnancy related abnormalities in order to avert maternal and neonatal deaths.Methods: Using a HU, we trained community healthcare workers (CHWs) to identify 5 obstetrical conditions: fetal viability and number, placental localization, amniotic fluid volume (AFV) and fetal presentation. Women, between 20th and 24th weeks age of gestation from 2 regions of the Philippines, were scanned using the HU and the GE Logic 5 Premium ultrasound machine for validation. Maternal and neonatal deaths averted were estimated as health outcome measures of the study.Results: Four hundred sixty women were scanned of which 146 (31.7%) showed abnormal ultrasound readings consisting of 17 PIAs, 123 fetal malpresentation, 3 twins and 3 AFV abnormalities. The use of HU could have possibly averted 29 (6.3%) maternal deaths and 14.6% neonatal deaths at the time of delivery. Thirty-two out of the 460 women (~7%) delivered at home and 93% in hospitals or birthing facilities/lying-in centers. We observed approximately 95% agreement between the ultrasound readings of the trainees and the trainers, and 99% agreement between the readings made from the HU with the validation machine.Conclusion: CHWs could be trained in the use of HU for scanning 5 obstetrical parameters. Early detection of abnormalities in these 5 obstetrical parameters can lead to early referral to facilities that are better equipped to manage obstetrical emergencies. Prenatal ultrasound can be an excellent point of care test for screening pregnant women at risk for possible complications and even death during labor and delivery.Trial Registration: Thai Clinical Trial Registry identification number TCTR20171128004 , retrospectively registered November 28, 2017. [ABSTRACT FROM AUTHOR]

Background: The concept of responsiveness was introduced by the World Health Organization (WHO) to address non-clinical aspects of service quality in an internationally comparable way. Responsiveness is defined as aspects of the way individuals are treated and the environment in which they are treated during health system interactions. The aim of this study is to assess responsiveness outcomes, their importance and factors influencing responsiveness outcomes during the antenatal and delivery phases of perinatal care.Method: The Responsiveness in Perinatal and Obstetric Health Care Questionnaire was developed in 2009/10 based on the eight-domain WHO concept and the World Health Survey questionnaire. After ethical approval, a total of 171 women, who were 2 weeks postpartum, were recruited from three primary care midwifery practices in Rotterdam, the Netherlands, using face-to-face interviews. We dichotomized the original five ordinal response categories for responsiveness attainment as 'poor' and good responsiveness and analyzed the ranking of the domain performance and importance according to frequency scores. We used a series of independent variables related to health services and users' personal background characteristics in multiple logistic regression analyses to explain responsiveness.Results: Poor responsiveness outcomes ranged from 5.9% to 31.7% for the antenatal phase and from 9.7% to 27.1% for the delivery phase. Overall for both phases, 'respect for persons' (Autonomy, Dignity, Communication and Confidentiality) domains performed better and were judged to be more important than 'client orientation' domains (Choice and Continuity, Prompt Attention, Quality of Basic Amenities, Social Consideration). On the whole, responsiveness was explained more by health-care and health related issues than personal characteristics.Conclusion: To improve responsiveness outcomes caregivers should focus on domains in the category 'client orientation'. [ABSTRACT FROM AUTHOR]

Background: The relation between grand multiparity (GMP) and the possible adverse pregnancy outcomes is not well identified. GMP (parity ≥5 births) frequently occurs in the Arab nations; therefore, this study aimed to identify the correlation between GMP and the different adverse maternal and neonatal outcomes in the Saudi population.Method: This cohort study was conducted on a total of 3327 women from the labour ward in King Khaled University Hospital, Riyadh, Saudi Arabia. Primiparous, multiparous and grand multiparous females were included. Socio-demographic data and pregnancy complications like gestational diabetes or hypertension, preeclampsia and intrauterine growth restriction were retrieved from the participants' files. In addition, the labour ward records were used to extract information about delivery events (e.g. spontaneous preterm delivery, caesarean section [CS]) and neonatal outcomes including anthropometric measurements, APGAR score and neonatal admission to the intensive care.Results: Primiparas responses were more frequent in comparison to multiparas and GMP (56.8% and 33%, and 10.2% respectively). In general, history of miscarriage was elevated (27.2%), and was significantly higher in GMP (58.3%, p < 0.01). Caesarean delivery was also elevated (19.5%) and was significantly high in the GMP subgroup (p < 0.01). However, after adjustment for age, GMP were less likely to deliver by CS (odds ratio: 0.6, 95% CI: 0.4-0.8; p < 0.01). The two most frequent pregnancy-associated complications were gestational diabetes and spontaneous preterm delivery (12.6% and 9.1%, respectively). The former was significantly more frequent in the GMP (p < 0.01). The main neonatal complication was low birth weight (10.7%); nevertheless, neonatal admission to ICU was significantly higher in GMP (p = 0.04), and low birth weight was more common in primiparas (p < 0.01). Furthermore, logistic regression analysis revealed an insignificant increase in the maternal or neonatal risks in GMP compared to multiparas after adjustment for age.Conclusion: Grand multiparous Saudi females have similar risks of maternal and neonatal complications compared to the other parity groups. Advanced age might play a major role on pregnancy outcomes in GMP. Nevertheless, grand multiparty might not be discouraged as long as women are provided with good perinatal care. [ABSTRACT FROM AUTHOR]

Background: In this protocol we describe a mixed methods study in the province of South Kivu, Democratic Republic of Congo evaluating the effectiveness of different demand side strategies to increase maternal health service utilization and the practice of birth spacing. Conditional service subsidization, conditional cash transfers and non-monetary incentives aim to encourage women to use maternal health services and practice birth spacing in two different health districts. Our methodology will comparatively evaluate the effectiveness of different approaches against each other and no intervention.Methods/design: This study comprises four main research activities: 1) Formative qualitative research to determine feasibility of planned activities and inform development of the quantitative survey; 2) A community-based, longitudinal survey; 3) A retrospective review of health facility records; 4) Qualitative exploration of intervention acceptability and emergent themes through in-depth interviews with program participants, non-participants, their partners and health providers. Female community health workers are engaged as core members of the research team, working in tandem with female survey teams to identify women in the community who meet eligibility criteria. Female community health workers also act as key informants and community entry points during methods design and qualitative exploration. Main study outcomes are completion of antenatal care, institutional delivery, practice of birth spacing, family planning uptake and intervention acceptability in the communities. Qualitative methods also explore decision making around maternal health service use, fertility preference and perceptions of family planning.Discussion: The innovative mixed methods design allows quantitative data to inform the relationships and phenomena to be explored in qualitative collection. In turn, qualitative findings will be triangulated with quantitative findings. Inspired by the principles of grounded theory, qualitative analysis will begin while data collection is ongoing. This "conversation" between quantitative and qualitative data will result in a more holistic, context-specific exploration and understanding of research topics, including the mechanisms through which the interventions are or are not effective. In addition, engagement of female community health workers as core members of the research team roots research methods in the realities of the community and provides teams with key informants who are simultaneously implicated in the health system, community and target population. [ABSTRACT FROM AUTHOR]

Background: Although the association between the presence of maternity waiting homes (MWHs) and the personal and environmental factors that affect the use of MWHs has been explained in qualitative terms, it has never been tested in quantitative terms. The aim of this study was to test the association between the presence of MWHs and personal and environmental factors that affect the use of MWHs.Methods: A cross-sectional study was conducted using an interviewer-administered questionnaire from 1st July to 31st August, 2014 among 340 women of reproductive age in 15 rural health centres in Kalomo district, Zambia. Tests of association (chi square, logistic regression analysis, odds ratio) were conducted to determine the strength of the association between the presence of MWHs and personal and environmental factors. Differences between respondents who used MWHs and those who did not were also tested.Results: Compared to respondents from health centres without MWHs, those from centres with MWHs had higher odds of expressing willingness to use MWHs (adjusted odds ratio [aOR] = 4.58; 95% confidence interval [CI]:1.39-15.17), perceived more benefits from using a MWH (aOR =8.63; 95% CI: 3.13-23.79), perceived more social pressure from important others to use MWH (aOR =27.09; 95% CI: 12.23-60.03) and higher personal risk from pregnancy and childbirth related complications (aOR =11.63; 95% CI: 2.52-53.62). Furthermore, these respondents had higher odds of staying at a health centre before delivery (aOR =1.78; 95% CI: 1.05-3.02), giving birth at a health facility (aOR = 3.36; 95% CI: 1.85-6.12) and receiving care from a skilled birth attendant (aOR =3.24; 95% CI: 1.80-5.84). In contrast, these respondents had lower odds of perceiving barriers regarding the use of MWHs (aOR =0.27; 95% CI: 0.16-0.47). Factors positively associated with the use of MWHs included longer distances to the nearest health centre (p = 0.004), higher number of antenatal care (ANC) visits (p = 0.001), higher proportions of complications during ANC (p = 0.09) and women's perception of benefits gained from staying in a MWH while waiting for delivery at the health centre (p = 0.001).Conclusion: These findings suggest a need for health interventions that focus on promoting ANC use, raising awareness about the risk and severity of pregnancy complications, promoting family and community support, and mitigating logistical barriers. [ABSTRACT FROM AUTHOR]

Background: Universal access to health care services does not automatically guarantee equity in the health system. In the post Millennium Development Goals (MDGs) era, the progress towards universal access to maternal health care services in a developing country, like Bangladesh requires an evaluation in terms of equity lens. This study, therefore, analysed the trend in inequity and identified the equity gap in the utilization of antenatal care (ANC) and delivery care services in Bangladesh between 2004 and 2011.Methods: The data of this study came from the Bangladesh Demographic and Health Survey. We employed rate ratio, concentration curve and concentration index to examine the trend in inequity of ANC and delivery care services. We also used logistic regression models to analyse the relationship between socioeconomic factors and maternal health care services.Results: The concentration index for 4+ ANC visits dropped from 0.42 in 2004 to 0.31 in 2011 with a greater decline in urban area. There was almost no change in the concentration index for ANC services from medically trained providers during this period. We also found a decreasing trend in inequity in the utilization of both health facility delivery and skilled birth assistance but this trend was again more pronounced in urban area compared to rural area. The concentration index for C-section delivery decreased by about 33 % over 2004-2011 with a similar rate in both urban and rural areas. Women from the richest households were about 3 times more likely to have 4+ ANC visits, delivery at a health facility and skilled birth assistance compared to women from the poorest households. Women's and their husbands' education were significantly associated with greater use of maternal health care services. In addition, women's exposure to mass media, their involvement in microcredit programs and autonomy in healthcare decision-making appeared as significant predictors of using some of these health care services.Conclusions: Bangladesh faces not only a persistent pro-rich inequity but also a significant rural-urban equity gap in the uptake of maternal health care services. An equity perspective in policy interventions is much needed to ensure safe motherhood and childbirth in Bangladesh. [ABSTRACT FROM AUTHOR]

Background: Maternal mortality remains a daunting problem in Mozambique and many other low-resource countries. High quality antenatal care (ANC) services can improve maternal and newborn health outcomes and increase the likelihood that women will seek skilled delivery care. This study explores the factors influencing provider uptake of the recommended package of ANC interventions in Mozambique. Methods: This study used qualitative research methods including key informant interviews with stakeholders from the health sector and a total of five focus group discussions with women with experience with ANC or women from the community. Study participants were selected from three health centers located in Maputo city, Tete, and Cabo Delgado provinces in Mozambique. Staff responsible for the medicines/supply chain at national, provincial and district level were interviewed. A check list was implemented to confirm the availability of the supplies required for ANC. Deductive content analysis was conducted. Results: Three main groups of factors were identified that hinder the implementation of the ANC package in the study setting: a) system or organizational: include chronic supply chain deficiencies, failures in the continuing education system, lack of regular audits and supervision, absence of an efficient patient record system and poor environmental conditions at the health center; b) health care provider factors: such as limited awareness of current clinical guidelines and a resistant attitude to adopting new recommendations; and c) Users: challenges with accessing ANC, poor recognition amongst women about the purpose and importance of the specific interventions provided through ANC, and widespread perception of an unfriendly environment at the health center. Conclusions: The ANC package in Mozambique is not being fully implemented in the three study facilities, and a major barrier is poor functioning of the supply chain system. Recommendations for improving the implementation of antenatal interventions include ensuring clinical protocols based on the ANC model. Increasing the community understanding of the importance of ANC would improve demand for high quality ANC services. The supply chain functioning could be strengthened through the introduction of a kit system with all the necessary supplies for ANC and a simple monitoring system to track the stock levels is recommended. [ABSTRACT FROM AUTHOR]

Background: Water immersion during labour can provide benefits including reduced need for regional analgesia and a shorter labour. However, in the United Kingdom a minority of women use a pool for labour or birth, with pool use particularly uncommon in obstetric-led settings. Maternity unit culture has been identified as an important influence on pool use, but this and other possible factors have not been explored in-depth. Therefore, the aim of this study was to identify factors influencing pool use through qualitative case studies of three obstetric units and three midwifery units in the UK.Methods: Case study units with a range of waterbirth rates and representing geographically diverse locations were selected. Data collection methods comprised semi-structured interviews, collation of service documentation and public-facing information, and observations of the unit environment. There were 111 interview participants, purposively sampled to include midwives, postnatal women, obstetricians, neonatologists, midwifery support workers and doulas. A framework approach was used to analyse all case study data.Results: Obstetric unit culture was a key factor restricting pool use. We found substantial differences between obstetric and midwifery units in terms of equipment and resources, staff attitudes and confidence, senior staff support and women's awareness of water immersion. Generic factors influencing use of pools across all units included limited access to waterbirth training, sociodemographic differences in desire for pool use and issues using waterproof fetal monitoring equipment.Conclusions: Case study findings provide new insights into the influence of maternity unit culture on waterbirth rates. Access to pool use could be improved through midwives based in obstetric units having more experience of waterbirth, providing obstetricians and neonatologists with information on the practicalities of pool use and improving accessibility of antenatal information. In terms of resources, recommendations include increasing pool provision, ensuring birth room allocation maximises the use of unit resources, and providing pool room environments that are acceptable to midwives. [ABSTRACT FROM AUTHOR]

Background: To evaluate if women with a history of myomectomy have a modified preterm birth risk compared to women with myomas during pregnancy.Methods: Retrospective cohort study including all women with a history of myomectomy (operated group) or uterine myomas during pregnancy (unoperated group) who delivered in a tertiary center between January, 2011 and December, 2017. The operated group included women who had a myomectomy history with or without myomas during the ongoing pregnancy. The unoperated group included women with uterine myoma(s) seen on at least one ultrasound during pregnancy without history of myomectomy. The primary outcome was preterm birth < 37 weeks, and the secondary outcome spontaneous preterm birth < 37 weeks. To control for confounding factors, a propensity score approach was used. Two sensitivity analysis were performed, one repeating the analysis using the propensity score after excluding operated women with persistent myomas and one using a classical multivariable logistic regression model.Results: The cohort included 576 women: 283 operated women and 293 unoperated women. The rate of preterm birth was similar in the two groups: 12.6% in the unoperated group and 12.0% in the operated group (p = 0.82). No difference in preterm birth risk was shown between unoperated and operated women in the cohort matched on the propensity score: OR 0.86; 95%CI [0.47-1.59]. These results were consistent for spontaneous preterm birth (OR 1.61; 95%CI [0.61-4.23]) and for the sensitivity analyses.Conclusion: In women with a leiomyomatous uterus, a history of myomectomy is not associated with a reduced preterm birth risk. [ABSTRACT FROM AUTHOR]

Background: Delays in accessing skilled delivery services are a major contributor to high maternal mortality in resource-limited settings. In 2015, the government of The Gambia initiated a results-based financing intervention that sought to increase uptake of skilled delivery. We performed a midline evaluation to determine the impact of the intervention and explore causes of delays.Methods: A mixed methods design was used to measure changes in uptake of skilled delivery and explore underlying reasons, with communities randomly assigned to four arms: (1) community-based intervention, (2) facility-based intervention, (3) community- and facility-based intervention, and (4) control. We obtained quantitative data from household surveys conducted at baseline (n = 1423) and midline (n = 1573). Qualitative data came from semi-structured interviews (baseline n = 20; midline n = 20) and focus group discussions (baseline n = 27; midline n = 39) with a range of stakeholders. Multivariable linear regression models were estimated using pooled data from baseline and midline. Qualitative data were recorded, transcribed, translated and thematically analyzed.Results: No increase was found in uptake of skilled delivery services between baseline and midline. However, relative to the control group, significant increases in referral to health facilities for delivery were found in areas receiving the community-based intervention (beta = 0.078, p < 0.10) and areas receiving both the community-based and facility-based interventions (beta = 0.198, p < 0.05). There was also an increase in accompaniment to health facilities for delivery in areas receiving only community-based interventions (beta = 0.095, p < 0.05). Transportation to health facilities for delivery increased in areas with both interventions (beta = 0.102, p < 0.05). Qualitative data indicate that delays in the decision to seek institutional delivery usually occurred when women had limited knowledge of delivery indications. Delays in reaching a health facility typically occurred due to transportation-related challenges. Although health workers noted shortages in supplies and equipment, women reported being supported by staff and experiencing minimal delays in receiving skilled delivery care once at the facility.Conclusions: Focusing efforts on informing the decision to seek care and overcoming transportation barriers can reduce delays in care-seeking among pregnant women and facilitate efforts to increase uptake of skilled delivery services through results-based financing mechanisms. [ABSTRACT FROM AUTHOR]