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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]

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: The underutilization of formal, evidence-based maternal health services continues to contribute to poor maternal outcomes among women living in rural Africa. Women’s choice of the type of maternal care they receive strongly influences their utilization of maternal health services. There is therefore a need to understand rural women’s preferred choices to help set priorities for initiatives attempting to make formal maternal care more responsive to women’s needs. The aim of this review was to explore and identify women’s preferences for different sources of childbirth and postnatal care and the factors that contribute to these preferences. Methods: A systematic literature search was conducted using the Ovid Medline, Embase, CINAHL, and Global Health databases. Thirty-seven studies that elicited women’s preferences for childbirth and postnatal care using qualitative methods were included in the review. A narrative synthesis was conducted to collate study findings and to report on patterns identified across findings. Results: During the intrapartum period, preferences varied across communities, with some studies reporting preferences for traditional childbirth with traditional care-takers, and others reporting preferences for a formal facility-based childbirth with health professionals. During the postpartum period, the majority of relevant studies reported a preference for traditional postnatal services involving traditional rituals and customs. The factors that influenced the reported preferences were related to the perceived need for formal or traditional care providers, accessibility to maternal care, and cultural and religious norms. Conclusion: Review findings identified a variety of preferences for sources of maternal care from intrapartum to postpartum. Future interventions aiming to improve access and utilization of evidence-based maternal healthcare services across rural Africa should first identify major challenges and priority needs of target populations and communities through formative research. Evidence-based services that meet rural women’s specific needs and expectations will increase the utilization of formal care and ultimately improve maternal outcomes across rural Africa. [ABSTRACT FROM AUTHOR]

Background: Low-educated native Dutch and non-western minority women have inadequate access to obstetric care. Moreover, the care they receive lacks responsiveness to their needs and cultural competences. Gaining a deeper understanding of their experiences and satisfaction with antenatal, birthing and maternity care will help to adjust healthcare responsiveness to meet their needs during pregnancy, childbirth and the postpartum period. Methods: We combined the World Health Organization conceptual framework of healthcare responsiveness with focus group research to measure satisfaction with antenatal, birthing and maternity care of women with a low-educated native Dutch and non-western ethnic background. Results: From September 2011 until December 2013, 106 women were recruited for 20 focus group sessions. Eighty-five percent of the women had a non-western immigrant background and 89% a low or intermediate educational attainment. The study population was mostly positive about the provided care during the antenatal phase. They were less positive about the other two phases of care. Moreover, the obstetric healthcare systems’ responsiveness in all phases of care (antenatal, birthing and maternity) did not meet these women’s needs. The ‘respect for persons’ domains ‘autonomy’, ‘communication’ and ‘dignity’ and the ‘client orientation’ domain ‘prompt attention’ were judged most negatively. Conclusions: The study findings give contextual meaning and starting points for improvement of responsiveness in the provision of obstetric care within a multi-ethnic women’s population. [ABSTRACT FROM AUTHOR]

Background: Improving quality of maternal healthcare services is key to reducing maternal mortality across developing nations, including India. Expanding access to institutionalized care alone has failed to address critical quality barriers to safe, effective, patient-centred, timely and equitable care. Multi-dimensional quality improvement focusing on Person Centred Care(PCC) has an important role in expanding utilization of maternal health services and reducing maternal mortality. Methods: Nine public health facilities were selected in two rural districts of Uttar Pradesh(UP), India, to understand women’s experiences of childbirth and identify quality gaps in the process of maternity care. 23 direct, non-participant observations of uncomplicated vaginal deliveries were conducted using checklists with special reference to PCC, capturing quality of care provision at five stages—admission; pre-delivery; delivery; post-delivery and discharge. Data was thematically analysed using the framework approach. Case studies, good practices and gaps were noted at each stage of delivery care. Results: Admission to maternity wards was generally prompt. All deliveries were conducted by skilled providers and at least one staff was available at all times. Study findings were discussed under two broad themes of care ‘structure’ and ‘process’. While infrastructure, supplies and human resource were available across most facilities, gaps were observed in the process of care, particularly during delivery and post-delivery stages. Key areas of concern included compromised patient safety like poor hand hygiene, usage of unsterilized instruments; inadequate clinical care like lack of routine monitoring of labour progression, inadequate postpartum care; partially compromised privacy in the labour room and postnatal ward; and few incidents of abuse and demand for informal payments. Conclusions: The study findings reflect gaps in the quality of maternity care across public health facilities in the study area and support the argument for strengthening PCC as an important effort towards quality improvement across the continuum of delivery care. [ABSTRACT FROM AUTHOR]

Background: Maternity care has to be available 24 hours a day, seven days a week. It is known that obstetric intervention can influence the time of birth, but no previous analysis at a national level in England has yet investigated in detail the ways in which the day and time of birth varies by onset of labour and mode of giving birth. Method: We linked data from birth registration, birth notification, and Maternity Hospital Episode Statistics and analysed 5,093,615 singleton births in NHS maternity units in England from 2005 to 2014. We used descriptive statistics and negative binomial regression models with harmonic terms to establish how patterns of timing of birth vary by onset of labour, mode of giving birth and gestational age. Results: The timing of birth by time of day and day of the week varies considerably by onset of labour and mode of birth. Spontaneous births after spontaneous onset are more likely to occur between midnight and 6am than at other times of day, and are also slightly more likely on weekdays than at weekends and on public holidays. Elective caesarean births are concentrated onto weekday mornings. Births after induced labours are more likely to occur at hours around midnight on Tuesdays to Saturdays and on days before a public holiday period, than on Sundays, Mondays and during or just after a public holiday. Conclusion: The timing of births varies by onset of labour and mode of birth and these patterns have implications for midwifery and medical staffing. Further research is needed to understand the processes behind these findings. [ABSTRACT FROM AUTHOR]

Introduction: Despite remarkable progress in maternal and neonatal health over past two decades, maternal and neonatal mortality in Bangladesh remain high, which is partially attributable to low use of skilled maternal and newborn health (MNH) services. Birth preparedness and complications readiness (BCPR) is recommended by the World Health Organization and by the Government of Bangladesh as a key intervention to increasing appropriate MNH services. This study aims to explore the status of BPCR in a hard-to-reach area of rural Bangladesh and to demonstrate how BPCR practices is associated with birth in the presence of a skilled birth attendant. Methods: Data was collected using multistage cluster sampling-based household survey in two sub-districts of Netrokona, Bangladesh in 2014. Interviews were conducted among women with a recent birth history in 12-months and their husbands. Univariate, bivariate, and multivariable analysis using Stata 14.0 were performed from 317 couples. Results: Mean age of respondents was 26.1 (SD ± 5.3) years. There was a significant difference in BPCR practice between women and couples for identification of the place of birth (84% vs. 75%), identification of a birth attendant (89% vs.72%), arranging transport for birth or emergencies (20% vs. 13%), and identification of a blood donor (15% vs. 8%). In multivariable analysis, odds of giving birth in presence of a skilled birth attendant consistently increased with higher completeness of preparedness (OR 3.3 for 3–5 BPCR components, OR 5.5 for 4–5 BPCR components, OR 10.4 for all 5 BPCR components). For different levels of completeness of BPCR practice, the adjusted odds ratios were higher for couple preparedness comparatively. Conclusions: BPCR is associated with birth in the presence of a skilled attendant and this effect is magnified when planning is carried out by the couple. Interventions aiming to increase BPCR practices should not focus on women only, as involving the couple is most likely lead to positive care-seeking practices. [ABSTRACT FROM AUTHOR]

Background: The WHO recommends maternity waiting homes (MWH) as one intervention to improve maternal and newborn health. However, persistent structural, cultural and financial barriers in their design and implementation have resulted in mixed success in both their uptake and utilization. Guidance is needed on how to design a MWH intervention that is acceptable and sustainable. Using formative research and guided by a sustainability framework for health programs, we systematically collected data from key stakeholders and potential users in order to design a MWH intervention in Zambia that could overcome multi-dimensional barriers to accessing facility delivery, be acceptable to the community and be financially and operationally sustainable. Methods and findings: We used a concurrent triangulation study design and mixed methods. We used free listing to gather input from a total of 167 randomly sampled women who were pregnant or had a child under the age of two (n = 59), men with a child under the age of two (n = 53), and community elders (n = 55) living in the catchment areas of four rural health facilities in Zambia. We conducted 17 focus group discussions (n = 135) among a purposive sample of pregnant women (n = 33), mothers-in-law (n = 32), traditional birth attendants or community maternal health promoters (n = 38), and men with a child under two (n = 32). We administered 38 semi-structured interviews with key informants who were identified by free list respondents as having a stake in the condition and use of MWHs. Lastly, we projected fixed and variable recurrent costs for operating a MWH. Respondents most frequently mentioned distance, roads, transport, and the quality of MWHs and health facilities as the major problems facing pregnant women in their communities. They also cited inadequate advanced planning for delivery and the lack of access to delivery supplies and baby clothes as other problems. Respondents identified the main problems of MWHs specifically as over-crowding, poor infrastructure, lack of amenities, safety concerns, and cultural issues. To support operational sustainability, community members were willing to participate on oversight committees and contribute labor. The annual fixed recurrent cost per 10-bed MWH was estimated as USD543, though providing food and charcoal added another $3,000USD. Respondents identified water pumps, an agriculture shop, a shop for baby clothes and general goods, and grinding mills as needs in their communities that could potentially be linked with an MWH for financial sustainability. Conclusions: Findings informed the development of an intervention model for renovating existing MWH or constructing new MWH that meets community standards of safety, comfort and services offered and is aligned with government policies related to facility construction, ownership, and access to health services. The basic strategies of the new MWH model include improving community acceptability, strengthening governance and accountability, and building upon existing efforts to foster financial and operational sustainability. The proposed model addresses the problems cited by our respondents and challenges to MWHs identified by in previous studies and elicits opportunities for social enterprises that could serve the dual purpose of meeting a community need and generating revenue for the MWH. [ABSTRACT FROM AUTHOR]

Background: Birth preparedness and complication readiness aims to reduce delays in care seeking, promote skilled birth attendance, and facility deliveries. Little is known about birth preparedness practices among populations living in hard-to-reach areas in Bangladesh. Objectives: To describe levels of birth preparedness and complication readiness among recently delivered women, identify determinants of being better prepared for birth, and assess the impact of greater birth preparedness on maternal and neonatal health practices. Methods: A cross-sectional survey with 2,897 recently delivered women was undertaken in 2012 as part of an evaluation trial done in five hard-to-reach districts in rural Bangladesh. Mothers were considered well prepared for birth if they adopted two or more of the four birth preparedness components. Descriptive statistics and multivariable logistic regression were used for analysis. Results: Less than a quarter (24.5%) of women were considered well prepared for birth. Predictors of being well-prepared included: husband’s education (OR = 1.3; CI: 1.1–1.7), district of residence, exposure to media in the form of reading a newspaper (OR = 2.2; CI: 1.2–3.9), receiving home visit by a health worker during pregnancy (OR = 1.5; CI: 1.2–1.8), and receiving at least 3 antenatal care visits from a qualified provider (OR = 1.4; CI: 1.0–1.9). Well-prepared women were more likely to deliver at a health facility (OR = 2.4; CI: 1.9–3.1), use a skilled birth attendant (OR = 2.4, CI: 1.9–3.1), practice clean cord care (OR = 1.3, CI: 1.0–1.5), receive post-natal care from a trained provider within two days of birth for themselves (OR = 2.6, CI: 2.0–3.2) or their newborn (OR = 2.6, CI: 2.1–3.3), and seek care for delivery complications (OR = 1.8, CI: 1.3–2.6). Conclusion: Greater emphasis on BPCR interventions tailored for hard to reach areas is needed to improve skilled birth attendance, care seeking for complications and essential newborn care and facilitate reductions in maternal and neonatal mortality in low performing districts in Bangladesh. [ABSTRACT FROM AUTHOR]

Background: One of the greatest obstacles facing efforts to address quality of care in low and middle income countries is the absence of relevant and reliable data. This article proposes a methodology for creating a single “Quality Index” (QI) representing quality of maternal and neonatal health care based upon data collected as part of the Demographic and Health Survey (DHS) program. Methods: Using the 2012 Indonesian Demographic and Health Survey dataset, indicators of quality of care were identified based on the recommended guidelines outlined in the WHO Integrated Management of Pregnancy and Childbirth. Two sets of indicators were created; one set only including indicators available in the standard DHS questionnaire and the other including all indicators identified in the Indonesian dataset. For each indicator set composite indices were created using Principal Components Analysis and a modified form of Equal Weighting. These indices were tested for internal coherence and robustness, as well as their comparability with each other. Finally a single QI was chosen to explore the variation in index scores across a number of known equity markers in Indonesia including wealth, urban rural status and geographical region. Results: The process of creating quality indexes from standard DHS data was proven to be feasible, and initial results from Indonesia indicate particular disparities in the quality of care received by the poor as well as those living in outlying regions. Conclusions: The QI represents an important step forward in efforts to understand, measure and improve quality of MNCH care in developing countries. [ABSTRACT FROM AUTHOR]