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Background: Second-trimester abortions are less common than abortions in the first trimester, yet they disproportionately account for a higher burden of abortion-related mortality and morbidity worldwide. Health workers play a crucial role in granting or denying access to these services, yet little is known about their experiences. Ethiopia has been successful in reducing mortality due to unsafe abortion over the past decade, but access to second trimester abortion remains a challenge. The aim of this study is to better understand this issue by exploring the experiences of second-trimester abortion providers working in Addis Ababa, Ethiopia. Methods: A qualitative study with 13 in-depth semi-structured interviews with 16 health workers directly involved in providing second-trimester abortions, this included obstetrician and gynaecologist specialists and residents, general practitioners, nurses, and midwives. Data was collected at four public hospitals and one non-governmental clinic in Addis Ababa, Ethiopia and analysed using Malterud's text-condensation method. Results: The providers recognized the critical need for second-trimester abortion services and were motivated by their empathy towards women who often sought care late due to marginalisation and poverty making it difficult to access abortion before the second trimester. However, service provision was challenging according to the providers, and barriers like lack of access to essential drugs and equipment, few providers willing to conduct abortions late in pregnancy and unclear guidelines were commonly experienced. This led to highly demanding working conditions. The providers experienced ethical dilemmas pertaining to the possible viability of the fetus and women desperately requesting the service after the legal limit. Conclusions: Second-trimester abortion providers faced severe barriers and ethical dilemmas pushing their moral threshold and medical risk-taking in efforts to deliver second-trimester abortions to vulnerable women in need of the service. Effort is needed to minimize health system barriers and improve guidelines and support for second-trimester abortion providers in order to increase access and quality of second-trimester abortion services in Ethiopia. The barriers forcing women into second trimester abortions also need to be addressed. [ABSTRACT FROM AUTHOR]

Background: Second-trimester abortions are less common than abortions in the first trimester, yet they disproportionately account for a higher burden of abortion-related mortality and morbidity worldwide. Health workers play a crucial role in granting or denying access to these services, yet little is known about their experiences. Ethiopia has been successful in reducing mortality due to unsafe abortion over the past decade, but access to second trimester abortion remains a challenge. The aim of this study is to better understand this issue by exploring the experiences of second-trimester abortion providers working in Addis Ababa, Ethiopia. Methods: A qualitative study with 13 in-depth semi-structured interviews with 16 health workers directly involved in providing second-trimester abortions, this included obstetrician and gynaecologist specialists and residents, general practitioners, nurses, and midwives. Data was collected at four public hospitals and one non-governmental clinic in Addis Ababa, Ethiopia and analysed using Malterud's text-condensation method. Results: The providers recognized the critical need for second-trimester abortion services and were motivated by their empathy towards women who often sought care late due to marginalisation and poverty making it difficult to access abortion before the second trimester. However, service provision was challenging according to the providers, and barriers like lack of access to essential drugs and equipment, few providers willing to conduct abortions late in pregnancy and unclear guidelines were commonly experienced. This led to highly demanding working conditions. The providers experienced ethical dilemmas pertaining to the possible viability of the fetus and women desperately requesting the service after the legal limit. Conclusions: Second-trimester abortion providers faced severe barriers and ethical dilemmas pushing their moral threshold and medical risk-taking in efforts to deliver second-trimester abortions to vulnerable women in need of the service. Effort is needed to minimize health system barriers and improve guidelines and support for second-trimester abortion providers in order to increase access and quality of second-trimester abortion services in Ethiopia. The barriers forcing women into second trimester abortions also need to be addressed. [ABSTRACT FROM AUTHOR]

Introduction: In sub-Saharan Africa, there is limited evidence on the COVID-19 health-related effect from front-line health provision settings. Therefore, this study aimed to analyse the effect of the COVID-19 pandemic on routine maternal and neonatal health services in three referral hospitals. Materials and methods: We conducted an observational study using aggregate monthly maternal and neonatal health services routine data for two years (March 2019–February 2021) in three referral hospitals including two maternities: Hôpital National Ignace Deen (HNID) in Conakry and Hôpital Regional de Mamou (HRM) in Mamou and one neonatology ward: Institut de Nutrition et de Santé de l'Enfant (INSE) in Conakry. We compared indicators of health service utilisation, provision and health outcomes before and during the COVID-19 pandemic periods. An interrupted time-series analysis (ITSA) was performed to assess the relationship between changes in maternal and neonatal health indicators and COVID-19 through cross-correlation. Results: During COVID-19, the mean monthly number (MMN) of deliveries decreased significantly in HNID (p = 0.039) and slightly increased in HRM. In the two maternities, the change in the MMN of deliveries were significantly associated with COVID-19. The ITSA confirmed the association between the increase in the MMN of deliveries and COVID-19 in HRM (bootstrapped F-value = 1.46, 95%CI [0.036–8.047], p < 0.01). We observed an increasing trend in obstetric complications in HNID, while the trend declined in HRM. The MMN of maternal deaths increased significantly (p = 0.011) in HNID, while it slightly increased in HRM. In INSE, the MMN of neonatal admissions significantly declined (p < 0.001) and this decline was associated with COVID-19. The MMN of neonatal deaths significantly decreased (p = 0.009) in INSE and this decrease was related to COVID-19. Conclusion: The pandemic negatively affected the maternal and neonatal care provision, health service utilisation and health outcomes in two referral hospitals located in Conakry, the COVID-19 most-affected region. [ABSTRACT FROM AUTHOR]

Background: Ebola outbreaks pose a major threat to global public health, especially in Sub-Saharan Africa. These outbreaks disrupt the already fragile maternal health services in West Africa. The aims of this study is to assess the effect of Ebola virus disease (EVD) on maternal health service utilisation and perinatal outcomes. Methods: This systematic review was conducted in West Africa, and the databases used were Medline, PubMed, CINAHL, Scopus, EMBASE and African journals online. Studies that reported the effect of the Ebola outbreak on maternal health services in West Africa were eligible for this systematic review. The search was limited to articles written in the English language only and published between 2013 and 2020. Three authors independently appraised the articles, and the data were extracted using a standardised data extraction format. The findings were synthesised using a narrative summary, tables, and figures. Results: Twelve studies met the inclusion criteria and were used for this systematic review synthesis. The results showed that antenatal care significantly decreased during Ebola virus disease and strove to recover post-Ebola virus disease. Women were less likely to have institutional childbirth during Ebola virus disease and struggled to recover post-Ebola virus disease. In addition, this review revealed a substantially higher rate of maternal mortality post EVD than those observed before or during the outbreak. Conclusion: Based on our findings, antenatal care, institutional childbirth, and postnatal care are attempting to recover post-Ebola virus disease. We recommended that responsible bodies and stakeholders need to prepare locally tailored interventions to increase the number of women attending ANC, institutional childbirth, and PNC services post-EVD and future outbreaks including COVID-19. In order to build trust, creating community networks between health care providers and trusted community leaders may increase the number of women attending antenatal care (ANC), institutional childbirth and postnatal care (PNC) post-EVD and during future outbreaks. Further studies are needed to examine health centre and hospital availability and accessibility, and capacity to deliver maternal health services post-Ebola virus disease and future outbreaks. Plain Language Summary: Ebola virus disease (EVD) is a serious public health concern affecting the health of humans and other primates. These outbreaks disrupt the already fragile maternal health services in West Africa. There is limited data on the effect of EVD on maternal health service utilisation and perinatal outcomes in West Africa. This systematic review aims to synthesise evidence on maternal health service utilisation and perinatal outcomes before EVD, during EVD and post EVD. This systematic review was conducted in West Africa, and the databases used were Medline, PubMed, CINAHL, Scopus, EMBASE and African journals online. Twelve studies met the inclusion criteria and were used for this systematic review synthesis. The results showed that antenatal care significantly decreased during the Ebola virus outbreak and strove to recover post-Ebola virus disease. This finding indicated that women were less likely to have an institutional birth during EVD and struggled to recover post-Ebola virus disease. Based on this finding, responsible bodies and stakeholders need to prepare locally tailored interventions to increase the number of women attending ANC, institutional childbirth, and PNC services post-EVD and future outbreaks. [ABSTRACT FROM AUTHOR]

Background: The world is making progress toward achieving maternal and child health (MCH) related components of the Sustainable Development Goals. Nevertheless, the progress of many countries in Sub-Saharan Africa is lagging. Geographical accessibility from residence to health facilities is considered a major obstacle hampering the use of appropriate MCH services. Benin, a country where the southern and northern parts belong to different geographical zones, has among the highest maternal mortality rate in the world. Adequate use of MCH care is important to save lives of women and their babies. This study assessed the effect of geographical accessibility to health facilities on antenatal care and delivery services utilization in Benin, with an emphasis on geographical zones. Methods: We pooled two rounds of Benin Demographic and Health Surveys (BDHS). The sample included 18,105 women aged 15–49 years (9111 from BDHS-2011/2012 and 8994 from BDHS-2017/2018) who had live births within five years preceding the surveys. We measured the distance and travel time from residential areas to the closest health center by merging the BDHS datasets with Benin's geographic information system data. Multivariate logistic regression analysis was performed to estimate the effect of geographical access on pregnancy and delivery services utilization. We conducted a propensity score-matching analysis to check for robustness. Results: Regression results showed that the distance to the closest health center had adverse effects on the likelihood of a woman receiving appropriate maternal healthcare. The estimates showed that one km increase in straight-line distance to the closest health center reduces the odds of the woman receiving at least one antenatal care by 0.042, delivering in facility by 0.092, and delivering her baby with assistance of skilled birth attendants by 0.118. We also confirmed the negative effects of travel time and altitude of women's residence on healthcare utilization. Nonetheless, these effects were mainly seen in the northern part of Benin. Conclusions: Geographical accessibility to health facilities is critically important for the utilization of antenatal care and delivery services, particularly in the northern part of Benin. Improving geographical accessibility, especially in rural areas, is significant for further use of maternal health care in Benin. Plain language summary: Maternal and neonatal mortality rates are still high in many countries in Sub-Saharan Africa. Antenatal care (ANC) visits and institutional delivery with skilled birth attendants are important to prevent maternal and neonatal deaths. Nevertheless, women's utilization of ANC and delivery services has decreased recently in Benin, a country where the southern and northern parts belong to different geographical zones. Geographical accessibility from residence to health facilities is considered a major obstacle hampering the use of appropriate maternal healthcare. This study assessed the effect of geographical accessibility on ANC and delivery services utilization in Benin by considering the geographical characteristics. We used the two rounds of the Benin Demographic and Health Survey 2011/2012 and 2017/2018 and conducted regression analysis. This study has three important findings: (1) We confirmed adverse effects of distance and travel time on the likelihood of a women receiving appropriate ANC and delivery services in Benin, but this effect was mainly observed in the northern part; (2) Distance and travel time to health facilities had a negative effect on the use of at least one ANC but no significant effect for four or more ANC; (3) Regarding the threshold of distance, we confirmed that women living within 5 km from the closest health center were more likely to use maternal healthcare compared to their counterparts. In conclusion, geographical accessibility to health facilities is critically important for the utilization of antenatal care and delivery services, particularly in the northern part of Benin. [ABSTRACT FROM AUTHOR]

Background: Maternal mortality is an important public health problem in low-income countries. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. There is limited evidence on the role of community health workers in the management of pregnancy complications. This study aimed to describe the feasibility of task-sharing the initial screening and initiation of obstetric emergency care for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and document healthcare facility preparedness to respond to referrals. Method: The study took place in Maputo and Gaza Provinces in southern Mozambique and aimed to inform the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial. This was a mixed-methods study. The quantitative data was collected through self-administered questionnaires completed by community health workers and a health facility survey; this data was analysed using Stata v13. The qualitative data was collected through focus group discussions and in-depth interviews with various community groups, health care providers, and policymakers. All discussions were audio-recorded and transcribed verbatim prior to thematic analysis using QSR NVivo 10. Data collection was complemented by reviewing existing documents regarding maternal health and community health worker policies, guidelines, reports and manuals. Results: Community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they have not been trained to manage obstetric emergencies. Furthermore, barriers at health facilities were identified, including lack of equipment, shortage of supervisors, and irregular drug availability. All primary and the majority of secondary-level facilities (57%) do not provide blood transfusions or have surgical capacity, and thus such cases must be referred to the tertiary-level. Although most healthcare facilities (96%) had access to an ambulance for referrals, no transport was available from the community to the healthcare facility. Conclusions: This study showed that task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia were deemed feasible and acceptable at the community-level, but an effort should be in place to address challenges at the health system level. Plain Language Summary: Maternal mortality is an important public health problem in Mozambique. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. We conducted a study to describe the feasibility of task-sharing the screening and initiation of management for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and to document healthcare facility preparedness to respond to referrals. The study was done to inform a future intervention trial known as the Community-Level Interventions for Pre-eclampsia (CLIP) study. We interviewed community health workers, women, various community groups, health care providers, and policymakers and assessed health facilities in Maputo and Gaza provinces, Mozambique. Our results showed that community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they were not trained or equipped to provide obstetric emergencies care prior to referral. Nurses at primary health facilities were supportive of task-sharing with community health workers; however, some barriers mentioned include a lack of equipment, shortage of supervisors, and irregular drug availability. Local stakeholders emphasized the need for comprehensive training and supervision of community health workers to take on new tasks. Task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia was deemed feasible at the community level in southern Mozambique, but still, to be addressed some health system level barriers to the management of pregnancies complications. [ABSTRACT FROM AUTHOR]