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Background: The Three Delays Framework was instrumental in the reduction of maternal mortality leading up to, and during the Millennium Development Goals. However, this paper suggests the original framework might be reconsidered, now that most mothers give birth in facilities, the quality and continuity of the clinical care is of growing importance. Methods: The paper explores the factors that contributed to maternal deaths in rural Pakistan and Mozambique, using 76 verbal autopsy narratives from the Community Level Interventions for Pre-eclampsia (CLIP) Trial. Results: Qualitative analysis of these maternal death narratives in both countries reveals an interplay of various influences, such as, underlying risks and comorbidities, temporary improvements after seeking care, gaps in quality care in emergencies, convoluted referral systems, and arrival at the final facility in critical condition. Evaluation of these narratives helps to reframe the pathways of maternal mortality beyond a single journey of care-seeking, to update the categories of seeking, reaching and receiving care. Conclusions: There is a need to supplement the pioneering "Three Delays Framework" to include focusing on continuity of care and the "Four Critical Connection Points": (1) between the stages of pregnancy, (2) between families and health care workers, (3) between health care facilities and (4) between multiple care-seeking journeys. Trial registration: NCT01911494, Date Registered 30/07/2013. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has been noted to decrease access to maternal health and family planning services globally. However, evidence from the Middle East and North Africa region is very scarce and limited. We qualitatively explored women's experiences in accessing maternal health and family planning services during the COVID-19 lockdown months in the two Egyptian governorates of Port Said and Souhag. Methods: Using a case study design, semi-structured phone interviews were conducted with a total of 40 women aged 18–35 years from Port Said and Souhag governorates in Egypt. Interviews explored women's experiences in accessing maternal health and family planning services during COVID-19 lockdown months, their coping strategies, and impact of challenges and/or coping strategies on participants and their families. The collected data was analyzed manually using qualitative thematic analysis. Results: Many participants were unable to access maternal health and family planning services during COVID-19 lockdown due to fear of contracting the virus, closure of health facilities, changing service hours, family planning method or drug stock-outs, and/or financial constraints. The above challenges in accessing services along with coping strategies that some women and their families used exposed women to additional health risks, including unintended pregnancies, and posed several social, emotional, and financial burdens to many. Conclusions: The COVID-19 pandemic and associated lockdown measures undermined women's access to maternal and family planning services and interfered with their ability to achieve their reproductive goals. The paper concludes with a number of recommendations to ensure access to maternal and family planning services at times of crisis. Those recommendations include: (1) adapting reliable guidelines from humanitarian settings, (2) providing adequate guidance to healthcare providers and the public to tackle fears and misinformation, (3) making self-care products available such as oral contraceptive pills, vaginal rings and self- administered injectables, (4) involving other health professionals in the provision of maternal and family planning services through task-sharing/shifting, (5) expanding the use of telemedicine and/or digital health services especially to those living in remote areas and (6) raising policymakers' awareness of the centrality of reproductive rights and the importance of protecting them at all times. [ABSTRACT FROM AUTHOR]

Background: Healthcare outcomes in child, adolescent and maternal in Tanzania are poor, and mostly characterised by fragmentary service provision. In order to address this weakness, digital technologies are sought to be integrated in the milieu of health as they present vast opportunities especially in the ability to improve health information management and coordination. Prior to the design and implementation of the Afya-Tek digital intervention, formative research was carried out to ensure that the solution meets the needs of the users. The formative research aimed to examine: the burden of disease and related health seeking behaviour; workflow procedures and challenges experiencing healthcare actors; adolescent health and health seeking behaviour; and lastly examine technological literacy and perceptions on the use of digital technologies in healthcare delivery. This paper therefore, presents findings from the formative research.Methods: The study employed exploratory design grounded in a qualitative approach. In-depth interview, focus group discussion, participant observation and documentary review methods were used for collecting data at different levels. The analysis was done thematically, whereby meaning was deduced behind the words which the participants used.Results: Findings suggest that the perceived burden of diseases and health seeking behaviour differ across age and social group. Multiple work-related challenges, such as lack of proper mechanism to track referrals and patient's information were noted across healthcare actors. There was a keen interest in the use of technologies shown by all study participants to improve care coordination and health outcomes among health system actors. Participants shared their views on how they envision the digital system working.Conclusion: The formative research provided insightful background information with regard to the study objectives. The findings are used for informing the subsequent phases of the co-development and implementation of the Afya-Tek digital health intervention; with a view to making it relevant to the needs of those who will use it in the future. As such, the findings have to a large extent met the purpose of the current study by envisaging the best ways to design digital intervention tailored to meet the needs of those who will be using it. [ABSTRACT FROM AUTHOR]

Background: The Manyata program is a quality improvement initiative for private healthcare facilities in India which provided maternity care services. Under this initiative, technical assistance was provided to selected facilities in the states of Uttar Pradesh, Jharkhand and Maharashtra which were interested in obtaining 'entry level certification' under the National Accreditation Board for Hospitals and Healthcare Providers (NABH) for provision of quality services. This paper describes the change in quality at those Manyata-supported facilities when assessed by the NABH standards of care. Methods: Twenty-eight private-sector facilities underwent NABH assessments in the three states from August 2017 to February 2019. Baseline assessment (by program staff) and NABH assessment (by NABH assessors) findings were compared to assess the change in quality of care as per NABH standards of care. The reported performance gaps from NABH assessments were then also classified by thematic areas and suggested corrective actions based on program implementation experience. Results: The overall adherence to NABH standards of care improved from 9% in the baseline assessment to 80% in the NABH assessment. A total of 831 performance gaps were identified by the NABH assessments, of which documentation issues accounted for a majority (70%), followed by training (19%). Most performance gaps could be corrected either by revising existing documentation or creating new documentation (62%), or by orienting facility staff on various protocols (35%). Conclusion: While the adherence of facilities to the NABH standards of care improved considerably, certain performance gaps remained, which were primarily related to documentation of facility policies and protocols and training of staff, and required corrective actions for the facilities to achieve NABH entry level certification. [ABSTRACT FROM AUTHOR]

Background: Rapid increases in caesarean section (CS) rates have been observed globally; however, CS rates exceeding 15% at a population-level have limited benefits for women and babies. Many interventions targeting healthcare providers have been developed to optimise use of CS, typically aiming to improve and monitor clinical decision-making. However, interventions are often complex, and effectiveness is varied. Understanding intervention and implementation features that likely lead to optimised CS use is important to optimise benefits. The aim of this study was to identify important components that lead to successful interventions to optimise CS, focusing on interventions targeting healthcare providers. Methods: We used Qualitative Comparative Analysis (QCA) to identify if certain combination of important intervention features (e.g. type of intervention, contextual characteristics, and how the intervention was delivered) are associated with a successful intervention as reflected in a reduction of CS. We included 21 intervention studies targeting healthcare providers to reduce CS, comprising of 34 papers reporting on these interventions. To develop potential theories driving intervention success, we used existing published qualitative evidence syntheses on healthcare providers' perspectives and experiences of interventions targeted at them to reduce CS. Results: We identified five important components that trigger successful interventions targeting healthcare providers: 1) training to improve providers' knowledge and skills, 2) active dissemination of CS indications, 3) actionable recommendations, 4) multidisciplinary collaboration, and 5) providers' willingness to change. Importantly, when one or more of these components are absent, dictated nature of intervention, where providers are enforced to adhere to the intervention, is needed to prompt successful interventions. Unsuccessful interventions were characterised by the absence of these components. Conclusion: We identified five important intervention components and combinations of intervention components which can lead to successful interventions targeting healthcare providers to optimise CS use. Health facility managers, researchers, and policy-makers aiming to improve providers' clinical decision making and reduce CS may consider including the identified components to optimise benefits. [ABSTRACT FROM AUTHOR]

Background: Poor Maternal and Child Health (MCH) outcomes pose challenges to India's ability to attain Goal-3 of the Sustainable Development Goals (SDGs). The government of India strengthened the existing network of frontline health workers (FHWs), under its National Rural Health Mission in 2005 and subsequent National Urban Health Mission in 2013 as a strategy to mitigate the shortage of skilled health workers and to provide affordable healthcare services. However, there is a lack of robust national-level empirical analysis on the role of maternal engagement with FHWs in influencing the level of maternal and child health care utilisation and child health outcomes in India.Methods: Using data from the nationally representative Indian National Family Health Survey (NFHS) 2015-2016, this paper aims to investigate the intensity of engagement of FHWs with married women of child-bearing age (15-49 years), its influence on utilisation of maternal and child healthcare services, and child health outcomes. Our empirical analyses use multivariate regression analyses, focusing on five maternal and child health indicators: antenatal care visits (ANC) (4 or > 4 times), institutional delivery, full-immunisation of children, postnatal care (PNC) (within 2 days of delivery), and child survival.Results: Our analysis finds that maternal engagement with FHWs is statistically significant and a positive predictor of maternal and child health care utilisation, and child survival. Further, the level of engagement with FHWs is particularly important for women from economically poor households. Our robustness checks across sub-samples of women who delivered only in public health institutions and those from rural areas provides an additional confidence in our main results.Conclusions: From a policy perspective, our findings highlight that strengthening the network of FHWs in the areas where they are in shortage which can help in further improving the utilisation of maternal and child healthcare services, and health outcomes. Also, the role of FHWs in the government health system needs to be enhanced by improving skills, working environment, and greater financial incentives. [ABSTRACT FROM AUTHOR]

Background: Access to affordable and adequate healthcare in a health system determines the universal health coverage achievement for all residents in a country. Achieving access to healthcare requires the availability of a financing system that ensures access to and provision of adequate care, regardless of the ability to pay. In sub-Saharan Africa, accessibility, use and coverage of prenatal visits are very low and poor, which reduces the quality of care. This paper explored the impact of a social health insurance scheme on the quality of antenatal care in Gabon.Methods: This qualitative study involved the analysis of data collected from semi-structured interviews and non-participant observations to assess the quality of antenatal care. The study elicited perceptions on the demand side (pregnant women) and the supply side (health professionals) in health facilities. Fifteen semi-structured interviews were conducted with pregnant women (aged between 15 and 49) and 5 with health professionals, who each had a seniority of at least 10 years, at different levels of care. Nine non-participant observations were also conducted. Coded transcripts were reviewed and analyzed using the Canadian Institute for Public Administration of Citizen-Centered Services model as an analytical guide.Results: On the demand side, women were generally satisfied with the prenatal services they receive in health facilities. However, complaints were made about the rudeness of some nurses, the high price of the delivery kit (50,000 XAF), and the fact that some essential medicines for maternity are not covered. On the supply side, participants agreed that compulsory health insurance is important in providing antenatal care access to those who need it the most. However, some problems remain. The participants outlined some logistical problems and a lack of medical equipment, including the stock of drugs, disinfectants, and the absence of clean water.Conclusion: Understanding the perceptions of pregnant women and health professionals regarding the quality of antenatal care can help to inform refinements to methods through which the services can be better provided. In addition, the study findings are vital to increasing the use of care, as well as combating high maternal mortality rates. Compulsory health insurance has improved the accessibility and utilization of healthcare services and has contributed to improved quality of care. [ABSTRACT FROM AUTHOR]

Background: Malawi is celebrated as one of the few countries in sub-Saharan Africa to meet the Millennium Development Goal of reducing under-5 mortality by two-thirds between 1990 and 2015. However, within this age range neonatal mortality rates are the slowest to decline, even though rates of facility births are increasing. Examining the quality of neonatal care at district-level facilities where most deliveries occur is warranted.Objective: The objective of this paper is to evaluate the quality of neonatal care in three district hospitals and one primary health centre in southern Malawi as well as to report the limitations and lessons learned on using the WHO integrated quality of care assessment tool.Methods: These facility assessments were part of the "Integrating a neonatal healthcare package for Malawi" project, a part of the Innovating for Maternal and Child Health in Africa (IMCHA) initiative. The WHO integrated quality of care assessment tool was used to assess quality of care and availability and quantity of supplies and resources. The modules on infrastructure, neonatal care and labour and delivery were included. Facility assessments were administered in November 2017 and aspects of care were scored on a Likert scale from one to five (a score of 5 indicating compliance with WHO standards of care; one as lowest indicating inadequate care).Results: The continuum of labour, delivery and neonatal care were assessed to identify areas that required improvements to meet standards of care. Critical areas for improvements included infection control (mean score 2.9), equipment, supplies and setup for newborn care in the labor ward (2.3), in the surgical theater (3.3), and nursery (3.4 nursery facilities, 3.0 supplies and equipment), as well as for management of sick newborns (3.2), monitoring and follow-up (3.6). Only one of the 12 domains, laboratory, met the standards of care with only minor improvements needed (4.0).Conclusion: The WHO integrated quality of care assessment tool is a validated tool that can shed light on the complex quality of care challenges faced by district-level health facilities. The results reveal that the quality of care needs improvement, particularly for sick and vulnerable newborns. [ABSTRACT FROM AUTHOR]

This document is a collection of abstracts and panel discussions on various topics related to maternal and newborn health. The abstracts cover a range of subjects, including the use of Networks of Care to improve quality of care, addressing racial disparities in maternal health, the role of midwives in reducing mortality, and the implementation of Continuous Positive Airway Pressure devices for newborns with respiratory distress. The panels discuss topics such as maternal and perinatal death surveillance, the importance of empathy and compassion in care, and the measurement and monitoring of maternal and newborn health outcomes. The studies emphasize the importance of addressing gender roles and norms, improving access to healthcare services, and addressing systemic barriers to improve maternal and child health outcomes. They also discuss the need for regular assessments, integration of nurturing care, and community involvement to improve maternal health. Additionally, the studies explore topics such as viral load monitoring, malnutrition in infants, and infection prevention and control practices. The findings highlight the need for tailored policies, improved access to quality care, and community engagement to improve maternal and newborn health outcomes in low- and middle-income countries. [Extracted from the article]

Background: The COVID-19 pandemic has adversely affected access to essential healthcare services. This study aimed to explore healthcare providers' perceptions and experiences of the response to the COVID-19 pandemic in three referral maternal and neonatal hospitals in Guinea. Methods: We conducted a longitudinal qualitative study between June and December 2020 in two maternities and one neonatology referral ward in Conakry and Mamou. Participants were purposively recruited to capture diversity of professional cadres, seniority, and gender. Four rounds of in-depth interviews (46 in-depth interviews with 18 respondents) were conducted in each study site, using a semi-structured interview guide that was iteratively adapted. We used both deductive and inductive approaches and an iterative process for content analysis. Results: We identified four themes and related sub-themes presented according to whether they were common or specific to the study sites, namely: 1) coping strategies & care reorganization, which include reducing staffing levels, maintaining essential healthcare services, suspension of staff daily meetings, insertion of a new information system for providers, and co-management with COVID-19 treatment center for caesarean section cases among women who tested positive for COVID-19; 2) healthcare providers' behavior adaptations during the response, including infection prevention and control measures on the wards and how COVID-19-related information influenced providers' daily work; 3) difficulties encountered by providers, in particular unavailability of personal protective equipment (PPE), lack of financial motivation, and difficulties reducing crowding in the wards; 4) providers perceptions of healthcare service use, for instance their fear during COVID-19 response and perceived increase in severity of complications received and COVID-19 cases among providers and parents of newborns. Conclusion: This study provides insights needed to be considered to improve the preparedness and response of healthcare facilities and care providers to future health emergencies in similar contexts. [ABSTRACT FROM AUTHOR]

Background: Anaemia in pregnancy causes a significant burden of maternal morbidity and mortality in sub-Saharan Africa, with prevalence ranging from 25 to 45% in Nigeria. The main treatment, daily oral iron, is associated with suboptimal adherence and effectiveness. Among pregnant women with iron deficiency, which is a leading cause of anaemia (IDA), intravenous (IV) iron is an alternative treatment in moderate or severe cases. This qualitative study explored the acceptability of IV iron in the states of Kano and Lagos in Nigeria. Methods: We purposively sampled various stakeholders, including pregnant women, domestic decision-makers, and healthcare providers (HCPs) during the pre-intervention phase of a hybrid clinical trial (IVON trial) in 10 healthcare facilities across three levels of the health system. Semi-structured topic guides guided 12 focus group discussions (140 participants) and 29 key informant interviews. We used the theoretical framework of acceptability to conduct qualitative content analysis. Results: We identified three main themes and eight sub-themes that reflected the prospective acceptability of IV iron therapy. Generally, all stakeholders had a positive affective attitude towards IV iron based on its comparative advantages to oral iron. The HCPs noted the effectiveness of IV iron in its ability to evoke an immediate response and capacity to reduce anaemia-related complications. It was perceived as a suitable alternative to blood transfusion for specific individuals based on ethicality. However, to pregnant women and the HCPs, IV iron could present a higher opportunity cost than oral iron for the users and providers as it necessitates additional time to receive and administer it. To all stakeholder groups, leveraging the existing infrastructure to facilitate IV iron treatment will stimulate coherence and self-efficacy while strengthening the existing trust between pregnant women and HCPs can avert misconceptions. Finally, even though high out-of-pocket costs might make IV iron out of reach for poor women, the HCPs felt it can potentially prevent higher treatment fees from complications of IDA. Conclusions: IV iron has a potential to become the preferred treatment for iron-deficiency anaemia in pregnancy in Nigeria if proven effective. HCP training, optimisation of information and clinical care delivery during antenatal visits, uninterrupted supply of IV iron, and subsidies to offset higher costs need to be considered to improve its acceptability. Trial registration ISRCTN registry ISRCT N6348 4804. Registered on 10 December 2020 Clinicaltrials.gov NCT04976179. Registered on 26 July 2021 Plain language summary: Low blood level in pregnancy is of public health importance and with common occurrence worldwide, but with a higher rate in low resource settings where its burden greatly affects both the mother and her baby. This low blood level is usually caused by poor intake of an iron-rich diet. It could lead to fatigue, decreased work capacity, and dizziness if not detected. Without treatment, this condition could affect the baby, possibly leading to its sudden demise in the womb, immediately after birth, or even the woman's death. The use of oral iron has been the primary treatment; however, it is associated with significant side effects, which have led to poor compliance. Fortunately, an alternative therapy in the form of a drip has been shown to overcome these challenges. However, it is not routinely used in countries like Nigeria. Moreover, being effective is different from being utilised. Therefore, this study was conducted to understand the factors that will make this treatment widely accepted. We interviewed pregnant women, family support and health care providers in 10 health facilities in Lagos and Kano States, Nigeria. Our findings revealed good attitudes to iron drip. However, its inclusion into routine antenatal health talk, training of health care providers, availability of space, drugs and health workers who will provide this care, and ensuring this drug is of low cost are some of the efforts needed for this treatment to be accepted. [ABSTRACT FROM AUTHOR]

Background: Birthing in health facilities in India has increased over the last few years, yet maternal and neonatal mortality rates remain high. Clinical mentoring with case sheets or checklists for nurses is viewed as essential for on-going knowledge transfer, particularly where basic training is inadequate. This paper summarizes a study of the effect of such a programme on staff knowledge and skills in a randomized trial of 295 nurses working in 108 Primary Health Centres (PHCs) in Karnataka, India.Methods: Stratifying by district, half of the PHCs were randomly assigned to be intervention sites and provided with regular mentoring visits where case sheet/checklists were a central job and teaching aid, and half to be control sites, where no support was provided except provision of case sheets. Nurses' knowledge and skills around normal labour, labour complications and neonate issues were tested before the intervention began and again one year later. Univariate and multivariate analyses were conducted to examine the effect of mentoring and case sheets.Results: Overall, on none of the 3 measures, did case sheet use without mentoring add anything to the basic nursing training when controlling for other factors. Only individuals who used both case-sheets and received mentoring scored significantly higher on the normal labour and neonate indices, scoring almost twice as high as those who only used case-sheets. This group was also associated with significantly higher scores on the complications of labour index, with their scores 2.3 times higher on average than the case sheet only control group. Individuals from facilities with 21 or more deliveries in a month tended to fare worse on all 3 indices. There were no differences in outcomes according to district or years of experience.Conclusions: This study demonstrates that provision of case sheets or checklists alone is insufficient to improve knowledge and practices. However, on-site mentoring in combination with case sheets can have a demonstrable effect on improving nurse knowledge and skills around essential obstetric and neonatal care in remote rural areas of India. We recommend scaling up of this mentoring model in order to improve staff knowledge and skills and reduce maternal and neonatal mortality in India.Trial Registration: This study is registered at clinicaltrials.gov, Identifier No. NCT02004912 , November 27, 2013. [ABSTRACT FROM AUTHOR]

Background: Nepal is committed to achieving the Sustainable Development Goal (SDG) 2030 target 3.1 of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. Along with increasing access to health facility (HF)-based delivery services, improving HF readiness is critically important. The majority of births in Nepal are normal low-risk births and most of them take place in public HFs, as does the majority of maternal deaths. This study aims to assess changes in HF readiness in Nepal between 2015 and 2021, notably, if HF readiness for providing high-quality services for normal low-risk deliveries improved; if the functionality of basic emergency obstetric and neonatal care (BEmONC) services increased; and if infection prevention and control improved. Methods: Cross-sectional data from two nationally representative HF-based surveys in 2015 and 2021 were analyzed. This included 457 HFs in 2015 and 804 HFs in 2021, providing normal low-risk delivery services. Indices for HF readiness for normal low-risk delivery services, BEmONC service functionality, and infection prevention and control were computed. Independent sample T-test was used to measure changes over time. The results were stratified by public versus private HFs. Results: Despite a statistically significant increase in the overall HF readiness index for normal low-risk delivery services, from 37.9% in 2015 to 43.7%, in 2021, HF readiness in 2021 remained inadequate. The availability of trained providers, essential medicines for mothers, and basic equipment and supplies was high, while that of essential medicines for newborns was moderate; availability of delivery care guidelines was low. BEmONC service functionality did not improve and remained below five percent facility coverage at both time points. In private HFs, readiness for good quality obstetrical care was higher than in public HFs at both time points. The infection prevention and control index improved over time; however, facility coverage in 2021 remained below ten percent. Conclusions: The slow progress and sub-optimal readiness for normal, low-risk deliveries and infection prevention and control, along with declining and low BEmONC service functionality in 2021 is reflective of poor quality of care and provides some proximate explanation for the moderately high maternal mortality and the stagnation of neonatal mortality in Nepal. To reach the SDG 2030 target of reducing maternal deaths, Nepal must hasten its efforts to strengthen supply chain systems to enhance the availability and utilization of essential medicines, equipment, and supplies, along with guidelines, to bolster the human resource capacity, and to implement mechanisms to monitor quality of care. In general, the capacity of local governments to deliver basic healthcare services needs to be increased. [ABSTRACT FROM AUTHOR]

Background: Despite the reduction in the maternal mortality ratio, barriers in obstetric care services (OCS) remain a significant risk factor for adverse maternal and perinatal outcomes in India. This review covers the 'continuum of care' (ANC, child delivery, and PNC services) and identifies multiple barriers in provisioning as well as utilization of OCS in India. We conducted a systematic review to understand the barriers using a mixed-methods approach. Methods: PubMed, Scopus, Web of Science, Google Scholar, and Science Direct databases were searched from 1 January 2000 to 30 June 2022. The methodological quality of the included studies was assessed using appropriate tools. After a full-text review of 164 studies, total of 56 studies (33 quantitative, 18 qualitative, and 5 mixed-methods studies) were finally included in the review. All the barriers were classified into five major themes: (i) individual and interpersonal barriers, (ii) social and cultural barriers, (iii) structural barriers, (iv) logistical barriers, and (v) organizational barriers. A thematic synthesis approach was used to present the findings of the included studies. Results: Lack of knowledge and awareness and less family support in availing the required OCS were key individual and interpersonal barriers. Negative social and cultural practices, such as belief in traditional herbs/healers, dietary restrictions, and discarding colostrum were frequently reported barriers, especially in rural settings. Poor economic status and high health service costs were the most often cited barriers to low institutional delivery and delayed ANC services. Long distances to health facilities and poor road conditions were the most frequently reported logistical barriers. On the provisioning side, poor quality of treatment, shortage of drugs and equipment, and non-cooperative attitude of health professionals were the most significant barriers. Conclusion: This review identified several important barriers ranging from individual and cultural to structural, logistical, and organizational, which are prevalent in India. To mitigate the barriers, the governments need to develop strategies at the individual and organizational levels. Innovative interventions and program implementation at the community and village levels could also be contributory steps towards improving OCS utilization in India. [ABSTRACT FROM AUTHOR]

Introduction: Early initiation of antenatal care visits is an essential component of services to improve maternal health. Conducting a detailed study about the mean difference in timing at first antenatal checks across regions and factors associated with timing at first antenatal checks among women attending antenatal in Ethiopia is essential to ensure maternal and newborn health. Therefore, this study aimed to describe the mean difference in timing at first antenatal visits and associated factors among pregnant women attending different health facilities across regions in Ethiopia. Method: The Ethiopian Demographic and Health Survey (EDHS) conducted a community-based cross-sectional study in 2019. In this study, data about the timing of the first antenatal check-ups were requested from the Demographic Health Survey in February 2023, and the required variables were downloaded in SAS and SPSS formats from the data set. A total of 2935 women from nine regional states and two city administrations with an age range of 15 to 49 years were included in the study. The mean difference in timing at first antenatal check-ups, its correlation and various factors were estimated using multiple linear regressions to identify factors. Result: The majority of the 2034 (69.3%) of pregnant women who participated in the study were rural residents. The mean (± SD) age of the pregnant women was 29 (± 6.5) years. Approximately 32.5% of pregnant women visited their first antenatal check after 4 months of pregnancy. The results showed that counselling by health workers during a previous pregnancy (p < 0.01) significantly predicts timing at first antenatal checks in months holding previous delivery, previous antenatal care at both government and private facilities, ever attended school, and highest educational level. Timing at the first antenatal check-in months is expected to decrease by 0.99 months for every counselling session at each pregnancy. The results of the analysis suggested that the regression model significantly predicted timing at the first antenatal check (p = 0.001). Conclusion: The mean difference in timing at the first antenatal check in months among Ethiopian pregnant women relatively significantly varies in two regions. Previous pregnancy counselling by health workers positively influences the timing of first antenatal check-ups for subsequent antenatal check follow-ups in Ethiopia. [ABSTRACT FROM AUTHOR]

Background: Quality improvement (QI) interventions are becoming more common in low- and middle-income countries, yet few studies have presented impact evaluations of these approaches. In this paper, we present an impact evaluation of a scale-up phase of 'Project Fives Alive!', a QI intervention in Ghana that aims to improve maternal and child health outcomes. 'Project Fives Alive!' employed a QI methodology to recognize barriers to care-seeking and care provision at the facility level and then to identify, test and implement simple and low-cost local solutions that address the barriers.Methods: A quasi-experimental design, multivariable interrupted time series analysis, with data coming from 744 health facilities and controlling for potential confounding factors, was used to study the effect of the project. The key independent variables were the change categories (interventions implemented) and implementation phase - Wave 2a (early phase) versus Wave 2b (later phase). The outcomes studied were early antenatal care (ANC), skilled delivery, facility-level under-five mortality and attendance of underweight infants at child welfare clinics. We stratified the analysis by facility type, namely health posts, health centres and hospitals.Results: Several of the specific change categories were significantly associated with improved outcomes. For example, three of five change categories (early ANC, four or more ANC visits and skilled delivery/immediate postnatal care (PNC)) for health posts and two of five change categories (health education and triage) for hospitals were associated with increased skilled delivery. These change categories were associated with increases in skilled delivery varying from 28% to 58%. PNC changes for health posts and health centres were associated with greater attendance of underweight infants at child welfare clinics. The triage change category was associated with increased early antenatal care in hospitals. Intensity, the number of change categories tested, was associated with increased skilled delivery in health centres and reduced under-five mortality in hospitals.Conclusions: Using an innovative evaluation technique we determined that 'Project Fives Alive!' demonstrated impact at scale for the outcomes studied. The QI approach used by this project should be considered by other low- and middle-income countries in their efforts to improve maternal and child health. [ABSTRACT FROM AUTHOR]

Background: There are recent efforts made to eliminate inequalities in the utilisation of basic health care services. More emphasis is given for improvement of health in developing countries including maternal and child health. However, disparities for the fast-growing population of urban poor are masked by the urban averages. The aim of this paper is to report on the findings of antenatal care adequacy among slum residents in Addis Ababa, Ethiopia.Methods: This was a quantitative and cross-sectional community based study design which employed a stratified two-stage cluster sampling technique to determine the sample. Data was collected using structured questionnaire administered to 870 women aged 15-49 years. Weighted 'backward selection' logistic regression models were employed to identify predictors of adequacy of antenatal care.Results: Majority of slum residents did not have adequate antenatal care services with only 50.3, 20.2 and 11.0 % of the slum resident women initiated antenatal care early, received adequate antenatal care service contents and had overall adequate antenatal care services respectively. Educational status and place of ANC visits were important determinant factors for adequacy of ANC in the study area. Women with secondary and above educational status were 2.7 times more likely to receive overall adequate care compared to those with no formal education. Similarly, clients of private healthcare facilities were 2.2 times respectively more likely to receive overall adequate antenatal care compared to those clients of public healthcare facilities.Conclusion: In order to improve ANC adequacy in the study area, the policy-making, planning, and implementation processes should address the poor adequacy of ANC among the disadvantaged groups in particular and the slum residents in general. [ABSTRACT FROM AUTHOR]

Background: In 2005-06, only 39 % of Indian women delivered in a health facility. Given that deliveries at home increase the risk of maternal mortality, it was in this context in 2005, that the Indian Government implemented the Janani Suraksha Yojana program that incentivizes poor women to give birth in a health facility by providing them with a cash transfer upon discharge. JSY helped raise institutional delivery to 74 % in the eight years since its implementation. Despite the success of the JSY in raising institutional delivery proportions, the large number of beneficiaries (105 million), and the cost of the program, there have been few qualitative studies exploring why women participate (or not) in the program. The objective of this paper was to explore this.Methods: In March 2013, we conducted 24 individual in-depth interviews with women who delivered within the previous 12 months in two districts of Madhya Pradesh, India. Qualitative framework analysis was used to analyze the data.Results: Our findings suggest that women's increased participation in the program reflect a shift in the social norm. Drivers of the shift include social pressure from the Accredited Social Health Activist (ASHA) to deliver in a health facility, and a growing individual perception of the importance for 'safe' and 'easy' delivery which was most likely an expression of the new social norm. While the incentive was an important influence on many women's choices, others did not perceive it as an important consideration in their decision to deliver in a health facility. Many women reported procedural difficulties to receive the benefit. Retaining the cash incentive was also an issue due to out-of-pocket expenditures incurred at the facility. Non-participation was often unintentional and caused by personal circumstances, poor geographic access or driven by a perception of poor quality of care provided in program facilities.Conclusions: In summary, while the cash incentive was important for some women in facilitating an institutional birth, the shift in social norm (possibly in part facilitated by the program) and therefore their own perceptions has played a major role in them giving birth in facilities. [ABSTRACT FROM AUTHOR]

Background: A strong health system requires a competent and caring workforce. A more satisfied and motivated health workforce should be more willing to serve in difficult areas, have lower turnover, and theoretically provide better care to patients. This paper examines the motivation, satisfaction, and correlation with clinical knowledge, of community health nurses (CHNs), a cadre of provider focused on maternal, newborn and child health in rural Ghana.Methods: This study employed three methods of evaluation. Two quantitative measurements were used: (1) a survey of health worker satisfaction and motivation and (2) a clinical knowledge assessment focusing on maternal, newborn and child health. Both were administered to all rostered CHNs working in the five sampled districts in the Greater Accra and Volta regions in Eastern Ghana (N = 205). Qualitative interviews (N = 29) and focus group discussions (N = 4) were held with selected CHNs in the same districts. These data were analysed using NVivo (Version 10) and Stata (Version 13.0) based on domains of extrinsic and intrinsic motivation including general satisfaction, work environment and access to resources, respect and recognition received and opportunities for advancement.Results: CHNs desired more training, especially those who were posted at the community level (a Community-based Health Planning and Services post or "CHPS") versus at a health facility. CHNs working at CHPS believed their work to be more difficult than those posted at health facilities, due to challenges associated with foot travel to visit patients at home, and they were more likely to report having insufficient resources to do their jobs (48% vs 36%). However, CHNs posted at health facilities were more likely to report insufficient opportunities for career advancement than the CHPS nurses (49% vs 33%). CHNs generally reported good relationships with colleagues and being respected by patients but desired more respect from supervisors. The median score on the knowledge assessment was 78%. On average, subgroups of CHNs with different reported levels of satisfaction did not perform differently on the knowledge assessment.Conclusions: CHNs in Ghana were satisfied overall but desired more training, more guidance and supervision, fair pay and opportunities to advance in their career. Improving health worker satisfaction and morale may be important for health worker retention and certain aspects of care but may not have a significant influence on clinical knowledge or performance. [ABSTRACT FROM AUTHOR]

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

Background: In Sub-Saharan Africa, the postnatal period is associated with high mortality and accounts for a substantial proportion of maternal deaths. Although postnatal care has been identified as critical in reducing maternal mortality, the quality of care provided is often inadequate. Tanzania and Zanzibar have not made sufficient progress towards achieving the Sustainable Development Goals on maternal health, and there is limited knowledge about the utilization and quality of postnatal follow-up. The aim of this study was therefore to explore factors affecting the provision of high-quality postnatal care services in the urban area of Zanzibar. Methods: Five focus group discussions were performed in Swahili with 25 healthcare providers from primary healthcare units in urban Zanzibar. Interviews were audio-recorded, transcribed verbatim, translated into English, and analysed using qualitative content analysis with an inductive approach. Results: Factors affecting provision of high-quality postpartum care services could be divided into three generic categories. Difficulty achieving high attendance comprised three subcategories: long waiting times, low awareness among women, and out-of-pocket payment. Lack of basic resources also comprised three subcategories: shortage of healthcare providers, lack of adequate space, and inadequate medical equipment. Insufficient care routines comprised two subcategories: lack of guidelines and deficient chain of information. Conclusions: The present findings suggest that the women's perceptions of postnatal care do not align with the intended purpose of routine postnatal care. Instead, the postnatal period primarily leads to visits to health facilities only when urgent care is required, and there is a lack of awareness about the importance of postnatal care. Moreover, limited resources, including equipment, staff, and space, as well as long waiting times, hinder the delivery of high-quality care and contribute to a negative reputation of postnatal care services. To effectively reach all women and improve postnatal care, it is necessary to increase basic resources, modify health education approaches, and enhance the flow of information between different levels of care using context-specific strategies. [ABSTRACT FROM AUTHOR]

Background: Efforts to improve maternal health are increasingly focused on improving the quality of care provided to women at health facilities, including the promotion of respectful care and eliminating mistreatment of women during childbirth. A WHO-led multi-country research project aims to develop and validate two tools (labor observation and community survey) to measure how women are treated during facility-based childbirth. This paper describes the development process for these measurement tools, and how they were implemented in a multi-country study (Ghana, Guinea, Myanmar and Nigeria).Methods: An iterative mixed-methods approach was used to develop two measurement tools. Methodological development was conducted in four steps: (1) initial tool development; (2) validity testing, item adjustment and piloting of paper-based tools; (3) conversion to digital, tablet-based tools; and (4) data collection and analysis. These steps included systematic reviews, primary qualitative research, mapping of existing tools, item consolidation, peer review by key stakeholders and piloting.Results: The development, structure, administration format, and implementation of the labor observation and community survey tools are described. For the labor observations, a total of 2016 women participated: 408 in Nigeria, 682 in Guinea, and 926 in Ghana. For the community survey, a total of 2672 women participated: 561 in Nigeria, 644 in Guinea, 836 in Ghana, and 631 in Myanmar. Of the 2016 women who participated in the labor observations, 1536 women (76.2%) also participated in the community survey and have linked data: 779 in Ghana, 425 in Guinea, and 332 in Nigeria.Conclusions: An important step to improve the quality of maternity care is to understand the magnitude and burden of mistreatment across contexts. Researchers and healthcare providers in maternal health are encouraged to use and implement these tools, to inform the development of more women-centered, respectful maternity healthcare services. By measuring the prevalence of mistreatment of women during childbirth, we will be able to design and implement programs and policies to transform maternity services. [ABSTRACT FROM AUTHOR]

Background: Ensuring universal access to maternal and reproductive health services is critical to the success of global efforts to reduce poverty and inequality. Engaging private providers has been proposed as a strategy for increasing access to healthcare in low- and middle-income countries; however, little consensus exists on how to estimate the extent of private sector use. Using research from sub-Saharan Africa, this study systematically compares and critiques quantitative measures of private sector family planning and childbirth service use and synthesizes evidence on the role of the private sector in the region.Methods: We conducted a systematic review of the Medline, Global Health, and Popline databases. All studies that estimated use of private sector of family planning or childbirth services in one or more sub-Saharan African countries were included in this review. For each study, we extracted data on the key study outcomes and information on the methods used to estimate private sector use.Results: Fifty-three papers met our inclusion criteria; 31 provided outcomes on family planning, and 26 provided childbirth service outcomes. We found substantial methodological variation between studies; for instance, while some reported on service use from any private sector source, others distinguished private sector providers either by their profit orientation or position within or outside the formal medical sector. Additionally, studies measured the use of private sector services differently, with some estimating the proportion of need met by the private sector and others examining the sector's share among the market of service users. Overall, the estimates suggest that the private sector makes up a considerable portion (> 20%) of the market for family planning and childbirth care, but its role in meeting women's need for these services is fairly low (< 10%).Conclusions: Many studies have examined the extent of private sector family planning and childbirth service provision; however, inconsistent methodologies make it difficult to compare results across studies and contexts. Policymakers should consider the implications of both private market share and coverage estimates, and be cautious in interpreting data on the scale of private sector health service provision without a clear understanding of the methodology. [ABSTRACT FROM AUTHOR]

Background: Approximately 25% of facility births take place in private health facilities. Recent national studies of maternal and newborn health (MNH) service availability and quality have focused solely on the status of public sector facilities, leaving a striking gap in information on the quality of maternal and newborn care services. Methods: A rapid cross-sectional assessment was conducted in November 2022 to assess the quality of MNH services at private hospitals in Iraq. Multi-stage sampling was used to select 15% of the country's 164 private hospitals. Assessment tools included a facility assessment checklist, a structured health worker interview tool, and a structured client exit interview tool. Data collection was conducted using KoboToolbox software on Android tablets, and analysis conducted using SPSS v28. Results: All hospitals visited provided MNH services and had skilled personnel present or on-call 24 h/day, 7 days/week. Most births (88%) documented between January and June 2022 were cesarean births. Findings indicate that nearly all hospitals have the human resources, equipment, medicines and supplies necessary for quality antenatal, intrapartum and early essential newborn care, and many are also equipped with special units and resources needed to care for small and sick babies. However, while resources are in place for basic and advanced care, there are gaps in knowledge and practice of high-impact interventions that require few or no resources to perform, including skin-to-skin thermal care and support for early initiation of breastfeeding. Person-centered maternity care scores suggest that private hospitals offer a positive experience of care for all clients, however there is room for improvement in provider–client communication. Conclusions: This assessment highlights the need for deeper dives into factors that underly decisions about how and where to give birth, and both understanding and practice of early essential newborn care and pre-discharge examinations and counseling at private healthcare facilities in Iraq. Engaging private health facility staff in efforts to monitor and improve the quality of maternal and newborn care, with a focus on early essential newborn care and provider–client communication for all clients, will ensure that women and newborns benefit from the best care possible with available resources. [ABSTRACT FROM AUTHOR]

Background: Healthcare financing through health insurance is gaining traction as developing countries strive to achieve universal health coverage and address the limited access to critical health services for specific populations including pregnant women and their children. However, these reforms are taking place despite limited evaluation of impact of health insurance on maternal health in developing countries including Kenya. In this study we evaluate the association of health insurance with access and utilization of obstetric delivery health services for pregnant women in Kenya.Methods: Nationally representative data from the Kenya Demographic and Health Survey 2008-09 was used in this study. 4082 pregnant women with outcomes of interest - Institutional delivery (Yes/No - delivery at hospital, dispensary, maternity home, and clinic) and access to skilled birth attendants (help by a nurse, doctor, or trained midwife at delivery) were selected from 8444 women ages 15-49 years. Linear and logistic regression, and propensity score adjustment are used to estimate the causal association of enrollment in insurance on obstetric health outcomes.Results: Mothers with insurance are 23 percentage points (p < 0.01) more likely to deliver at an institution and 20 percentages points (p < 0.01) more likely have access to skilled birth attendants compared to those not insured. In addition mothers of lower socio-economic status benefit more from enrollment in insurance compared to mothers of higher socio-economic status. For both institutional delivery and access to skilled birth attendants, the average difference of the association of insurance enrollment compared to not enrolling for those of low SES is 23 percentage points (p < 0.01), and 6 percentage points (p < 0.01) for those of higher SES.Conclusions: Enrolling in health insurance is associated with increased access and utilization of obstetric delivery health services for pregnant women. Notably, those of lower socio-economic status seem to benefit the most from enrollment in insurance. [ABSTRACT FROM AUTHOR]

Background: Simulation has been shown to improve clinical and behavioral skills of birth attendants in low-resource settings at a low scale. Populous, low-resource settings such as Bihar, India, require large cadres of simulation educators to improve maternal and newborn health. It's unknown if simulation facilitation skills can be adopted through a train of trainers' cascade. To fill this gap, we designed a study to evaluate the simulation and debrief knowledge, attitudes and skills of a third generation of 701 simulation educators in Bihar, India. In addition, we assessed the physical infrastructure where simulation takes place in 40 primary healthcare facilities in Bihar, India. Methods: We performed a 1 year before–after intervention study to assess the simulation facilitation strengths and weaknesses of a cadre of 701 nurses in Bihar, India. The data included 701 pre-post knowledge and attitudes self-assessments; videos of simulations and associated debriefs conducted by 701 providers at 40 primary healthcare centers. Results: We observed a statistically significant difference in knowledge and attitude scores before and after the 4-day PRONTO simulation educator training. The average number of participants in a simulation video was 5 participants (range 3-8). The average length of simulation videos was 10:21 minutes. The simulation educators under study, covered behavioral in 90% of debriefs and cognitive objectives were discussed in all debriefs. Conclusion: This is the first study assessing the simulation and debrief facilitation knowledge and skills of a cadre of 701 nurses in a low-resource setting. Simulation was implemented by local nurses at 353 primary healthcare centers in Bihar, India. Primary healthcare centers have the physical infrastructure to conduct simulation training. Some simulation skills such as communication via whiteboard were widely adopted. Advanced skills such as eliciting constructive feedback without judgment require practice. [ABSTRACT FROM AUTHOR]

Background: Given the intricate relationship between mothers and their children with the continuum of care, it is quintessential for their healthcare and interventions to be enhanced through a continuum of care approach. We examined the factors associated with the continuum of care for maternal, newborn, and child health in sub-Saharan Africa.Methods: Data for the study were pooled from the Demographic and Health Surveys of 17 countries in sub-Saharan Africa. We extracted the data from the women's files in all 17 countries. We included 15,359 married and cohabiting women with the most recent children aged 12-23 months at the time of the survey in the study. Multivariable multilevel logistic regression analysis was performed to examine the factors associated with continuum of care. Results were presented as adjusted odds ratios (aORs) with their 95% confidence interval.Results: Women whose partners had secondary or higher level of education [aOR = 1.52; 95%CI = 1.07, 2.16], those with health insurance [aOR = 1.64; 95%CI = 1.18, 2.30], those who decide alone on their healthcare [aOR = 1.38; 95%CI = 1.01, 1.89], those with joint healthcare decision [aOR = 1.33; 95%CI = 1.02, 1.74], those exposed to radio [aOR = 1.38; 95%CI = 1.06, 1.79], those who started antenatal care early [aOR = 1.88; 95%CI = 1.50, 2.36] and those in southern Africa [aOR = 7.02; 95%CI = 3.23, 15.27] had higher odds of completing the continuum of care.Conclusion: We found that only 3.4% of women across the 17 sub-Saharan African countries included in this study completed all of the 11 maternal, newborn, and child health care interventions along the continuum of care. The factors that are associated with the maternal, newborn, and child health continuum of care include women's autonomy in decision-making, partners' level of education, health insurance coverage, early initiation of antenatal care, exposure to radio, and residing in Southern Africa. Problem with the distance to the facility lowered women's odds of completing the continuum of care. Governments and departments of health services across sub-Saharan African countries must leverage the radio to disseminate critical messages about the need to complete the continuum of care. Much commitment must be made toward advancing the autonomy of women. Health insurance coverage would have to be extended to reach all women to facilitate the completion of the continuum of care. [ABSTRACT FROM AUTHOR]

Background: Globally, 11.4 million untreated obstetric complications did not receive Emergency Obstetric and Newborn Care (EmONC) services yearly, with the highest burden in low and middle-income countries. Half of the Ethiopian women with obstetric complications did not receive EmONC services. However, essential aspects of the problem have not been assessed in depth. This study, therefore, explored the various aspects of barriers and enablers to women's EmONC services utilization in southern Ethiopia.Methodology: A qualitative case study research design was used in nine districts of the Wolaita Zone. A total of 37 study participants were selected using a purposive stratified sampling technique and interviewed till data saturation. Twenty-two key informant interviews were conducted among front-line EmONC service providers, managers, community leaders, and traditional birth attendants (TBAs). Individual in-depth interviews were conducted among 15 women with obstetric complications. The trustworthiness of the research was assured by establishing credibility, transferability, conformability, and dependability. NVivo 12 was used to assist with the thematic data analysis.Result: Five themes emerged from the analysis: service users' perception and experience (knowledge, perceived quality, reputation, respectful care, and gender); community-related factors (misconceptions, traditional practices, family and peer influence, and traditional birth attendants' role); access and availability of services (infrastructure and transportation); healthcare financing (drugs and supplies, out-of-pocket expenses, and fee exemption); and health facility-related factors (competency, referral system, waiting time, and leadership).Conclusion: Many women and their newborns in the study area suffered severe and life-threatening complications because of the non-utilization or delayed utilization of EmONC services. A key policy priority should be given to enhancing women's awareness, eliminating misconceptions, improving women's autonomy, and ensuring traditional practices' role in EmONC service utilization. Community awareness interventions are required to enhance service uptake. Furthermore, the health systems must emphasize improving the quality of care, inequitable distribution of EmONC facilities, and essential drugs. The financial constraints need to be addressed to motivate women from low socioeconomic status. Furthermore, intersectoral collaboration is required to maintain a legal framework to control and prohibit home deliveries and empower women. [ABSTRACT FROM AUTHOR]

Background: Uganda, a low resource country, implemented the skilled attendance at birth strategy, to meet a key target of the 5th Millenium Development Goal (MDG), 75% reduction in maternal mortality ratio. Maternal mortality rates remained high, despite the improvement in facility delivery rates. In this paper, we analyse the strategies implemented and bottlenecks experienced as Uganda's skilled birth attendance policy was rolled out. These experiences provide important lessons for decision makers as they implement policies to further improve maternity care.Methods: This is a case study of the implementation process, involving a document review and in-depth interviews among key informants selected from the Ministry of Health, Professional Organisations, Ugandan Parliament, the Health Service Commission, the private not-for-profit sector, non-government organisations, and District Health Officers. The Walt and Gilson health policy triangle guided data collection and analysis.Results: The skilled birth attendance policy was an important priority on Uganda's maternal health agenda and received strong political commitment, and support from development partners and national stakeholders. Considerable effort was devoted to implementation of this policy through strategies to increase the availability of skilled health workers for instance through expanded midwifery training, and creation of the comprehensive nurse midwife cadre. In addition, access to emergency obstetric care improved to some extent as the physical infrastructure expanded, and distribution of medicines and supplies improved. However, health worker recruitment was slow in part due to the restrictive staff norms that were remnants of previous policies. Despite considerable resources allocated to creating the comprehensive nurse midwife cadre, this resulted in nurses that lacked midwifery skills, while the training of specialised midwives reduced. The rate of expansion of the physical infrastructure outpaced the available human resources, equipment, blood infrastructure, and several health facilities were not fully functional.Conclusion: Uganda's skilled birth attendance policy aimed to increase access to obstetric care, but recruitment of human resources, and infrastructural capacity to provide good quality care remain a challenge. This study highlights the complex issues and unexpected consequences of policy implementation. Further evaluation of this policy is needed as decision-makers develop strategies to improve access to skilled care at birth. [ABSTRACT FROM AUTHOR]

Background: A growing number of women in Cambodia are seeking support from health facilities during delivery, up from 8% in 2000 to 82% in 2014. This growth may be attributed to increased national level attention to incentivize hospital births and reduce potential barriers. This paper address three related questions regarding the impact of increased utilization of health care in Cambodia. First, did increasing health facility deliveries occur most among disadvantaged women? Second, as health facility utilization increased, did the benefit of delivery location on child health outcomes weaken? Finally, did socioeconomic disparities in child outcomes decline as a result of increased health facility deliveries? Methods: Data is from the 2010 and 2014 Cambodian Demographic and health surveys. Regression models include logistic regression to predict utilization of a health facility, linear regression to predict child nutritional status and Cox regression to measure child survival. Propensity score matching was used to account for selectivity. Results: Analysis shows that health facility delivery is associated with better nutritional status and survival and the effectiveness of a health center delivery remains with this rapidly increasing care. However, the largest increases in delivery at a health facility did not occur among less educated, less wealthy, and rural Cambodian women, and inequalities in child health outcomes remain. Conclusions: Cambodian women have participated in a rapid increase in health center deliveries and those health facility deliveries remain beneficial for future child outcomes. However, initiatives to increase care are not addressing inequity in access to care among disadvantaged women. Additionally, disparities in children's health outcomes remain, suggesting that health facility births are not sufficient in reducing disparities among children of disadvantaged mothers. Moving forward, current initiatives are rapidly increasing facility deliveries and maintaining their efficacy, but further efforts need to be placed on targeting disadvantaged women and their children. [ABSTRACT FROM AUTHOR]

Background: The highest risk of maternal and perinatal deaths occurs during and shortly after childbirth and is preventable if functional referral systems enable women to reach appropriate health services when obstetric complications occur. Rising numbers of deliveries in health facilities, including in high mortality settings like Nigeria, require formalised coordination across the health system to ensure that women and newborns get to the right level of care, at the right time. This study describes and critically assesses the extent to which referral and its components can be captured using three different data sources from Nigeria, examining issues of data quality, validity, and usefulness for improving and monitoring obstetric care systems.Methods: The study included three data sources on referral for childbirth care in Nigeria: a nationally representative household survey, patient records from multiple facilities in a state, and patient records from the apex referral facility in a city. We conducted descriptive analyses of the extent to which referral status and components were captured across the three sources. We also iteratively developed a visual conceptual framework to guide our critical comparative analysis.Results: We found large differences in the proportion of women referred, and this reflected the different denominators and timings of the referral in each data source. Between 16 and 34% of referrals in the three sources originated in government hospitals, and lateral referrals (origin and destination facility of the same level) were observed in all three data sources. We found large gaps in the coverage of key components of referral as well as data gaps where this information was not routinely captured in facility-based sources.Conclusions: Our analyses illustrated different perspectives from the national- to facility-level in the capture of the extent and components of obstetric referral. By triangulating across multiple data sources, we revealed the strengths and gaps within each approach in building a more complete picture of obstetric referral. We see our visual framework as assisting further research efforts to ensure all referral pathways are captured in order to better monitor and improve referral systems for women and newborns. [ABSTRACT FROM AUTHOR]

Background: The Covid-19 pandemic has so far infected more than 30 million people in the world, having major impact on global health with collateral damage. In Mozambique, a public state of emergency was declared at the end of March 2020. This has limited people's movements and reduced public services, leading to a decrease in the number of people accessing health care facilities. An implementation research project, The Alert Community for a Prepared Hospital, has been promoting access to maternal and child health care, in Natikiri, Nampula, for the last four years. Nampula has the second highest incidence of Covid-19. The purpose of this study is to assess the impact of Covid-19 pandemic Government restrictions on access to maternal and child healthcare services. We compared health centres in Nampula city with healthcare centres in our research catchment area. We wanted to see if our previous research interventions have led to a more resilient response from the community.Methods: Mixed-methods research, descriptive, cross-sectional, retrospective, using a review of patient visit documentation. We compared maternal and child health care unit statistical indicators from March-May 2019 to the same time-period in 2020. We tested for significant changes in access to maternal and child health services, using KrushKall Wallis, One-way Anova and mean and standard deviation tests. We compared interviews with health professionals, traditional birth attendants and patients in the two areas. We gathered data from a comparable city health centre and the main city referral hospital. The Marrere health centre and Marrere General Hospital were the two Alert Community for a Prepared Hospital intervention sites.Results: Comparing 2019 quantitative maternal health services access indicators with those from 2020, showed decreases in most important indicators: family planning visits and elective C-sections dropped 28%; first antenatal visit occurring in the first trimester dropped 26%; hospital deliveries dropped a statistically significant 4% (p = 0.046), while home deliveries rose 74%; children vaccinated down 20%.Conclusion: Our results demonstrated the negative collateral effects of Covid-19 pandemic Government restrictions, on access to maternal and child healthcare services, and highlighted the need to improve the health information system in Mozambique. [ABSTRACT FROM AUTHOR]

Background: In rural areas of Ethiopia, 57% of births occur at home without the assistance of skilled birth attendants, geographical inaccessibility being one of the main factors that hinder skilled birth attendance. Establishment of maternity waiting homes (MWH) is part of a strategy to improve access to skilled care by bringing pregnant women physically close to health facilities. This study assessed barriers to MWHs in Arba Minch Zuria District, Southern Ethiopia. Methods: A community-based cross-sectional study was undertaken from February 01 to 28, 2019. Study participants were selected by computer-generated random numbers from a list of women who gave birth from 2017 to 2018 in Arba Minch Health and Demographic Surveillance System site. Data were collected using a pre-tested and interviewer-administered questionnaire. Stata software version-15 was used for data management and analysis, and variables with p-values ≤ 0.2 in bivariate analysis were considered for multivariable logistic regression analysis. Level of statistical significance was declared at a p-value < 0.05. Qualitative data were analyzed manually based on thematic areas. Results: MWH utilization was found to be 8.4%. Wealth index (lowest wealth quintile aOR 7.3; 95% CI 1.2, 42), decisions made jointly with male partners (husbands) for obstetric emergencies (aOR 3.6; 95% CI 1.0, 12), birth preparedness plan practice (aOR 6.5; 95% CI 2.3, 18.2), complications in previous childbirth (aOR 3; 95% 1.0, 9), history of previous institutional childbirth (aOR 12; 95% CI 3.8, 40), residence in areas within two hours walking distance to the nearest health facility (aOR 3.3; 95% CI: 1.4, 7.7), and ease of access to transport in obstetric emergencies (aOR 8.8; 95% CI: 3.9, 19) were factors that showed significant associations with MWH utilization. Conclusions: A low proportion of women has ever used MWHs in the study area. To increase MWH utilization, promoting birth preparedness practices, incorporating MWH as part of a personalized birth plan, improving access to health institutions for women living far away and upgrading existing MWHs are highly recommended. [ABSTRACT FROM AUTHOR]

Background: Access to health care facilities is a key requirement to enhance safety for mothers and newborns during labour and delivery. Haydom Lutheran Hospital (HLH) is a regional hospital in rural Tanzania with a catchment area of about two million inhabitants. Up to June 2013 ambulance transport and delivery at HLH were free of charge, while a user fee for both services was introduced from January 2014. We aimed to explore the impact of introducing user fees on the population of women giving birth at HLH in order to document potentially unwanted consequences in the period after introduction of fees.Methods: Retrospective analysis of data from a prospective observational study. Data was compared between the period before introduction of fees from February 2010 through June 2013 and the period after from January 2014 through January 2017. Logistic regression modelling was used to construct risk-adjusted variable-life adjusted display (VLAD) and cumulative sum (CUSUM) plots to monitor changes.Results: A total of 28,601 births were observed. The monthly number of births was reduced by 17.3% during the post-introduction period. Spontaneous vaginal deliveries were registered less frequently with a decrease of about 17/1000 births in non-cephalic presentations. Labour complications and caesarean sections increased with about 80/1000 births. There was a reduction in newborns with birth weight less than 2500 g. The observed changes were stable over time. For most variables, a significant change could be detected after a few weeks.Conclusion: After the introduction of ambulance and delivery fees, an increase in labour complications and caesarean sections and a decrease in newborns with low birthweight were observed. This might indicate that women delay the decision to seek skilled birth attendance or do not seek help at all, possibly due to financial reasons. Lower rates of births in a safe health care facility like HLH is of great concern, as access to skilled birth attendance is a key requirement in order to further reduce perinatal mortality. Therefore, free delivery care should be a high priority. [ABSTRACT FROM AUTHOR]

Background: Disparities in health persist even in high-income countries, and healthcare systems do not reach disadvantaged families as needed. A number of home-visiting interventions in high-income countries offering peer support for parents have been implemented to bridge the gaps in health in a cost-effective way. The lack of standard for intervention design has however resulted in a large variety of the strategies used. The objective for this article is to conduct a review of peer support home visiting interventions for parents and children in high-income countries, aiming to assess the strategies used, their outcomes and the challenges faced by peer supporters.Methods: Relevant articles published in English between January 2004 and August 2019 were identified using PubMed, and reference lists were reviewed to identify additional articles. Studies were included if they reported on individual peer support health interventions, delivered at home to socioeconomically disadvantaged parents in high-income countries. Nineteen studies were found that met the inclusion criteria, and data were extracted on study characteristics, intervention design and outcomes. Data on intervention design was characterized iteratively to generate overarching categories of strategies used in the programs.Results: Most studies used healthcare facilities for recruitment, even when the interventions were not delivered by the formal healthcare system. The strategies used to engage supported parents included (1) connection in the form of emotional support, relationship building and matching for background, (2) flexibility in regards to content, intensity, location and mode of contact, and (3) linking through referrals and facilitation of other contacts. A number of significant quantifiable improvements could be demonstrated. Due to large heterogeneity of outcomes, meta-analyses were not viable. Peer supporters experienced challenges with involving other family members than the supported parent as well as with finding their role in relation to other support structures.Conclusions: Peer support delivered as home visiting interventions have been used for hard-to-reach parents in a variety of high-income contexts and for a multitude of health concerns. Overall, despite variation in intervention design, the strategies employed followed common themes and were generally well received. [ABSTRACT FROM AUTHOR]

Background: In Rwanda, maternal community health workers (M-CHWs) are involved in the country's overall health system. In maternal health, their role includes the provision of preventive and promotional health services at the community level. They provide services such as health education on maternal health wellbeing, advice and information on access and timely utilization of health facilities for prenatal, delivery and postpartum care. The contribution of M-CHWs in the health sector combined with other government initiatives led the country to achieving the fifth Millennium Development Goal (MDG) - target 5A- that aimed to improve maternal health through the reduction of maternal mortality ratio by 75% between 1990 and 2015). The objective of this study was to explore M-CHWs' perceptions and experiences on access and provision of maternal health services.Methods: We used a case study methodology, a qualitative research approach to explore M-CHWs' experiences and perceptions on access and provision of maternal health services at the community level in Rwanda. For the period of June-August 2014, in-depth interviews were conducted with sixteen M-CHWs who had been providing maternal health services in the Eastern Province of Rwanda. Participants shared their experiences and perceptions on access and provision of maternal health service in their communities.Results: The results of this research highlight the role of M-CHWs in promoting the use of health facilities for prenatal care and delivery and the ways they use to reach out to women. Several challenges prohibit M-CHWs to deliver adequate maternal health services and these are related to the poor resources settings in which they operate.Conclusion: The results of this study highlight the experiences and perceptions of M-CHWs on the provision and access to maternal health services in their communities. The fact that M-CHWs are volunteers operating in limited resources settings with no formal training in maternal health and with considerable workloads translates into challenges regarding the quality and quantity of services they provide in their communities. Such challenges create an impact on M-CHWs service provision, satisfaction and retention. The voices of M-CHWs and the communities they serve are needed to explore areas that are specific to each community context that would contribute to making the M-CHW program sustainable to achieve equitable access to maternal health services. [ABSTRACT FROM AUTHOR]

Background: Despite policies and guidelines recommending integration of health services in South Africa, provision of maternal and child health services remains fragmented. This study evaluated a rapid, scaleable, quality improvement (QI) intervention to improve integration of maternal and child health and HIV services at a primary health level, in KwaZulu-Natal, South Africa.Methods: A three-month intervention comprised of six QI mentoring visits, learning sessions with clinic staff to share learnings, and a self-administered checklist aimed to assist health workers monitor and implement an integrated package of health services for mothers and children. The study evaluated 27 clinics in four sub-districts using a stepped-wedge design. Each sub-district received the intervention sequentially in a randomly selected order. Five waves of data collection were conducted in all participating clinics between December 2016-February 2017. A multi-level, mixed effects logistic regression was used to account for random cluster fixed time and group effects using Stata V13.1.Results: Improvements in some growth monitoring indicators were achieved in intervention clinics compared to control clinics, including measuring the length of the baby (77% vs 63%; p = 0.001) and health workers asking mothers about the child's feeding (74% vs 67%; p = 0.003), but the proportion of mothers who received feeding advice remained unchanged (38% vs 35%; p = 0.48). Significantly more mothers in the intervention group were asked about their baby's health (44% vs 36%; p = 0.001), and completeness of record keeping improved (40% vs 26%; I = < 0.0001). Discussions with the mother about some maternal health services improved: significantly more mothers in the intervention group were asked about HIV (26.5% vs 19.5%; p = 0.009) and family planning (33.5% vs 19.5%; p <  0.001), but this did not result in additional services being provided to mothers at the clinic visit.Conclusion: This robust evaluation shows significant improvements in coverage of some services, but the QI intervention was unable to achieve the substantial changes required to provide a comprehensive package of services to all mothers and children. We suggest the QI process be adapted to complex under-resourced health systems, building on the strengths of this approach, to provide workable health systems strengthening solutions for scalable implementation.Trial Registration: ClinicalTrials.gov NCT04278612. Date of Registration: February 19, 2020. Retrospectively registered. [ABSTRACT FROM AUTHOR]

Background: Most maternal health programs in low- and middle- income countries estimate gestational age to provide appropriate antenatal care at the correct times throughout the pregnancy. Although various gestational dating methods have been validated in research studies, the performance of these methods has not been evaluated on a larger scale, such as within health systems. The objective of this research was to investigate the magnitude and impact of errors in estimated delivery dates on health facility delivery among women enrolled in a maternal health program in Zanzibar.Methods: This study included 4225 women who were enrolled in the Safer Deliveries program and delivered before May 31, 2017. The exposure of interest was error in estimated delivery date categorized as: severe overestimate, when estimated delivery date (EDD) was 36 days or more after the actual delivery date (ADD); moderate overestimate, when EDD was 15 to 35 days after ADD; accurate, when EDD was 6 days before to 14 days after ADD; and underestimate, when EDD was 7 days or more before ADD. We used Chi-squared tests to identify factors associated with errors in estimated delivery dates. We performed logistic regression to assess the impact of errors in estimated delivery dates on health facility delivery adjusting for age, district of residence, HIV status, and occurrence of past home delivery.Results: In our data, 28% of the estimated delivery dates were a severe overestimate, 23% moderate overestimate, 41% accurate, and 8% underestimate. Compared to women with an accurate delivery date, women with a moderate or severe overestimate were significantly less likely to deliver in a health facility (OR = 0.71, 95% CI: [0.59, 0.86]; OR = 0.74, 95% CI: [0.61, 0.91]). When adjusting for multiple confounders, women with moderate overestimates were significantly less likely to deliver in a health facility (AOR = 0.76, 95% CI: [0.61, 0.93]); the result moved slightly towards null for women with severe overestimates (AOR = 0.84, 95% CI: [0.69, 1.03]).Conclusions: The overestimation of women's EDDs reduces the likelihood of health facility delivery. To address this, maternal health programs should improve estimation of EDD or attempt to curb the effect of these errors within their programs. [ABSTRACT FROM AUTHOR]

Background: Timely access to emergency obstetric care is crucial in preventing mortalities associated with pregnancy and childbirth. The referral of patients from lower levels of care to higher levels has been identified as an integral component of the health care delivery system in Ghana. To this effect, in 2012, the National Referral Policy and Guidelines was developed by the Ministry of Health (MOH) to help improve standard procedures and reduce delays which affect access to emergency care. Nonetheless, ensuring timely access to care during referral of obstetric emergencies has been problematic. The study aimed to identify barriers associated with the referral of emergency obstetric cases to the leading national referral centre. It specifically examines the lived experiences of patients, healthcare providers and relatives of patients on the referral system.Methods: Korle Bu Teaching Hospital, Accra was used as a case study in 2016.The qualitative method was used and in-depth interviews were conducted with 89 respondents: healthcare providers [n = 34];patients [n = 31] and relatives of patients [n = 24] using semi-structured interview guides. Purposive sampling techniques were used in selecting healthcare providers and patients and convenience sampling techniques were used in selecting relatives of patients.Results: The study identified a range of barriers encountered in the referral process and broadly fall under the major themes: referral transportation system, referrer-receiver communication barriers, inadequate infrastructure and supplies and insufficient health personnel. Some highlights of the problem included inadequate use of ambulance services, poor management of patients during transit, lack of professional escort, unannounced emergency referrals, lack of adequate information and feedback and limited supply of beds, drugs and blood. These findings have implications on type II and III of the three delays model.Conclusions: Initiatives to improve the transportation system for the referral of obstetric emergencies are vital in ensuring patients' safety during transfer. Communication between referring and receiving facilities should be enhanced. A strong collaboration is needed between teaching hospitals and other stakeholders in the referral chain to foster good referral practices and healthcare delivery. Concurrently, supply side barriers at referred facilities including ensuring sufficient provision for bed, blood, drugs, and personnel must be addressed. [ABSTRACT FROM AUTHOR]

Background: This study explored the role of health facility availability as it relates to maternal and newborn PNC use in rural Malawi.Methods: Malawi Demographic and Health Survey (MDHS) 2015-16 data, MDHS 2015-16 household cluster GPS data, Malawi Service Provision Assessment (MSPA) 2013-14 data and MSPA 2013-14 facility GPS data were used. Household clusters were spatially linked with facilities using buffers. Descriptive analyses were performed and generalized estimating equations (GEE) were used to determine the effects of having different types of facilities at varying distances from household clusters on receipt of maternal and newborn PNC in rural Malawi.Results: In rural Malawi, around 96% of women had facilities providing PNC within 10 km of where they live. Among women who have clinic-level facilities within 5 km of where they live, around 25% had clinic-level facilities that provide PNC. For rural women who gave birth in the past 5 years preceding the survey, only about 3% received maternal PNC within 24 h and about 16% received maternal PNC within the first week. As for newborn PNC, 3% of newborns had PNC within 24 h and about 26% had newborn PNC within the first week. PNC mostly took place at facilities (94% for women and 95% for newborns). For women who delivered at home, having a health center providing PNC within 5 km was positively associated with maternal and newborn PNC. For women who delivered at facilities, having a health center providing PNC within 5 km was positively associated with maternal PNC and having a health center providing PNC between 5 km and 10 km was positively associated with both maternal and newborn PNC. Regardless of the place of delivery and distance band, having a clinic-level facility providing PNC did not have significant positive effects on maternal and newborn PNC.Conclusions: Providers should be trained to perform quality PNC at all facilities. It would also be important to address concerns related to health workers. Lastly, it would be key to increase community awareness about the importance of seeking timely PNC and about the utility of lower-level facilities for receiving preventative PNC. [ABSTRACT FROM AUTHOR]

Background: Better quality of care around the time of childbirth can significantly improve maternal and newborn survival. In countries like India, where the private sector contributes to a considerable proportion of institutional deliveries, it is important to assess the quality of maternity care offered by private sector healthcare facilities. This study seeks to fill that information gap by analysing baseline assessments conducted for the Manyata program, which aims to improve the quality of maternity care at private facilities.Methods: An observation checklist based on 16 clinical standards endorsed by the Federation of Obstetric and Gynaecological Societies of India (FOGSI) was used to assess 201 private sector healthcare facilities in Maharashtra, Jharkhand, and Uttar Pradesh. Data on facility characteristics came from profiles completed when facilities enrolled in Manyata. Differences in the mean number of standards met were analysed by facility characteristics and the availability of essential supplies.Results: Around half (47.1%) of all nursing staff engaged in maternity care services at these private healthcare facilities were under qualified. The mean number of clinical standards met by facilities was 3.2 (SD 2.4). Facilities with a monthly delivery load between 20 and 50 met a significantly higher number of standards, as did facilities that had more than 70% of essential supplies available. Both these factors were also significant in a multiple linear regression analysis.Conclusions: The overall quality of maternity care in private healthcare facilities is poor in all three states, especially for clinical standards related to management of complications. [ABSTRACT FROM AUTHOR]

Background: In fragile and war-affected setting such as South Sudan, a combination of physical environmental, socioeconomic factors and healthcare's characteristic contributes to higher rates of home delivery attended by unskilled attendants. This study aims to understand the community members' experience, perceptions and the barriers in relation to accessing and utilizing maternal healthcare services in South Sudan.Methods: We conducted in-depth one-on-one interview with 30 women and 15 men to investigate their perspectives on the barriers to access maternal and child health related services. We purposively selected women and their partners in this study.Results: Our study revealed that inadequate quality of antenatal care services such as lack of essential medicine, supplies and tools was linked to individual's mothers dissatisfaction with the services they received. In addition, sudden onset of labor and lack of safety and security were important reasons for home delivery in this study. Furthermore, lack of transport as a result of a combination of long distance to a facility and associated costs either restricted or delayed women reaching the health facilities.Conclusions: Our study highlighted an urgent need for the government of South Sudan to implement security and safety measures in order to improved access to delivery service at night. Incorporating private transports to provide access to affordable and reliable transport services for pregnant and post-partum women is also important. Increasing the budget allocation for medicine and health supplies and improving management of medicine and supply chain logistics are essential. [ABSTRACT FROM AUTHOR]

Background: Births before arrival (BBA) to health care facilities are associated with higher rates of perinatal morbidity and mortality compared to facility deliveries or planned home births. Research on such births has been conducted in several high-income countries, but there are almost no studies from low-income settings where a majority of maternal and newborn deaths occur. Methods: Drawing on a household survey of women and in-depth interviews with women and their partners, we examined the experience of BBA in rural districts of Morogoro Region, Tanzania. Results: Among survey respondents, 59 births (4 %) were classified as BBAs. Most of these births occurred in the presence of a family member (47 %) or traditional birth attendant (24 %). Low socioeconomic status was the strongest predictor of BBA. After controlling for wealth via matching, high parity and a low number of antenatal care (ANC) visits retained statistical significance. While these variables are useful indicators of which women are at greater risk of BBA, their predictive power is limited in a context where many women are poor, multiparous, and make multiple ANC visits. In qualitative interviews, stories of BBAs included themes of partner disagreement regarding when to depart for facilities and financial or logistical constraints that underpinned departure delays. Women described wanting to depart earlier to facilities than partners. Conclusion: As efforts continue to promote facility birth, we highlight the financial demands associated with facility delivery and the potential for these demands to place women at a heightened risk for BBAs. [ABSTRACT FROM AUTHOR]

Background: The majority of women in sub-Saharan Africa now deliver in a facility, however, little is known about the quality of services for maternal and newborn basic and emergency care, nor how this is associated with patient's perception of their experiences. Methods: Using data from the Service Provision Assessment (SPA) survey from Kenya 2010 and Namibia 2009, we explore whether facilities have the necessary signal functions for providing emergency and basic maternal (EmOC) and newborn care (EmNC), and antenatal care (ANC) using descriptives and multivariate regression. We explore differences by type of facility (hospital, center or other) and by private and public facilities. Finally, we see if patient satisfaction (taken from exit surveys at antenatal care) is associated with the quality of services (specific services provided). Results: We find that most facilities do not have all of the signal functions, with 46 and 27 % in Kenya and 18 and 5 % in Namibia of facilities have high/basic scores in routine and emergency obstetric care, respectively. We found that hospitals preform better than centers in general and few differences emerged between public and private facilities. Patient perceptions were not consistently associated with services provided; however, patients had fewer complaints in private compared to public facilities in Kenya (-0.46 fewer complaints in private) and smaller facilities compared to larger in Namibia (-0.26 fewer complaints in smaller facilities). Service quality itself (measured in scores), however, was only significantly better in Kenya for EmOC and EmNC. Conclusions: This analysis sheds light on the inadequate levels of care for saving maternal and newborn lives in most facilities in two countries of Africa. It also highlights the disconnect between patients' perceptions and clinical quality of services. More effort is needed to ensure that high quality supply of services is present to meet growing demand as an increasing number of women deliver in facilities. [ABSTRACT FROM AUTHOR]

Background: Policymakers and program planners consider antenatal care (ANC) coverage to be a primary measure of improvements in maternal health. Yet, evidence from multiple countries indicates that ANC coverage has no necessary relationship with the content of services provided. This study examines the relationship between the timing of the first ANC check-up, a potential predictor of the content of services, and the provision of WHO recommended services to women during their pregnancy.Methods: The study uses data from a representative household survey of Sindh with a sample comprising of 4,000 women aged 15-49 who had had a live birth in the two years before the survey. The survey obtained information about the elements of care provided during pregnancy, the timing of the first ANC check-up, the number of ANC visits made during the last pregnancy and women's socio-economic and demographic characteristics. Bivariate analysis was conducted to examine the relationship between the proportion of women who receive six WHO recommended services and the timing of their first ANC check-up. Multivariate analysis was conducted to identify predictors of the number of elements of care provided.Results: While most women in Sindh (87 %) receive an ANC check-up, its timing varies by parity, education and household wealth. The median time to the first ANC check-up was 3 months for women in the richest and 7 months for women in the poorest wealth quintiles. In multivariate analysis, wealth, education, parity and age at marriage were significant predictors of the number of elements of care provided. Women who received an early ANC check-up were much more likely to receive WHO recommended services than other women, independent of a range of socio-economic and demographic variables and independent of the number of ANC visits made during pregnancy.Conclusions: In Sindh, the timing of the first ANC check-up has an independent effect on the content of care provided to pregnant women. While it is extremely important that providers are adequately trained and motivated to provide the WHO recommended standards of care, these findings suggest that motivating women to make an early first ANC check-up may be another mechanism through which the quality of care provided may be improved. Such a focus is most likely to benefit the poorest, least educated and highest parity women. Based on these findings, we recommend that routine data collected at health facilities in Pakistan should include the month of pregnancy at the time of the first ANC check-up. [ABSTRACT FROM AUTHOR]

Background: Herpes simplex virus type-2 is the common cause of genital ulcer disease worldwide. Genital herpes infection is a major concern in pregnancy due to the risk of neonatal transmission. Method: A Cross-sectional survey was conducted from December 2013 to September 2014 in randomly selected 28 health centers to assess the seroprevalence and risk factors of herpes simplex virus type-2 infection among pregnant women attending antenatal care in Wolaita zone, Southern Ethiopia. After taking written consent socio demographic, behavioral, obstetric history and family planning data along with blood samples were collected from 252 pregnant women using pre-structured questionnaire. Sera were tested using HerpeSelect-2 ELISA IgG. Data entry and analysis was done using Epi info 3.5.4 and SPSS 21.00 respectively. Binary logistic regression was performed to identify the risk factors associated with HSV-2 seropositivity. P-values less than 0.05 were considered statistically significant. Results: The overall seroprevalence of HSV-2 infection was 32.1 % (81/252) among pregnant women in Wolaita zone. Independent predictors of HSV-2 infection includes daily laborer (AOR 1.293, 95 % CI: 1.033-1.739; p = 0.022), having one sexual partners (AOR 0.476, 95 % CI: 0 .250 -0.904; p = 0.023), history of STDs (AOR 2.822, 95 % CI: 1.50-5.289; p = 0.001) and use of contraceptive (AOR 2.602, 95 % CI: 1.407-4.812; p = 0.002). Conclusion: Overall seroprevalence of HSV-2 infection among pregnant women of Wolaita Zone is high. Awareness creation among high risk groups like women who have history of STD should be strengthened. Strengthening the quality of health service delivery and expansion of health service coverage is mandatory. [ABSTRACT FROM AUTHOR]

Background: Expanding institutional deliveries is a policy priority to achieve MDG5. India adopted a policy to encourage facility births through a conditional cash incentive scheme, yet 28% of deliveries still occur at home. In this context, it is important to understand the care experience of women who have delivered at home, and also at health facilities, analyzing any differences, so that services can be improved to promote facility births. This study aims to understand women's experience of delivery care during home and facility births, and the factors that influence women's decisions regarding their next place of delivery.Method: A community-based cross-sectional survey was undertaken in a district of Jharkhand state in India. Interviews with 500 recently delivered women (210 delivered at facility and 290 delivered at home) included socio-demographic characteristics, experience of their recent delivery, and preference of future delivery site. Data analysis included frequencies, binary and multiple logistic regressions.Results: There is no major difference in the experience of care between home and facility births, the only difference in care being with regard to pain relief through massage, injection and low cost of delivery for those having home births. 75% women wanted to deliver their next child at a facility, main reasons being availability of medicine (29.4%) and perceived health benefits for mother and baby (15%). Women with higher education (AOR = 1.67, 95% CI = 1.04-3.07), women who were above 25 years (AOR = 2.14, 95% CI = 1.26-3.64), who currently delivered at facility (AOR = 5.19, 95% CI = 2.97-9.08) and had health problem post-delivery (AOR = 1.85, 95% CI = 1.08-3.19) were significant predictors of future facility-based delivery.Conclusion: The predictors for facility deliveries include, availability of medicines and supplies, potential health benefits for the mother and newborn and the perception of good care from the providers. There is a growing preference for facility delivery particularly among women with higher age group, education, income and those who had antennal checkup. In order to uptake facility births, the quality improvement initiatives should regularly assess and address women's experiences of care. [ABSTRACT FROM AUTHOR]

Background: Thousands of women and newborns still die preventable deaths from pregnancy and childbirth-related complications in poor settings. Delivery with a skilled birth attendant is a vital intervention for saving lives. Yet many women, particularly where maternal mortality ratios are highest, do not have a skilled birth attendant at delivery. In Uganda, only 58 % of women deliver in a health facility, despite approximately 95 % of women attending antenatal care (ANC). This study aimed to (1) identify key factors underlying the gap between high rates of antenatal care attendance and much lower rates of health-facility delivery; (2) examine the association between advice during antenatal care to deliver at a health facility and actual place of delivery; (3) investigate whether antenatal care services in a post-conflict district of Northern Uganda actively link women to skilled birth attendant services; and (4) make recommendations for policy- and program-relevant implementation research to enhance use of skilled birth attendance services.Methods: This study was carried out in Gulu District in 2009. Quantitative and qualitative methods used included: structured antenatal care client entry and exit interviews [n = 139]; semi-structured interviews with women in their homes [n = 36], with health workers [n = 10], and with policymakers [n = 10]; and focus group discussions with women [n = 20], men [n = 20], and traditional birth attendants [n = 20].Results: Seventy-five percent of antenatal care clients currently pregnant reported they received advice during their last pregnancy to deliver in a health facility, and 58 % of these reported having delivered in a health facility. After adjustment for confounding, women who reported they received advice at antenatal care to deliver at a health facility were significantly more likely (aOR = 2.83 [95 % CI: 1.19-6.75], p = 0.02) to report giving birth in a facility. Despite high antenatal care coverage, a number of demand and supply side barriers deter use of skilled birth attendance services. Primary barriers were: fear of being neglected or maltreated by health workers; long distance and other difficulties in access; poverty, and material requirements for delivery; lack of support from husband/partner; health systems deficiencies such as inadequate staffing/training, work environment, and referral systems; and socio-cultural and gender issues such as preferred birthing position and preference for traditional birth attendants.Conclusions: Initiatives to improve quality of client-provider interaction and respect for women are essential. Financial barriers must be abolished and emergency transport for referrals improved. Simultaneously, supply-side barriers must be addressed, notably ensuring a sufficient number of health workers providing skilled obstetric care in health facilities and creating habitable conditions and enabling environments for them. [ABSTRACT FROM AUTHOR]