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Introduction: Poor psychosocial support and lack of respectful care for women during childbirth are commonplace in health facilities in low- and middle-income countries. While WHO recommends providing supportive care to pregnant women, there is a scarcity of material for building the capacity of maternity staff to provide systematic and inclusive psychosocial support to women in the intrapartum phase, and prevent work stress and burnout in maternity teams. To address this need we adapted WHO's mhGAP for maternity staff to provide psychosocial support in labour room settings in Pakistan. Mental Health Gap Action Programme (mhGAP) is an evidence-based guidance which provides psychosocial support in resource-limited health care settings. This paper aims to describe the adaptation of mhGAP to develop psychosocial support capacity building materials for maternity staff to provide support to maternity patients, and also to staff, in the labour room context. Methods: Adaptation was conducted within the Human-Centered-Design framework in three phases: inspiration, ideation, and implementation feasibility. In inspiration, a review of national-level maternity service-delivery documents and in-depth interviews of maternity staff were conducted. Ideation involved a multidisciplinary team to develop capacity-building materials by adapting mhGAP. This phase was iterative and included cycles of pretesting, deliberations, and revision of materials. In implementation feasibility, materials were tested via the training of 98 maternity staff and exploring system feasibility via post-training visits to health facilities. Results: Inspiration phase identified gaps in policy directives and implementation and formative study identified limited understanding and skills of staff to assess patients' psychosocial needs and provide appropriate support. Also, it became evident that staff themselves needed psychosocial support. In ideation, team developed capacity-building materials comprising two modules: one dedicated to conceptual understanding, the other to implementing psychosocial support in collaboration with maternity staff. In implementation feasibility, staff found the materials relevant and feasible for the labour room setting. Finally, users and experts endorsed usefulness of the materials. Conclusion: Our work in developing psychosocial-support training materials for maternity staff extends the utility of mhGAP to maternity care settings. These materials can be used for capacity-building of maternity staff and their effectiveness can be assessed in diverse maternity care settings. [ABSTRACT FROM AUTHOR]

Background: Over a third of pregnant women (around 250,000) each year in the United Kingdom have experienced trauma such as domestic abuse, childhood trauma or sexual assault. These experiences can have a long-term impact on women's mental and physical health. This global qualitative evidence synthesis explores the views of women and maternity care professionals on routine discussion of previous trauma in the perinatal period. Methods: Systematic database searches (MEDLINE, EMBASE, CINAHL Plus, APA PsycINFO and Global Index Medicus) were conducted in July 2021 and updated in April 2022. The quality of each study was assessed using the Critical Appraisal Skills Programme. We thematically synthesised the data and assessed confidence in findings using GRADE-CERQual. Results: We included 25 papers, from five countries, published between 2001 and 2022. All the studies were conducted in high-income countries; therefore findings cannot be applied to low- or middle-income countries. Confidence in most of the review findings was moderate or high. The findings are presented in six themes. These themes described how women and clinicians felt trauma discussions were valuable and worthwhile, provided there was adequate time and appropriate referral pathways. However, women often found being asked about previous trauma to be unexpected and intrusive, and women with limited English faced additional challenges. Many pregnant women were unaware of the extent of the trauma they have suffered, or its impact on their lives. Before disclosing trauma, women needed to have a trusting relationship with a clinician; even so, some women chose not to share their histories. Hearing trauma disclosures could be distressing for clinicians. Conclusion: Discussions of previous trauma should be undertaken when women want to have the discussion, when there is time to understand and respond to the needs and concerns of each individual, and when there are effective resources available for follow up if needed. Continuity of carer should be considered a key feature of routine trauma discussion, as many women will not disclose their histories to a stranger. All women should be provided with information about the impact of trauma and how to independently access support in the event of non-disclosures. Care providers need support to carry out these discussions. [ABSTRACT FROM AUTHOR]

Background: Evidence shows that a gap in the documentation of patients' past medical history leads to errors in, or duplication of, treatment and is a threat to patient safety. Home-based or patient-held records (HBR) are widely used in low and middle-income countries (LMIC) in maternal and childcare. The aim is to systematically review the evidence on HBRs in LMICs for (1) improving informational continuity for providers and women/families across health care visits and facilities, (2) to describe the perceived usefulness by women/families and healthcare providers, and (3) maternal and child health outcomes of using HBRs for maternal and child health care. Methods: The protocol was registered in PROSPERO (CRD42019139365). We searched MEDLINE, EMBASE, CINAHL, and Global Index Medicus databases for studies with home-based records from LMICs. Search terms pertained to women or parent-held records and LMICs. Two reviewers assessed studies for inclusion using a priori study selection criteria- studies explaining the use of HBRs in LMIC for maternal and child health care. The included study quality was appraised using the Mixed Methods Appraisal Tool (MMAT). Results from all study designs were summarised narratively. Results: In total, 41 papers were included in the review from 4514 potential studies. Included studies represented various study designs and 16 countries. The least evaluated function of HBR was information continuity across health care facilities (n = 6). Overall, there were limited data on the usefulness of HBRs to providers and mothers/families. Home-based records were mostly available for providers during health care visits. However, the documentation in HBRs varied. The use of HBRs is likely to lead to improved antenatal visits and immunisation uptake, and skilled birth delivery in some settings. Mothers' knowledge of breastfeeding practices and danger signs in pregnancy improved with the use of HBRs. One randomised trial found the use of HBRs reduced the risk of cognitive development delay in children and another reported on trial lessened the risk of underweight and stunted growth in children. Conclusion: There is limited literature from LMICs on the usefulness of HBRs and for improving information transfer across healthcare facilities, or their use by women at home. Current HBRs from LMICs are sub-optimally documented leading to poor informational availability that defeats the point of them as a source of information for future providers. [ABSTRACT FROM AUTHOR]

How women are cared for while having a baby can have lasting effects on their lives. Women value relational care with continuity—when caregivers get to know them as individuals. Despite evidence of benefit and global policy support, few maternity care systems across the world routinely offer relational continuity. Women experiencing socioeconomic adversity have least access to good quality maternity care. Community-based doula support programs offer complementary care for these women and are known to, on average, have positive outcomes. Less understood is how, when, and why these programs work. A realist evaluation of an Australian volunteer doula program explored these questions. The program provides free social, emotional, and practical support by trained doulas during pregnancy, birth, and early parenting. This paper reports the testing and refinement of one program theory from the larger study. The theory, previously developed from key informant interviews and rapid realist review of literature, hypothesised that support increased a woman's confidence via two possible pathways—by being with her and enabling her to see her own strength and value; and by praising her, and her feeling validated as a mother. This study aimed to test the theory in realist interviews with clients, focus groups with doulas, and with routinely collected pre-post data. Seven English-speaking and six Arabic-speaking clients were interviewed, and two focus groups with a total of eight doulas were conducted, in January-February 2020. Qualitative data were analysed in relation to the hypothesised program theory. Quantitative data were analysed for differential outcomes. Formal theories of Recognition and Relational reflexivity supported explanatory understanding. The refined program theory, Recognition, explains how and when a doula's recognition of a woman, increases confidence, or not. Five context-mechanism-outcome configurations lead to five outcomes that differ by nature and longevity, including absence of felt confidence. [ABSTRACT FROM AUTHOR]

Introduction: Quality antenatal care is a window of opportunity for improving maternal and neonatal outcomes. Numerous studies have shown a positive effect of women empowerment on improved coverage of maternal and reproductive health services, including antenatal care (ANC). However, there is scarce evidence on the association between women's empowerment and improved ANC services both in terms of coverage and quality. Addressing this gap, this paper examines the relationship between multi-dimensional measures of women empowerment on utilization of quality ANC (service coverage and consultation) in Pakistan. Methods: We used Pakistan Demographic and Health Survey 2017–18 (PDHS) data which comprises of 6,602 currently married women aged between 15–49 years who had a live birth in the past five years preceding the survey. Our exposure variables were three-dimensional measures of women empowerment (social independence, decision making, and attitude towards domestic violence), and our outcome variables were quality of antenatal coverage [i.e. a composite binary measure based on skilled ANC (trained professional), timeliness (1st ANC visit during first trimester), sufficiency of ANC visits (4 or more)] and quality of ANC consultation (i.e. receiving at least 7 or more essential antenatal components out of 8). Data were analysed in Stata 16.0 software. Descriptive statistics were used to describe sample characteristics and binary logistic regression was employed to assess the association between empowerment and quality of antenatal care. Results: We found that 41.4% of the women received quality ANC coverage and 30.6% received quality ANC consultations during pregnancy. After controlling for a number of socio-economic and demographic factors, all three measures of women's empowerment independently showed a positive relationship with both outcomes. Women with high autonomy (i.e. strongly opposed the notion of violence) in the domain of attitude to violence are 1.66 (95% CI 1.30–2.10) and 1.45 (95% CI 1.19–1.75) and times more likely to receive antenatal coverage and quality ANC consultations respectively, compared with women who ranked low on attitude to violence. Women who enjoy high social independence had 1.87 (95% CI 1.44–2.43) and 2.78 (95% CI 2.04–3.79) higher odds of quality antenatal coverage and consultations respectively, as compared with their counterparts. Similarly, women who had high autonomy in household decision making 1.98 (95% CI 1.60–2.44) and 1.56 (95% CI 2.17–1.91) were more likely to receive quality antenatal coverage and consultation respectively, as compared to women who possess low autonomy in household decision making. Conclusion: The quality of ANC coverage and consultation with service provider is considerably low in Pakistan. Women's empowerment related to social independence, gendered beliefs about violence, and decision-making have an independent positive association with the utilisation of quality antenatal care. Thus, efforts directed towards empowering women could be an effective strategy to improve utilisation of quality antenatal care in Pakistan. [ABSTRACT FROM AUTHOR]

The use of contraceptives for family planning improves women's lives and may prevent maternal deaths. However, many women in low and middle-income countries, including the Pacific region, still die from pregnancy-related complications. While most health centres offer family planning services with some basic contraceptive methods, many people do not access these services. More than 60% of women who would like to avoid or delay their pregnancies are unable to do so. This scoping review identifies and analyses evidence about family planning service provision in Pacific Island Countries and Territories (PICTs), with the aim of better informing family planning services for improved maternal health outcomes in the Pacific. We used Arksey and O'Malley's scoping review guidelines, supported by Levac, Colquhoun and O'Brien to identify gaps in family planning service provision. Selected studies included peer-reviewed publications and grey literature that provided information about family planning services from 1994 to 2019. Publication data was charted in MS Excel. Data were thematically analysed and key issues and themes identified. A total of 45 papers (15 peer-reviewed and 30 grey literature publications) were critically reviewed. Five themes were identified: i) family planning services in the Pacific; ii) education, knowledge and attitudes; iii) geographical isolation and access; iv) socio-cultural beliefs, practices and influences; and v) potential enabling factors for improved family planning, such as appropriate family planning awareness by health care providers and services tailored to meet individual needs. While culture and religion were considered as the main barriers to accessing family planning services, evidence showed health services were also responsible for limiting access. Family planning services do not reach everyone. Making relevant and sustainable improvements in service delivery requires generation of local evidence. Further research is needed to understand availability, accessibility and acceptability of current family planning services for different age groups, genders, social and marital status to better inform family planning services in the Pacific. [ABSTRACT FROM AUTHOR]

Background: Many women stop breastfeeding before they intend to as they cannot overcome breastfeeding difficulties. Breastfeeding support, as an evidence-based intervention by trained lay or professional breastfeeding support providers, can prevent early unintended cessation. Yet some women report dissatisfaction with support and reluctantly stop breastfeeding despite receiving this intervention. Understanding the experiences which shape how support is provided can inform effective implementation of breastfeeding support interventions. This review aims to synthesise experiences of trained breastfeeding support providers in high income settings and how these may influence their breastfeeding support practices. Methods: A qualitative systematic review of trained breastfeeding supporters' experiences of supporting women to breastfeed, as part of a generic healthcare role or focused breastfeeding support role, will be conducted. A systematic search will be performed of the databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL +), MEDLINE ALL, Maternity and Infant Care, EMBASE, APA PsycINFO, Web of Science and Scopus. Title and abstract screening using eligibility criteria will be conducted using Covidence software. Eligible papers will be agreed by the review team following full text screening and reported using PRISMA guidelines. CASP and COREQ tools will assess study methodological quality and quality of reporting. Data will be extracted using a bespoke form and coded, using Excel software for data management. Analysis will involve the three stages of thematic synthesis: initial free coding, development of descriptive and subsequent analytical themes. Confidence in findings will be assessed using the CERQual framework. Discussion: This review is the first to date to synthesise qualitative evidence on experiences which influence how trained lay and professional providers support women with breastfeeding. Findings will enable deeper understanding of the underpinning mechanisms of breastfeeding support provision and inform the development of tailored interventions to improve breastfeeding rates. Systematic review registration: PROSPERO registration number: CRD42020207380 [ABSTRACT FROM AUTHOR]

Introduction: The global COVID-19 pandemic has radically changed the way health care is delivered in many countries around the world. Evidence on the experience of those receiving or providing maternity care is important to guide practice through this challenging time. Methods: A cross-sectional study was conducted in Australia. Five key stakeholder cohorts were included to explore and compare the experiences of those receiving or providing care during the COVID-19 pandemic. Women, their partners, midwives, medical practitioners and midwifery students who had received or provided maternity care from March 2020 onwards in Australia were recruited via social media and invited to participate in an online survey released between 13th May and 24th June 2020; a total of 3701 completed responses were received. Findings: While anxiety related to COVID-19 was high among all five cohorts, there were statistically significant differences between the responses from each cohort for most survey items. Women were more likely to indicate concern about their own and family's health and safety in relation to COVID-19 whereas midwives, doctors and midwifery students were more likely to be concerned about occupational exposure to COVID-19 through working in a health setting than those receiving care through attending these environments. Midwifery students and women's partners were more likely to respond that they felt isolated because of the changes to the way care was provided. Despite concerns about care received or provided not meeting expectations, most respondents were satisfied with the quality of care provided, although midwives and midwifery students were less likely to agree. Conclusion: This paper provides a unique exploration and comparison of experiences of receiving and providing maternity care during the COVID-19 pandemic in Australia. Findings are useful to support further service changes and future service redesign. New evidence provided offers unique insight into key stakeholders' experiences of the rapid changes to health services. [ABSTRACT FROM AUTHOR]

In this paper we examine whether it is just the financial cost of maternal healthcare that prevents poor women from utilising free or low-cost government provided healthcare in Dhaka, Bangladesh, or there are other factors at play, in conjunction with poverty. To answer this question, we analyse the perceptions and experiences about the use of maternal health care for childbirth by a group of women residing in poor and lower socio-economic households in Dhaka. Data for this study were collected through in-depth interviews of 34 such women who have already had a child or had become pregnant at least once in the preceding five years. The findings of our analysis suggest that these women have a deeply rooted fear of medical intervention in childbirth for several perceived and practical reasons, including the fear of having to make undocumented payments, unfamiliarity with institutional processes, lack of social and family network support within their neighbourhood, concept of honour and shame [sharam], a culture of silence and inadequate spousal communication on health issues. As a result, even though low-cost health care facilities may be within their reach in terms of physical distance and affordable in terms of financial cost these women and their families are unwilling to deliver their babies at such health facilities. Therefore, in order to allay their perceived fear of hospital-based childbirth, one needs to consider factors other than financial cost and physical distance, and provide these women with factual information and culturally sensitive counselling. [ABSTRACT FROM AUTHOR]

Background: Psychological aspects of labor and birth have received little attention within maternity care service planning or clinical practice. The aim of this paper is to propose a model demonstrating how neurohormonal processes, in particular oxytocinergic mechanisms, not only control the physiological aspects of labor and birth, but also contribute to the subjective psychological experiences of birth. In addition, sensory information from the uterus as well as the external environment might influence these neurohormonal processes thereby influencing the progress of labor and the experience of birth. Methodology: In this new model of childbirth, we integrated the findings from two previous systematic reviews, one on maternal plasma levels of oxytocin during physiological childbirth and one meta-synthesis of women´s subjective experiences of physiological childbirth. Findings: The neurobiological processes induced by the release of endogenous oxytocin during birth influence maternal behaviour and feelings in connection with birth in order to facilitate birth. The psychological experiences during birth may promote an optimal transition to motherhood. The spontaneous altered state of consciousness, that some women experience, may well be a hallmark of physiological childbirth in humans. The data also highlights the crucial role of one-to-one support during labor and birth. The physiological importance of social support to reduce labor stress and pain necessitates a reconsideration of many aspects of modern maternity care. Conclusion: By listening to women's experiences and by observing women during childbirth, factors that contribute to an optimized process of labor, such as the mothers' wellbeing and feelings of safety, may be identified. These observations support the integrative role of endogenous oxytocin in coordinating the neuroendocrine, psychological and physiological aspects of labor and birth, including oxytocin mediated. decrease of pain, fear and stress, support the need for midwifery one-to-one support in labour as well as the need for maternity care that optimizes the function of these neuroendocrine processes even when birth interventions are used. Women and their partners would benefit from understanding the crucial role that endogenous oxytocin plays in the psychological and neuroendocrinological process of labor. [ABSTRACT FROM AUTHOR]

Objective: Public insurance (Medicaid) covered 42% of all U.S. births in 2018. This paper describes and analyzes the self-reported experiences of women with Medicaid versus commercial insurance relating to autonomy, control and respectful treatment in maternity care. Methods: The sampling frame for the Listening to Mothers in California survey was drawn from 2016 California birth certificate files. The 30-minute survey had a 55% response rate. A secondary multivariable analysis of results from the survey included 2,318 women with commercial private insurance (1,087) or public (Medi-Cal) (1,231) coverage. Results were weighted and were representative of all births in 2016 in California. The multivariable analysis of variables related to maternal agency included engagement in decision making regarding interventions such as vaginal birth after cesarean and episiotomy, feeling pressured to have interventions and sense of fair treatment. We examined their relationship to insurance status adjusted for maternal age, race/ethnicity, education, nativity and attitude toward birth as well as type of prenatal provider, type of birth attendant and pregnancy complications. Results: Women with Medi-Cal had a demographic profile distinct from those with commercial insurance. In multivariable analysis, women with Medi-Cal reported less control over their maternity care experience than women with commercial insurance, including less choice of prenatal provider (AOR 1.61 95%C.I. 1.20, 2.17), or a vaginal birth after cesarean (AOR 2.93 95%C.I. 1.49, 5.73). Mothers on Medi-Cal were also less likely to be consulted before experiencing an episiotomy (AOR 0.30 95%C.I. 0.09, 0.94). They were more likely to report feeling pressure to have a primary cesarean (AOR 2.54 95%C.I. 1.55, 4.16) and less likely to be encouraged by staff to make their own decisions (AOR 0.63 95%C.I. 0.47, 0.85). Conclusions: Childbearing women with public insurance in California clearly and consistently reported less opportunity to choose their care than women with private insurance. These inequities are a call to action for increased accountability and quality improvement relating to care of the many childbearing women with Medicaid coverage. [ABSTRACT FROM AUTHOR]

Background: The introduction of bundled payment for maternity care, aimed at improving the quality of maternity care, may affect pregnant women's choice in providers of maternity care. This paper describes a Dutch study which examined pregnant women's preferences when choosing a maternity care provider. The study focused on factors that enhance the quality of maternity care versus (restricted) provider choice. Methods: A discrete choice experiment was conducted amongst 611 pregnant women living in the Netherlands using an online questionnaire. The data were analysed with Latent Class Analyses. The outcome measure consisted of stated preferences in the discrete choice experiment. Included factors were: information exchange by care providers through electronic medical records, information provided by midwife, information provided by friends, freedom to choose maternity care provider and travel distance. Results: Four different preference structures were found. In two of those structures, respondents found aspects of the maternity care related to quality of care more important than being able to choose a provider (provider choice). In the two other preference structures, respondents found provider choice more important than aspects related to quality of maternity care. Conclusions: In a country with presumed high-quality maternity care like the Netherlands, about half of pregnant women prefer being able to choose their maternity care provider over organisational factors that might imply better quality of care. A comparable amount of women find quality-related aspects most important when choosing a maternity care provider and are willing to accept limitations in their choice of provider. These insights are relevant for policy makers in order to be able to design a bundled payment model which justify the preferences of all pregnant women. [ABSTRACT FROM AUTHOR]

Background: Under the Free Maternity Policy (FMP), Kenya has witnessed an increase in health facility deliveries rather than home deliveries with Traditional Birth Attendants (TBA) resulting in improved maternal and neonatal outcomes. Despite these gains, maternal and infant mortality and morbidity rates in Kenya remain unacceptably high indicating that more needs to be done. Aim: Using data from the Access to Quality Care through Extending and Strengthening Health Systems (AQCESS) project's qualitative gender assessment, this paper examines women's experience of disrespectful care during pregnancy, labour, and delivery. The goal is to promote an improved understanding of the actual care conditions to inform the development of interventions that can lift the standard of care, increase maternity facility use, and improve health outcomes for both women and newborns. Methodology: We conducted sixteen focus group discussions (FGDs), two each for adolescent females, adult females, adult males, and community health committee members. As well, twenty-four key Informants interviews (KII) were also conducted including religious leaders, and persons from local government representatives, Ministry of Health (MOH), and local women's organizations. Data were captured through audio recordings and reflective field notes. Research site: Kisii and Kilifi Counties in Kenya. Findings: Findings show nursing and medical care during labour and delivery were at times disrespectful, humiliating, uncompassionate, neglectful, or abusive. In both counties, male health workers were preferred by women giving birth, as they were perceived as more friendly and sensitive. Adolescent females were more likely to report abuse during maternity care while women with disabled children reported being stigmatized. Structural barriers related to transportation and available resources at facilities associated with disrespectful care were identified. Conclusions: A focus on quality and compassionate care as well as more facility resources will lead to increased, successful, and sustainable use of facility care. Interpreting these results within a systems perspective, Kenya needs to implement, enforce, and monitor quality of care guidelines for pregnancy and delivery including respectful maternity care of pregnant women. To ensure these procedures are enforced, measurable benchmarks for maternity care need to be established, and hospitals need to be regularly monitored to ensure these benchmarks are achieved. [ABSTRACT FROM AUTHOR]

Background: Geospatial data are important in monitoring many aspects of healthcare development. Geographically linking health facility data with population data is an important area of public health research. Examining healthcare problems spatially and hierarchically assists with efficient resource allocation and the monitoring and evaluation of service efficacy at different levels. This paper explored methodological issues associated with geographic data linkage, and the spatial and multilevel analyses that could be considered in analysing maternal health service data. Methods: The 2016 Ethiopia Demographic and Health Survey and the 2014 Ethiopia Service Provision Assessment data were used. Two geographic data linking methods were used to link these two datasets. Administrative boundary link was used to link a sample of health facilities data with population survey data for analysing three areas of maternal health service use. Euclidean buffer link was used for a census of hospitals to analyse caesarean delivery use in Ethiopia. The Global Moran’s I and the Getis-Ord Gi* statistics need to be carried out for identifying hot spots of maternal health service use in ArcGIS software. In addition to this, since the two datasets contain hierarchical data, a multilevel analysis was carried out to identify key determinants of maternal health service use in Ethiopia. Results: Administrative boundary link gave more types of health facilities and more maternal health services as compared to the Euclidean buffer link. Administrative boundary link is the method of choice in case of sampled health facilities. However, for a census of health facilities, the Euclidean buffer link is the appropriate choice as this provides cluster level service environment estimates, which the administrative boundary link does not. Applying a False Discovery Rate correction enables the identification of true spatial clusters of maternal health service use. Conclusions: A service environment link minimizes the methodological issues associated with geographic data linkage. A False Discovery Rate correction needs to be used to account for multiple and dependent testing while carrying out local spatial statistics. Examining maternal health service use both spatially and hierarchically has tremendous importance for identifying geographic areas that need special emphasis and for intervention purposes. [ABSTRACT FROM AUTHOR]

Background: For countries to contribute to Sustainable Development Goal 3.1 of reducing the global maternal mortality ratio (MMR) to less than 70 per 100,000 live births by 2030, identifying the drivers of maternal mortality is critically important. The ability of countries to identify the key drivers is however hampered by the lack of data sources with sufficient observations of maternal death to allow a rigorous analysis of its determinants. This paper overcomes this problem by utilising census data. In the context of Indonesia, we merge individual-level data on pregnancy-related deaths and households’ socio-economic status from the 2010 Indonesian population census with detailed data on the availability and quality of local health services from the Village Census. We use these data to test the hypothesis that health service access and quality are important determinants of maternal death and explain the differences between high maternal mortality and low maternal mortality provinces. Methods: The 2010 Indonesian Population Census identifies 8075 pregnancy-related deaths and 5,866,791 live births. Multilevel logistic regression is used to analyse the impacts of demographic characteristics and the existence of, distance to and quality of health services on the likelihood of maternal death. Decomposition analysis quantifies the extent to which the difference in maternal mortality ratios between high and low performing provinces can be explained by demographic and health service characteristics. Findings: Health service access and characteristics account for 23% (CI: 17.2% to 28.5%) of the difference in maternal mortality ratios between high and low-performing provinces. The most important contributors are the number of doctors working at the community health centre (8.6%), the number of doctors in the village (6.9%) and distance to the nearest hospital (5.9%). Distance to health clinics and the number of midwives at community health centres and village health posts are not significant contributors, nor is socio-economic status. If the same level of access to doctors and hospitals in lower maternal mortality Java-Bali was provided to the higher maternal mortality Outer Islands of Indonesia, our model predicts 44 deaths would be averted per 100,000 pregnancies. Conclusion: Indonesia has employed a strategy over the past several decades of increasing the supply of midwives as a way of decreasing maternal mortality. While there is evidence of reductions in maternal mortality continuing to accrue from the provision of midwife services at village health posts, our findings suggest that further reductions in maternal mortality in Indonesia may require a change of focus to increasing the supply of doctors and access to hospitals. If data on maternal death is collected in a subsequent census, future research using two waves of census data would prove a useful validation of the results found here. Similar research using census data from other countries is also likely to be fruitful. [ABSTRACT FROM AUTHOR]

Poor intra-facility maternity care is a major contributor to maternal mortality in low- and middle-income countries. Close to 830 women die each day due to preventable maternal complications, partly due to the increasing number of women giving birth in health facilities that are not adequately resourced to manage growing patient populations. Barriers to adequate care during the ‘last mile’ of healthcare delivery are attributable to deficiencies at multiple levels: education, staff, medication, facilities, and delays in receiving care. Moreover, the scope and multi-scale interdependence of these factors make individual contributions of each challenging to analyze, particularly in settings where basic data registration is often lacking. To address this need, we have designed and implemented a novel systems-level and dynamic mathematical model that simulates the impact of hospital resource allocations on maternal mortality rates at Mnazi Mmoja Hospital (MMH), a referral hospital in Zanzibar, Tanzania. The purpose of this model is to provide a rigorous and flexible tool that enables hospital administrators and public health officials to quantitatively analyze the impact of resource constraints on patient outcomes within the maternity ward, and prioritize key areas for further human or capital investment. Currently, no such tool exists to assist administrators and policy makers with effective resource allocation and planning. This paper describes the structure and construct of the model, provides validation of the assumptions made with anonymized patient data and discusses the predictive capacity of our model. Application of the model to specific resource allocations, maternal treatment plans, and hospital loads at MMH indicates through quantitative results that medicine stocking schedules and staff allocations are key areas that can be addressed to reduce mortality by up to 5-fold. With data-driven evidence provided by the model, hospital staff, administration, and the local ministries of health can enact policy changes and implement targeted interventions to improve maternal health outcomes at MMH. While our model is able to determine specific gaps in resources and health care delivery specifically at MMH, the model should be viewed as an additional tool that may be used by other facilities seeking to analyze and improve maternal health outcomes in resource constrained environments. [ABSTRACT FROM AUTHOR]

In this paper, we examine the inequality in the dynamics of the total fertility rate within 21 sub-Saharan African countries by wealth quintiles. We also examine the associated inequality within each country in the proximate determinants of fertility–marriage, contraception, and breastfeeding. Applying Bongaarts’ proximate determinants of fertility framework, for 14/21 countries we analyze, we find that those in the richest wealth quintiles have had a more rapid decline in fertility rates than those in the poorest wealth quintiles. The rapid decline for those in the richest wealth quintiles is attributable to delayed marriage and modest increases in contraceptive use. Although the poorest lag in fertility decline, postpartum abstinence and breastfeeding are the most important factors for them for fertility regulation. Further encouraging maternal health programs that focus on natural methods of fertility regulation will work in favor of the poorest in sub-Saharan Africa in moving through the demographic transition. [ABSTRACT FROM AUTHOR]

Background: Poor quality of care including fear of disrespect and abuse (D&A) perpetuated by health workers influences women’s decisions to seek maternity care. Key manifestations of D&A include: physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination, abandonment, and detention in facilities. This paper describes manifestations of D&A experienced in Kenya and measures their prevalence. Methods: This paper is based on baseline data collected during a before-and-after study designed to measure the effect of a package of interventions to reduce the prevalence of D&A experienced by women during labor and delivery in thirteen Kenyan health facilities. Data were collected through an exit survey of 641 women discharged from postnatal wards. We present percentages of D&A manifestations and odds ratios of its relationship with demographic characteristics using a multivariate fixed effects logistic regression model. Results: Twenty percent of women reported any form of D&A. Manifestations of D&A includes: non-confidential care (8.5%), non-dignified care (18%), neglect or abandonment (14.3%), Non-consensual care (4.3%) physical abuse (4.2%) and, detainment for non-payment of fees (8.1). Women aged 20-29 years were less likely to experience non-confidential care compared to those under 19; OR: [0.6 95% CI (0.36, 0.90); p=0.017]. Clients with no companion during delivery were less likely to experience inappropriate demands for payment; OR: [0.49 (0.26, 0.95); p=0.037]; while women with higher parities were three times more likely to be detained for lack of payment and five times more likely to be bribed compared to those experiencing there first birth. Conclusion: One out of five women experienced feeling humiliated during labor and delivery. Six categories of D&A during childbirth in Kenya were reported. Understanding the prevalence of D&A is critical in developing interventions at national, health facility and community levels to address the factors and drivers that influence D&A in facilities and to encourage clients’ future facility utilization. [ABSTRACT FROM AUTHOR]

Objective and the context: This paper examines the beliefs and experiences of women and their families in remote mountain villages of Nepal about perinatal sickness and death and considers the implications of these beliefs for future healthcare provision. Methods: Two mountain villages were chosen for this qualitative study to provide diversity of context within a highly disadvantaged region. Individual in-depth interviews were conducted with 42 women of childbearing age and their family members, 15 health service providers, and 5 stakeholders. The data were analysed using a thematic analysis technique with a comprehensive coding process. Findings: Three key themes emerged from the study: (1) ‘Everyone has gone through it’: perinatal death as a natural occurrence; (2) Dewata (God) as a factor in health and sickness: a cause and means to overcome sickness in mother and baby; and (3) Karma (Past deeds), Bhagya (Fate) or Lekhanta (Destiny): ways of rationalising perinatal deaths. Conclusion: Religio-cultural interpretations underlie a fatalistic view among villagers in Nepal’s mountain communities about any possibility of preventing perinatal deaths. This perpetuates a silence around the issue, and results in severe under-reporting of ongoing high perinatal death rates and almost no reporting of stillbirths. The study identified a strong belief in religio-cultural determinants of perinatal death, which demonstrates that medical interventions alone are not sufficient to prevent these deaths and that broader social determinants which are highly significant in local life must be considered in policy making and programming. [ABSTRACT FROM AUTHOR]

Objectives: This paper assesses inequalities in access to reproductive and maternal health services among females affected by forced displacement and sexual and gender-based violence in conflict settings in Colombia. This was accomplished through the following approaches: first, we assessed the gaps and gradients in three selected reproductive and maternal health care services. Second, we analyzed the patterns of inequalities in reproductive and maternal health care services and changes over time. And finally, we identified challenges and strategies for reaching girls and women who are the hardest to reach in conflict settings, in order to accelerate progress towards universal health coverage and to contribute to meeting the Sustainable Development Goals of good health and well-being and gender equality by 2030. Methods: Three types of data were required: data about health outcomes (relating to rates of females affected by conflict), information about reproductive and maternal health care services to provide a social dimension to unmask inequalities (unmet needs in family planning, antenatal care and skilled births attendance); and data on the female population. Data sources used include the National Information System for Social Protection, the National Registry of Victims, the National Administrative Department of Statistics, and Demographic Health Survey at three specific time points: 2005, 2010 and 2015. We estimated the slope index of inequality to express absolute inequality (gaps) and the concentration index to expresses relative inequality (gradients), and to understand whether inequality was eliminated over time. Results: Our findings show that even though absolute health care service-related inequalities dropped over time, relative inequalities worsened or remain unchanged. All summary measures still indicated the existence of inequalities as well as common patterns. Our findings suggest that there is a pattern of marginal exclusion and incremental patterns of inequality in the reproductive and maternal health care service provided to female affected by armed conflict. Conclusions: Overall, the effects of conflict continue to threaten reproductive and maternal health in Colombia, impeding progress towards the realization of universal health care (UHC) and reinforcing already-existing inequities. Key messages and steps forward include the need to understand the two distinct patterns of inequalities identified in this study in order to prompt improved general policy responses. Addressing unmet needs in reproductive and maternal health requires supporting gender equality and prioritizing the girls and women in regions with the highest rates of victims of armed conflict, with the objective of leaving no girl or woman behind. This analysis represents the first attempt to analyze coverage-related inequality in reproductive and maternal health care services for female affected by armed conflict in Colombia. As the World Health Organization and global health systems leaders call for more inclusive engagement, this approach may serve as the key to shaping people-centred health systems. In this particular case, health care facilities must be located in close proximity to girls and women in conflict and post-conflict settings in order to deliver essential reproductive and maternal health care services. Finally, reducing inequalities in opportunities would not only promote equity, but also drive sustainable development. [ABSTRACT FROM AUTHOR]

Background: Despite remarkable progress in maternal and child health, inequity persists in maternal care utilization in Bangladesh. Government of Bangladesh (GOB) with technical assistance from United Nation Population Fund (UNFPA), United Nation Children’s Fund (UNICEF) and World Health Organization (WHO) started implementing Maternal and Neonatal Health Initiatives in selected districts of Bangladesh (MNHIB) in 2007 with an aim to reduce inequity in healthcare utilization. This study examines the effect of MNHIB on inequity in maternal care utilization. Method: Two surveys were carried out in four districts in Bangladesh- baseline in 2008 and end-line in 2013. The baseline survey collected data from 13,206 women giving birth in the preceding year and in end-line 7,177 women were interviewed. Inequity in maternal healthcare utilization was calculated pre and post-MNHIB using rich-to-poor ratio and concentration index. Results: Mean age of respondents were 23.9 and 24.6 years in 2008 and 2013 respectively. Utilization of pregnancy-related care increased for all socioeconomic strata between these two surveys. The concentration indices (CI) for various maternal health service utilization in 2013 were found to be lower than the indices in 2008. However, in comparison to contemporary BDHS data in nearby districts, MNHIB was successful in reducing inequity in receiving ANC from a trained provider (CI: 0.337 and 0.272), institutional delivery (CI: 0.435 in 2008 to 0.362 in 2013), and delivery by skilled personnel (CI: 0.396 and 0.370). Conclusions: Overall use of maternal health care services increased in post-MNHIB year compared to pre-MNHIB year and inequity in maternal service utilization declined for three indicators out of six considered in the paper. The reductions in CI values for select maternal care indicators imply that the program has been successful not only in improving utilization of maternal health services but also in lowering inequality of service utilization across socioeconomic groups. Maternal health programs, if properly designed and implemented, can improve access, partially overcoming the negative effects of socioeconomic disparities. [ABSTRACT FROM AUTHOR]

Globally, the burden of deaths and illness is still unacceptably high at the day of birth. Annually, approximately 300.000 women die related to childbirth, 2.7 million babies die within their first month of life, and 2.6 million babies are stillborn. Many of these fatalities could be avoided by basic, but prompt care, if birth attendants around the world had the necessary skills and competencies to manage life-threatening complications around the time of birth. Thus, the innovative Helping Babies Survive (HBS) and Helping Mothers Survive (HMS) programs emerged to meet the need for more practical, low-cost, and low-tech simulation-based training. This paper provides users of HBS and HMS programs a 10-point list of key implementation steps to create sustained impact, leading to increased survival of mothers and babies. The list evolved through an Utstein consensus process, involving a broad spectrum of international experts within the field, and can be used as a means to guide processes in low-resourced countries. Successful implementation of HBS and HMS training programs require country-led commitment, readiness, and follow-up to create local accountability and ownership. Each country has to identify its own gaps and define realistic service delivery standards and patient outcome goals depending on available financial resources for dissemination and sustainment. [ABSTRACT FROM AUTHOR]

Background: While a number of studies have examined the factors affecting accessibility to and utilisation of healthcare services by persons with disability in general, there is little evidence about disabled women's access to maternal health services in low-income countries and few studies consult disabled women themselves to understand their experience of care and the challenges they face in accessing skilled maternal health services. The objective of this paper is to explore the challenges women with disabilities encounter in accessing and using institutional maternal healthcare services in Ghana. Methods and Findings: A qualitative study was conducted in 27 rural and urban communities in the Bosomtwe and Central Gonja districts of Ghana with a total of 72 purposively sampled women with different physical, visual, and hearing impairments who were either lactating or pregnant at the time of this research. Semi-structured in-depth interviews were used to gather data. Attride-Stirling’s thematic network framework was used to analyse the data. Findings suggest that although women with disability do want to receive institutional maternal healthcare, their disability often made it difficult for such women to travel to access skilled care, as well as gain access to unfriendly physical health infrastructure. Other related access challenges include: healthcare providers’ insensitivity and lack of knowledge about the maternity care needs of women with disability, negative attitudes of service providers, the perception from able-bodied persons that women with disability should be asexual, and health information that lacks specificity in terms of addressing the special maternity care needs of women with disability. Conclusions: Maternal healthcare services that are designed to address the needs of able-bodied women might lack the flexibility and responsiveness to meet the special maternity care needs of women with disability. More disability-related cultural competence and patient-centred training for healthcare providers as well as the provision of disability-friendly transport and healthcare facilities and services are needed. [ABSTRACT FROM AUTHOR]

Background: In 2003, the Ethiopian Ministry of Health established the Health Extension Program (HEP), with the goal of improving access to health care and health promotion activities in rural areas of the country. This paper aims to assess the association of the HEP with improved utilization of maternal health services in Northern Ethiopia using institution-based retrospective data. Methods: Average quarterly total attendances for antenatal care (ANC), delivery care (DC) and post-natal care (PNC) at health posts and health care centres were studied from 2002 to 2012. Regression analysis was applied to two models to assess whether trends were statistically significant. One model was used to estimate the level and trend changes associated with the immediate period of intervention, while changes related to the post-intervention period were estimated by the other. Results: The total number of consultations for ANC, DC and PNC increased constantly, particularly after the late-intervention period. Increases were higher for ANC and PNC at health post level and for DC at health centres. A positive statistically significant upward trend was found for DC and PNC in all facilities (p<0.01). The positive trend was also present in ANC at health centres (p = 0.04), but not at health posts. Conclusion: Our findings revealed an increase in the use of antenatal, delivery and post-natal care after the introduction of the HEP. We are aware that other factors, that we could not control for, might be explaining that increase. The figures for DC and PNC are however low and more needs to be done in order to increase the access to the health care system as well as the demand for these services by the population. Strengthening of the health information system in the region needs also to be prioritized. [ABSTRACT FROM AUTHOR]

Objective: This paper investigated the cost-effectiveness of a computer-assisted Clinical Decision Support System (CDSS) in the identification of maternal complications in Ghana. Methods: A cost-effectiveness analysis was performed in a before- and after-intervention study. Analysis was conducted from the provider’s perspective. The intervention area was the Kassena- Nankana district where computer-assisted CDSS was used by midwives in maternal care in six selected health centres. Six selected health centers in the Builsa district served as the non-intervention group, where the normal Ghana Health Service activities were being carried out. Results: Computer-assisted CDSS increased the detection of pregnancy complications during antenatal care (ANC) in the intervention health centres (before-intervention= 9 /1,000 ANC attendance; after-intervention= 12/1,000 ANC attendance; P-value=0.010). In the intervention health centres, there was a decrease in the number of complications during labour by 1.1%, though the difference was not statistically significant (before-intervention =107/1,000 labour clients; after-intervention= 96/1,000 labour clients; P-value=0.305). Also, at the intervention health centres, the average cost per pregnancy complication detected during ANC (cost –effectiveness ratio) decreased from US$17,017.58 (before-intervention) to US$15,207.5 (after-intervention). Incremental cost –effectiveness ratio (ICER) was estimated at US$1,142. Considering only additional costs (cost of computer-assisted CDSS), cost per pregnancy complication detected was US$285. Conclusions: Computer –assisted CDSS has the potential to identify complications during pregnancy and marginal reduction in labour complications. Implementing computer-assisted CDSS is more costly but more effective in the detection of pregnancy complications compared to routine maternal care, hence making the decision to implement CDSS very complex. Policy makers should however be guided by whether the additional benefit is worth the additional cost. [ABSTRACT FROM AUTHOR]

Background: Whilst there is compelling evidence of an almost 2-fold increased risk of still births, and suggestive evidence of increased mortality among offspring of mothers with psychotic disorders, only three studies have addressed the role of antenatal depression (AND) on survival of the baby. We examined these associations in a large cohort of pregnant women in Ghana. Methods: A Cohort study nested within 4-weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths in the Kintampo Health Research Centre study area of Ghana. Women were screened for AND using the Patient Health Questionnaire (PHQ-9) to ascertain DSM-IV major or minor depression. Outcomes were adverse birth outcomes, maternal/infant morbidity, and uptake of key newborn care practices, examined using logistic regression; effect sizes reported as relative risks with 95% confidence intervals. Results: 20679 (89.6%) pregnant women completed the PHQ-9. The prevalence of AND was 9.9% (n = 2032) (95% confidence interval 9.4%–10.2%). AND was associated with: prolonged labour (RR 1.25, 95% CI 1.02–1.53); peripartum complications (RR 1.11, 95% CI 1.07–1.15);postpartum complications (RR 1.27, 96% CI 1.21–1.34); non-vaginal delivery (RR 1.19, 95% CI 1.02–1.40); newborn illness (RR 1.52, 95% CI 1.16–1.99); and bed net use during pregnancy (RR 0.93, 95% CI 0.89–0.98), but not neonatal deaths, still births, low birth weight, immediate breast feeding initiation, or exclusive breastfeeding. AND was marginally associated with preterm births (RR 1.32, 95% CI 0.98–1.76). Conclusion: This paper has contributed important evidence on the role of antenatal depression as a potential contributor to maternal and infant morbidity. Non-pharmacological treatments anchored on primary care delivery structures are recommended as an immediate step. We further recommend that trials are designed to assess if treating antenatal depression in conjunction with improving the quality of obstetric care results in improved maternal and newborn outcomes. [ABSTRACT FROM AUTHOR]

Background: Inadequate water and sanitation during childbirth are likely to lead to poor maternal and newborn outcomes. This paper uses existing data sources to assess the water and sanitation (WATSAN) environment surrounding births in Tanzania in order to interrogate whether such estimates could be useful for guiding research, policy and monitoring initiatives. Methods: We used the most recent Tanzania Demographic and Health Survey (DHS) to characterise the delivery location of births occurring between 2005 and 2010. Births occurring in domestic environments were characterised as WATSAN-safe if the home fulfilled international definitions of improved water and improved sanitation access. We used the 2006 Service Provision Assessment survey to characterise the WATSAN environment of facilities that conduct deliveries. We combined estimates from both surveys to describe the proportion of all births occurring in WATSAN-safe environments and conducted an equity analysis based on DHS wealth quintiles and eight geographic zones. Results: 42.9% (95% confidence interval: 41.6%–44.2%) of all births occurred in the woman's home. Among these, only 1.5% (95% confidence interval: 1.2%–2.0%) were estimated to have taken place in WATSAN-safe conditions. 74% of all health facilities conducted deliveries. Among these, only 44% of facilities overall and 24% of facility delivery rooms were WATSAN-safe. Combining the estimates, we showed that 30.5% of all births in Tanzania took place in a WATSAN-safe environment (range of uncertainty 25%–42%). Large wealth-based inequalities existed in the proportion of births occurring in domestic environments based on wealth quintile and geographical zone. Conclusion: Existing data sources can be useful in national monitoring and prioritisation of interventions to improve poor WATSAN environments during childbirth. However, a better conceptual understanding of potentially harmful exposures and better data are needed in order to devise and apply more empirical definitions of WATSAN-safe environments, both at home and in facilities. [ABSTRACT FROM AUTHOR]

Background: A vast body of global research shows that cultural factors affect the use of skilled maternity care services in diverse contexts. While interventions have sought to address this issue, the literature on these efforts has not been synthesised. This paper presents a systematic mapping of interventions that have been implemented to address cultural factors that affect women's use of skilled maternity care. It identifies and develops a map of the literature; describes the range of interventions, types of literature and study designs; and identifies knowledge gaps. Methods and Findings: Searches conducted systematically in ten electronic databases and two websites for literature published between 01/01/1990 and 28/02/2013 were combined with expert-recommended references. Potentially eligible literature included journal articles and grey literature published in English, French or Spanish. Items were screened against inclusion and exclusion criteria, yielding 96 items in the final map. Data extracted from the full text documents are presented in tables and a narrative synthesis. The results show that a diverse range of interventions has been implemented in 35 countries to address cultural factors that affect the use of skilled maternity care. Items are classified as follows: (1) service delivery models; (2) service provider interventions; (3) health education interventions; (4) participatory approaches; and (5) mental health interventions. Conclusions: The map provides a rich source of information on interventions attempted in diverse settings that might have relevance elsewhere. A range of literature was identified, from narrative descriptions of interventions to studies using randomised controlled trials to evaluate impact. Only 23 items describe studies that aim to measure intervention impact through the use of experimental or observational-analytic designs. Based on the findings, we identify avenues for further research in order to better document and measure the impact of interventions to address cultural factors that affect use of skilled maternity care. [ABSTRACT FROM AUTHOR]

Background: India, with a population of more than 1.21 billion, has the highest maternal mortality in the world (estimated to be 56000 in 2010); and adolescent (aged 15–19) mortality shares 9% of total maternal deaths. Addressing the maternity care needs of adolescents may have considerable ramifications for achieving the Millennium Development Goal (MDG)–5. This paper assesses the socioeconomic differentials in accessing full antenatal care and professional attendance at delivery by adolescent mothers (aged 15–19) in India during 1990–2006. Methods and Findings: Data from three rounds of the National Family Health Survey of India conducted during 1992–93, 1998–99, and 2005–06 were analyzed. The Cochran-Armitage and Chi-squared test for linear and non-linear time trends were applied, respectively, to understand the trend in the proportion of adolescent mothers utilizing select maternity care services during 1990–2006. Using pooled multivariate logistic regression models, the probability of select maternal healthcare utilization among women by key socioeconomic characteristics was appraised. After adjusting for potential socio-demographic and economic characteristics, the likelihood of adolescents accessing full antenatal care increased by only 4% from 1990 to 2006. However, the probability of adolescent women availing themselves of professional attendance at delivery increased by 79% during the same period. The study also highlights the desolate disparities in maternity care services among adolescents across the most and the least favoured groups. Conclusion: Maternal care interventions in India need focused programs for rural, uneducated, poor adolescent women so that they can avail themselves of measures to delay child bearing, and for better antenatal consultation and delivery care in case of pregnancy. This study strongly advocates the promotion of a comprehensive ‘adolescent scheme’ along the lines of ‘Continuum of Maternal, Newborn and Child health Care’ to address the unmet need of reproductive and maternal healthcare services among adolescent women in India. [ABSTRACT FROM AUTHOR]

In 2007, the World Health Organization (WHO) received a criticism for a lack of transparency and systematic methods in the development of guidelines, which were at that time perceived as substantially driven by expert opinion. In this paper we assessed the quality of maternal and perinatal health guidelines developed since then. We used the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool to evaluate the quality of methodological rigour and transparency of four different WHO guidelines published between 2007 and 2011. Our findings showed high scores among the most recent guidelines on maternal and perinatal health suggesting higher quality. However, there is still potential for improvement, especially in including different stakeholder views, transparency of guidelines regarding the role of the funding body and presentation of the guideline document. [ABSTRACT FROM AUTHOR]

Background: Coupled with the largest number of maternal deaths, adolescent pregnancy in India has received paramount importance due to early age at marriage and low contraceptive use. The factors associated with the utilization of maternal healthcare services among married adolescents in rural India are poorly discussed. Methodology/Principal Findings: Using the data from third wave of National Family Health Survey (2005-06), available in public domain for the use by researchers, this paper examines the factors associated with the utilization of maternal healthcare services among married adolescent women (aged 15-19 years) in rural India. Three components of maternal healthcare service utilization were measured: full antenatal care, safe delivery, and postnatal care within 42 days of delivery for the women who gave births in the last five years preceding the survey. Considering the framework on causes of maternal mortality proposed by Thaddeus and Maine (1994), selected socioeconomic, demographic, and cultural factors influencing outcome events were included as the predictor variables. Bi-variate analyses including chi-square test to determine the difference in proportion, and logistic regression to understand the net effect of predictor variables on selected outcomes were applied. Findings indicate the significant differences in the use of selected maternal healthcare utilization by educational attainment, economic status and region of residence. Muslim women, and women belonged to Scheduled Castes, Scheduled Tribes, and Other Backward Classes are less likely to avail safe delivery services. Additionally, adolescent women from the southern region utilizing the highest maternal healthcare services than the other regions. Conclusions: The present study documents several socioeconomic and cultural factors affecting the utilization of maternal healthcare services among rural adolescent women in India. The ongoing healthcare programs should start targeting household with married adolescent women belonging to poor and specific sub-groups of the population in rural areas to address the unmet need for maternal healthcare service utilization. [ABSTRACT FROM AUTHOR]

Background: Relative to the attention given to improving the quality of and access to maternal health services, the influence of women's socio-economic situation on maternal health care use has received scant attention. The objective of this paper is to examine the relationship between women's economic, educational and empowerment status, introduced as the 3Es, and maternal health service utilization in developing countries. Methods/Principal Findings: The analysis uses data from the most recent Demographic and Health Surveys conducted in 31 countries for which data on all the 3Es are available. Separate logistic regression models are fitted for modern contraceptive use, antenatal care and skilled birth attendance in relation to the three covariates of interest: economic, education and empowerment status, additionally controlling for women's age and residence. We use meta-analysis techniques to combine and summarize results from multiple countries. The 3Es are significantly associated with utilization of maternal health services. The odds of having a skilled attendant at delivery for women in the poorest wealth quintile are 94% lower than that for women in the highest wealth quintile and almost 5 times higher for women with complete primary education relative to those less educated. The likelihood of using modern contraception and attending four or more antenatal care visits are 2.01 and 2.89 times, respectively, higher for women with complete primary education than for those less educated. Women with the highest empowerment score are between 1.31 and 1.82 times more likely than those with a null empowerment score to use modern contraception, attend four or more antenatal care visits and have a skilled attendant at birth. Conclusions/Significance: Efforts to expand maternal health service utilization can be accelerated by parallel investments in programs aimed at poverty eradication (MDG 1), universal primary education (MDG 2), and women's empowerment (MDG 3). [ABSTRACT FROM AUTHOR]