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Objective: An innovative approach by two Queensland health services was taken to establish a shared maternity services' research agenda by partnering with consumers and clinicians. The objective was to set the top five research priorities to ensure that the future direction of maternity research was relevant to end-user and organisational needs. Methods: A modified James Lind Alliance (JLA) methodology was applied between August 2022 and February 2023 across two south-east Queensland Health Services which included five participating maternity units and involved partnership with consumers, healthcare professionals and clinician researchers. The reporting guideline for priority setting of health research (REPRISE) was followed. Results: There were 192 respondents to the initial harvesting survey, generating 461 research suggestions. These were aggregated into 122 unique questions and further summarised into a list of 44 research questions. The 157 eligible interim prioritisation survey respondents short-listed 27 questions ready for ranking at a final consensus workshop. The top five question themes were: (1) maternity care experience, engagement and outcomes of priority populations; (2) increasing spontaneous vaginal birth; (3) experiences and perceptions of woman/person-centred care; (4) best practice care during the 'fourth' trimester; and (5) antibiotic use during labour and birth. Conclusion: Applying an adapted JLA framework can successfully shape and establish a research agenda within Australian health services, through partnership with consumers and practicing clinicians. This is a transparent process that strengthens the legitimacy and credibility of research agendas, and it can form a replicable framework for other settings. What is known about the topic? Establishment of research agendas often neglects the participation of research end-users, consumers and practising clinicians, consequently limiting relevance and translation. What does this paper add? Prioritised specific maternity research questions were jointly generated by consumers and front-line clinicians to highlight areas of focus for research funding and support. What are the implications for practitioners? By partnering with consumers and practising clinicians health service research priorities can be established to optimise patient outcomes and ensure future research is both translational and relevant. [ABSTRACT FROM AUTHOR]

Objective: To describe change in costs to different funders over time for women giving birth in Queensland between 2012 and 2018. Methods: A whole-of-population linked administrative dataset was used that contained all health service use in Queensland for women who gave birth between 1 July 2012 and 30 June 2018 and their babies. Aggregated costs for mother and baby from pregnancy to 12 months postpartum were used to compare the change in costs to funders over time. Results: There was an increase in mean total cost to all funders per birth in the public system and private system from 2012 to 2018. North West Hospital and Health Service (HHS) had the highest mean total cost (in Australian dollars) in 2018 (A$42 353), while home births had the lowest (A$6105). For the majority of HHSs the proportion of births with a positive birth outcome (as defined by a composite outcome measure) has remained largely static or declined during this time period. Cairns and Hinterland HHS and Townsville HHS had the largest declines of 15% and 16% respectively, while mean total cost to all funders rose 36.39% and 46.41%, respectively. Conclusions: There has been an increase over time across Queensland in the cost of childbirth in public hospitals and in the private system, while the cost of home birth has remained static. For most HHSs this increase in cost is also associated with little change or a decline in the percentage of births with a positive outcome. Increases in cost are therefore not being translated into better outcomes for women and their babies. Routine performance monitoring of cost, quality and safety should be adopted to ensure the provision of high value maternity care in Australia. What is known about the topic? Public maternity care costs vary in Australia dependent upon place of birth, even after adjusting for clinical and demographic factors. What does this paper add? This paper compares the change in costs for mother and baby from birth through to 12 months for births across Queensland over time. Costs for maternity care have increased over time and higher-cost treatment does not necessarily result in better health outcomes. What are the implications for practitioners? Reporting of cost alongside clinical outcomes should be included in performance monitoring of public hospital maternity care. [ABSTRACT FROM AUTHOR]

Background: Women's childbirth experiences in health facilities is at the core of quality of care. Their perceptions of poor-quality care, including disrespectful care at health facilities during childbirth, is recognized as a significant barrier to seeking care for subsequent births. Research that explores women's perspectives of the dimensions of disrespect and mistreatment during childbirth in Arab countries is scarce, and there is none pertaining to refugee groups who carry the burden of multiple vulnerabilities and who suffer from discontinued care, especially in fragile health systems. This paper aims at presenting Palestinian, Iraqi and Syrian refugee women's experiences, understanding and interpretation of disrespect and mistreatment during childbirth in hospitals in Lebanon.Methods: This study employed phenomenology, a qualitative research design to generate data through in-depth interviews. Women who were 3 to 6 months postpartum were recruited through the non-governmental organizations (NGOs) that are actively engaged in providing welfare and healthcare services to different populations of refugee women in Lebanon. In total, 24 women were interviewed. All interviews were audio recorded, transcribed verbatim and subjected to thematic analysis.Results: Of the 24 women who participated in this study, 9 were Palestinian, 12 were Syrian and 3 were Iraqi. The participants spoke of restricted choices to hospitals, care providers and to types of birth, while revealing adverse experiences during childbirth in healthcare facilities, including verbal and physical abuse, disrespectful verbal and non-verbal communication by healthcare providers. They also reported sub-standard care, denial of birth companions and breaches to their privacy. Our findings exemplify how the coverage of the cost of facility-based births by UN agencies and NGOs increase refugee women's vulnerability to disrespect and mistreatment during childbirth.Conclusion: This study shows how disrespect and mistreatment are intertwined in a complex system which is devised to ensure access to facility-based birth for displaced populations. Implications for programs and policies point to the need for strengthening capacity and for providing resources for the adaptation of global guidelines into context-specific strategies for the provision of quality maternity care during humanitarian crises and beyond. [ABSTRACT FROM AUTHOR]

This paper examines the sequential impact of components of maternal and child health care on the continuum of care in India using data from the Indian National Family Health Surveys conducted in 2005–06 and 2015–16. Continuum of care (CoC) for maternal and child health is defined in this paper as the sequential uptake of three key maternal services (antenatal care, institutional delivery and postnatal care for the mother). Women who received all three services were classified as full CoC recipients. Characteristics odd ratios for achieving CoC were estimated by mother's place of residence, household wealth status, mother's education, birth order and child full vaccination. Odds ratios were computed to understand the relative impact of each preceding service utilization on the odds of subsequent service uptake. At national level, 30.5% and 55.5% of women achieved full CoC in 2005–06 and 2015–16, respectively, and the overall progress of CoC over the 10-year period was 25.5 percentage points, with significant variation across states and socioeconomic groups. Full CoC improved from 7.5% to 32.4% among the poorest women, whereas among the richest women it improved from 70.5% to 75.1%. Similarly, among uneducated women full CoC improved from 11.7% to 35.9% as against 75.1% to 80.5% among educated mothers over the same period. Furthermore, greater CoC was observed among parity one women. The conditionality between various components of CoC indicated that at national level the odds of having an institutional delivery with antenatal care were 9 times higher in the earlier period as against 4.5 times higher in the more recent period. Furthermore, women who had institutional deliveries complied more with mother's postnatal care compared with women who did not have institutional deliveries. This again helps increase the likelihood of a child receiving full vaccination. [ABSTRACT FROM AUTHOR]

Objective: This study sought to compare costs for women giving birth in different public hospital services across Queensland and their babies. Methods: A whole-of-population linked administrative dataset was used containing all health service use in a public hospital in Queensland for women who gave birth between 1 July 2012 and 30 June 2015 and their babies. Generalised linear models were used to compare costs over the first 1000 days between hospital and health services. Results: The mean unadjusted cost for each woman and her baby (n = 134 910) was A$17406 in the first 1000 days. After adjusting for clinical and demographic factors and birth type, women and their babies who birthed in the Cairns Hospital and Health Service (HHS) had costs 19% lower than those who birthed in Gold Coast HHS (95% confidence interval (CI) –32%, –4%); women and their babies who birthed at the Mater public hospitals had costs 28% higher than those who birthed at Gold Coast HHS (95% CI 8, 51). Conclusions: There was considerable variation in costs between hospital and health services in Queensland for the costs of delivering maternity care. Cost needs to be considered as an important additional element of monitoring programs. What is known about the topic?: The Australian maternal care system delivers high-quality, safe care to Australian mothers. However, this comes at a considerable financial cost to the Australian public health system. It is known that there are variations in the cost of care depending upon the model of care a woman receives, and the type of delivery she has, with higher-cost treatment not necessarily being safer or producing better outcomes. What does this paper add?: This paper compares the cost of delivering a full cycle of maternity care to a woman at different HHSs across Queensland. It demonstrates that there is considerable variation in cost across HHSs, even after adjusting for clinical and demographic factors. What are the implications for practitioners?: Reporting of cost should be an ongoing part of performance monitoring in public hospital maternity care alongside clinical outcomes to ensure the sustainability of the high-quality maternal health care Australian public hospitals deliver. [ABSTRACT FROM AUTHOR]

Internationally, politicians and practitioners have focused strongly on humanization of births, to enable fewer medicalized birth care procedures. In this paper, we explore policy efforts to support better births in order to comprehend developments in maternity care in Denmark and France, two countries previously identified as having different birth cultures. Our analysis has been fueled by the question of how birth policies have developed in both countries in an era in which medicalization of birth has been problematized internationally. Using discourse analysis, we examine the political constructions of specific problems in central policy documents. The analysis shows which problematizations around maternity care are discursively constructed, what solutions are discursively presented and on what assumptions the problematizations are based. The article supports the conclusion of other scholars that a pervading risk discourse on birth and birthing bodies constitutes how maternity care can be experienced and practiced. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this paper is to share the results of a systematic review on the state of inequalities in access to and utilization of maternal, newborn and child health (MNCH) services in the sub-Saharan African region. The focus of the review was on urban settings where growing needs and challenges have been registered over the past few years due to rapid increase in urban populations and urban slums. Methods: The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies published in English between 2000 and 2019 were included. A narrative synthesis of both qualitative and quantitative data was undertaken. The record for registration in PROSPERO was CRD42019122066. Results: The review highlights a great variation in MNCH services utilization across urban sub-Saharan Africa (SSA). The main aspects of vulnerability to unequal and poor MNCH services utilization in urban settings of the region include poverty, low level of education, unemployment, lower socioeconomic status and poor livelihoods, younger maternal age, low social integration and social support, socio-cultural taboos, residing in slums, and being displaced, refugee, or migrant. At the health system level, persistent inequalities are associated with distance to health facility, availability of quality services and discriminating attitudes from health care personnel. Conclusion: Context-specific intervention programs that aim at resolving the identified barriers to access and use MNCH services, particularly for the most vulnerable segments of urban populations, are essential to improve the overall health of the region and universal health coverage (UHC) targets. [ABSTRACT FROM AUTHOR]

Aims This article presents a meta-ethnographic synthesis of studies on women's experiences of sustaining a third or fourth degree tear during childbirth. Background It has been reported that for women who sustain third or fourth degree perineal tears (severe perineal trauma) some may experience extensive physical and psychological outcomes. Design A meta-ethnographic synthesis. Data sources The CINAHL, PubMed, Scopus, MD Consult, and SocIndex with Full Text databases were searched for the period January 1996-June 2011. Out of 478 papers retrieved four met the review aim. Review methods A meta-ethnographic synthesis approach was undertaken using analytic strategies and theme synthesis techniques of reciprocal translation and refutational investigation. Quality appraisal was undertaken using the Critical Appraisal Skills Programme ( CASP) tool. Findings Four qualitative papers were included, with three major themes identified: 'I am broken and a failure', 'Dismissed, devalued and disregarded', and 'The practicalities of the unpredictable perineum'. Conclusion There is evidence to suggest that for women who experience severe perineal trauma during childbirth the physical and psychological outcomes can be complex, with some women experiencing social isolation and marginalization due to their ongoing symptomatology. Severe perineal trauma appeared to affect not only physiological and psychological well-being but also altered the women's understanding of their identity as sexual beings. Health professionals should be mindful of the language that they use and their actions during suturing and the postpartum period to avoid causing unnecessary distress. [ABSTRACT FROM AUTHOR]

The first two papers in this series described the early development, and ongoing evolution of a caseholding team in the north-west of England (Byrom and Downe, 2007; Fleming and Downe, 2007). We described the outcomes of the scheme and suggested that nine key factors may underpin the success of the project, namely: continuity of carer; visibility in the community; multi-agency involvement; inter-disciplinary collaboration; leadership; strategic partnership; ability to be innovative and flexible; involvement of local community and individuals; and shared group philosophy. Based on principles of service user involvement it was agreed that the ongoing monitoring of the project would include an invitation to all those using the service to write their birth story to summarize their experiences with the scheme. This paper presents a selection of these stories as a reflection on the processes and outcomes of the scheme. The stories indicate that the benefits of the scheme are evident for both the women using the service, and the midwives providing it. They also illustrate many of the nine core factors for success identified in our previous paper. Specifically, the scheme offers the opportunity for women at high clinical and socio-demographic risk to experience positive childbirth experiences. It also offers the opportunity for midwives to exercise their skills in normalizing birth in complex situations. [ABSTRACT FROM AUTHOR]

Background: This paper examines two state-led public-private demand-side financial support programs aiming to raise hospital delivery rates in two neighbouring Indian states-Gujarat and Madhya Pradesh. The national Janani Suraksha Yojana (JSY) was complemented with a public-private partnership program Janani Sahayogi Yojana (JSaY) in Madhya Pradesh in which private obstetricians were paid to deliver poor women. A higher amount was paid for caesarean sections (CS) than for vaginal deliveries (VD). In Gujarat state, the state program Chiranjeevi Yojana (CY) paid private obstetricians a fixed amount for a block 100 deliveries irrespective of delivery mode. The two systems thus offered an opportunity to observe the influence of supplier-induced demand (SID) from opposite incentives related to delivery mode. Methods: The data from the two programs was sourced from the Departments of Health and Family Welfare, Governments of Gujarat and Madhya Pradesh, India. Results: In JSaY program the CS rate increased from 26.6 % (2007-2008) to 40.7 % (2010-2011), against the background rate for CS in Madhya Pradesh, of only 4.9 % (2004-2006). Meanwhile in CY program in Gujarat, the CS rate decreased to 4.3 % (2010-2011) against a background CS rate of 8.1 % (2004-2006). Conclusions: The findings from India are unique in that they not only point to a significant impact from the introduction of the financial incentives but also how disincentives have an inverse impact on the choice of delivery method. [ABSTRACT FROM AUTHOR]

Background: Most existing research on rural–urban health inequalities focuses on disparities in service access and health outcomes based on region. This paper examines rural–urban disparities in maternal healthcare utilization and delivery modes based on household registration (hukou) status to understand the role of state institutions in producing healthcare disparities in China. Methods: Utilizing administrative data from the Public Maternal Health Insurance scheme, we analyzed 54,733 live births in City A (2015–2019) and 25,849 live births in City B (2018–2019) in Guangdong Province in China. We constructed regression models using hukou status (rural versus urban) as the explanatory variable. Results: While there is no statistically significant difference in rural and urban mothers' probability of obtaining the minimum recommended number of prenatal care checkups in City A (OR = 0.990 [0.950, 1.032]), mothers with rural hukou status have a lower probability of obtaining the minimum recommended number of visits in City B than their counterparts with urban hukou (OR = 0.781 [0.740, 0.825]). The probability of delivering in tertiary hospital is lower among mothers with rural hukou than among those with urban hukou in both cities (City A: OR = 0.734 [0.701, 0.769]; City B: OR = 0.336 [0.319, 0.354]). Mothers with rural hukou are more likely to have a Cesarean section than those with urban hukou in both cities (City A: OR = 1.065 [1.027, 1.104]; City B: OR = 1.127 [1.069, 1.189]). Compared with mothers with urban hukou, mothers with rural hukou incurred 4 % (95 % CI [-0.046, -0.033]) and 9.4 % (95 % CI [-0.120, -0.068]) less in total medical costs for those who delivered via Cesarean section and 7.8 % (95 % CI [-0.085, -0.071]) and 19.9 % (95 % CI [-0.221, -0.177]) less for those who delivered via natural delivery in City A and City B, respectively. Conclusions: Rural hukou status is associated with younger age, no difference or lower probability of having a minimum number of prenatal checkups, higher likelihood of delivering in nontertiary hospitals, increased Cesarean delivery rates, and lower medical cost for delivery in these two Chinese cities. Evaluating how hukou status influences maternal healthcare in Chinese cities is important for devising targeted public policies to promote more equitable maternal health services. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to understand the complex relationship between maternal complications and women's characteristics in India. Methods: The present study builds structural equation modeling (SEM) using the data from the National Family Health Survey round 4 (2015–16) and includes 190, 898 women who had given their last birth during 5 years preceding the survey. Based on eight questions related to maternal complications, the SEM constructed two latent variables – complications during pregnancy (PREGCOMP) and delivery (DELCOMP). Results: Result shows that prolonged labor was highly prevalent (42%) among women, followed by vaginal bleeding (34%) and swelling in legs, body or face (32%). Women from affluent households (β = −0.02 for each‐middle, richer and richest quantile), with higher education (β = −0.02), timing when they received first ANC (β = −0.003) and women who received full ANC (β = −0.01) had a lower risk of PREGCOMP. However, consanguineous marriage (β = 0.01) was positively related to PREGCOMP. Further, women with PREGCOMP (β = 0.20), rural residents (β = 0.02), having exposure to mass media (β = 0.01), and who had facility delivery (β = 0.04) were at high risk of DELCOMP. Women with pregnancy complications are more likely to have delivery complications. [Correction added on 27 November, after first online publication: The statement "who received full antenatal care (ANC) (β = −0.05)" has been removed.] Conclusion: Socioeconomic and demographic factors significantly affect both the latent variables. This study concludes that the use of intensive healthcare services reduces health complications. The paper recommends early visits and full ANC checkups to reduce pregnancy complications. [ABSTRACT FROM AUTHOR]

Introduction: Although India has made significant progress in institutional delivery after the implementation of the National Rural Health Mission under which the Janani Suraksha Yojana (JSY) is a sub-programme which played a vital role in the increase of institutional delivery in public facilities. Therefore, this paper aims to provide an understanding of the JSY coverage at the district level in India. Further, it tries to carve out the factors responsible for the regional disparity of JSY coverage at district levels. Methods: The study used the National Family Health Survey data, which is a cross-sectional survey conducted in 2015–16, India. The sample size of this study was 148,145 women aged 15–49 years who gave last birth in the institution during 5 years preceding the survey. Bivariate and multivariate regression analysis was used to fulfill the study objectives. Additionally, Moran's I statistics and bivariate Local Indicator for Spatial Association (LISA) maps were used to understand spatial dependence and clustering of JSY coverage. Ordinary least square, spatial lag and spatial error models were used to examine the correlates of JSY utilization. Results: The value of spatial-autocorrelation for JSY was 0.71 which depicts the high dependence of the JSY coverage over districts of India. The overall coverage of JSY in India is 36.4% and it highly varied across different regions, districts, and even socioeconomic groups. The spatial error model depicts that if in a district the women with no schooling status increase by 10% then the benefits of JSY get increased by 2.3%. Similarly, if in a district the women from poor wealth quintile, it increases by 10% the benefits of JSY also increased by 4.6%. However, the coverage of JSY made greater imperative to understand it due to its clustering among districts of specific states only. Conclusion: It is well reflected in the EAGs states in terms of spatial-inequality in service coverage. There is a need to universalize the JSY programme at a very individual level. And, it is required to revisit the policy strategy and the implementation plans at regional or district levels. [ABSTRACT FROM AUTHOR]

The perinatal period involves major developmental transitions which can be conceptualized through a biopsychosocial (BPS; Engel in Science 196:129–136, 1977, 10.1126/science.847460, in The American Journal of Psychiatry 137:535–544, 1980, 10.1176/ajp.137.5.535), systemic (von Bertalanffy, General system theory: Foundations, development, applications, George Braziller, New York, 1968) framework. Thus, no one domain of health in the perinatal period can be understood without exploring how the other domains are both impacted by and impacting the others. As a result of COVID-19, popular media is paying special attention to the biomedical domain of women in the perinatal period as it relates to health outcomes and changes in perinatal healthcare policies; however, considerably less attention is being paid to the other BPS health domains and systemic impacts. This paper will outline U.S. changes in healthcare as a result of the COVID-19 pandemic for individuals, couples, and families within the perinatal period (i.e., family planning and conception, prenatal, labor and delivery, and postpartum) and explore the unique psychosocial, systemic impacts. Recommendations for care, including telehealth and virtual support options, and future directions for research will be provided. [ABSTRACT FROM AUTHOR]

Background: Disrespect and abuse or mistreatment of women by health care providers in maternity settings has been identified as a key deterrent to women seeking delivery care. Mistreatment includes physical and verbal abuse, stigma and discrimination, a poor relationship between women and providers and policy and health systems challenges. This paper uses qualitative data to describe mistreatment of women in Kenya.Methods: Data are drawn from implementation research conducted in 13 facilities and communities. Researchers conducted a range of in-depth interviews with women (n-50) who had given birth in a facility policy makers health managers and providers (n-63); and focus group discussions (19) with women and men living around study facilities. Data were captured on paper and audio tapes, transcribed and translated and exported into Nvivo for analysis. Subsequently we applied a typology of mistreatment which includes first order descriptive themes, second and third-order analytical themes. Final analysis was organized around description of the nature, manifestations and experiences, and factors contributing to mistreatment.Results: Women describe: their negative experiences of childbirth; frustration with lack of confidentiality and autonomy; abandonment by the providers, and dirty maternity units. Providers admit to challenges but describe reasons for apparent abuse (slapped on thighs to encourage women to focus on birthing process) and 'detention' is because relatives have abandoned them. Men try to overcome challenges by paying providers to ensure they look after their wives. Drivers of mistreatment are perpetuated by social and gender norms at family and community levels. At facility level, poor managerial oversight, provider demotivation, and lack of equipment and supplies, contribute to a poor experience of care. Weak or non-existent legal redress perpetuate the problem.Conclusion: This paper builds on the expanding literature on mistreatment during labour and childbirth -outlining drivers from an individual, family, community, facility and policy level. New frameworks to group the manifestations into themes or components makes it increasingly more focused on specific interventions to promote respectful maternity care. The Kenya findings resonate with budding literature - demonstrating that this is indeed a global issue that needs a global solution. [ABSTRACT FROM AUTHOR]

Background Many low- and middle-income countries (LMICs) prioritise minimising maternal, neonatal, and infant mortality. To improve maternal and child health, various evidence-based interventions have been introduced. Quality of care is pertinent while strengthening service utilisations. Achieving optimal-quality care is often marred with difficulties, such as inadequate skills and knowledge of health workers, poor fidelity to protocols, and poor user acceptance. Angola is a LMIC facing these problems. This study aimed to demonstrate the influence of health facilities' quality of care at antenatal care (ANC) on subsequent maternal, newborn and child health (MNCH) service utilisation in Angolan pregnant women. Methods Population-based cohort data from the Maternal and Child Health Handbook (MCH-HB) effectiveness study were analysed. The original study was conducted among women who became pregnant between March and April 2019 in Benguela Province, Angola. Socioeconomic and MNCH service utilisation indicators were collected through interviewer-administered structured questionnaires. The indicator of quality of care was a composite measure that assessed the implementation of the MCH-HB based on the RE-AIM framework, mostly consisted of common factors related to delivery and management of MNCH services. A multivariate logistic regression analysis was performed between quality of care, socioeconomic factors, and service utilisation indicators among the intervention group participants who had at least one ANC visit. Results Of the 3351 pregnant women who visited ANC at least once, 2911 without missing values among explanatory or dependent variables were included in the analysis. Among them, 2032 (69.8%) were exposed to optimal-quality ANC, and 2058 (70.7%), 1573 (54.0%), and 941 (32.3%) achieved ANC target, facility delivery, and vaccination target for six-month-old infants, respectively. Exposure to suboptimal-quality care at ANC was associated with lower odds for facility delivery (adjusted odds ratio (AOR)=0.60, 95% CI=0.49-0.73) and the achievement of the vaccination target (AOR=0.43, 95% CI=0.33-0.55). A low socioeconomic status was inversely associated with health service utilisation indicators. Conclusions Health facilities' quality of care influences subsequent MNCH service utilisation. Therefore, simultaneous efforts to improve quality of care and the mobilisation of pregnant women and communities are essential for enhancing maternal and child health. [ABSTRACT FROM AUTHOR]

Background The extent to which a favorable policy environment influences health care utilization and outcomes for pregnant and postpartum women is largely unknown. In this study, we aimed to describe the maternal health policy environment and examines its relationship with maternal health service utilization in low- and middle-income countries (LMICs). Methods We used data from World Health Organization's 2018-2019 sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) policy survey linked with key contextual variables from global databases, as well as UNICEF data on antenatal care (ANC), institutional delivery, and postnatal care (PNC) utilization in 113 LIMCs. We grouped maternal health policy indicators into four categories - national supportive structures and standards, service access, clinical guidelines, and reporting and review systems. For each category and overall, we calculated summative scores accounting for available policy indicators in each country. We explored variations of policy indicators by World Bank income group using c2 tests and fitted logistic regression models for ≥85% coverage for each of four or more antenatal care visits (ANC4+), institutional delivery, PNC for the mothers, and for all ANC4+, institutional delivery, and PNC for mothers, adjusting for policy scores and contextual variables. Results The average scores for the four policy categories were as follows: 3 for national supportive structures and standards (score range = 0-4), 5.5 for service access (score range = 0-7), 6. for clinical guidelines (score range = 0-10), and 5.7 for reporting and review systems (score range = 0-7), for an average total policy score of 21.1 (score range = 0-28) across LMICs. After adjusting for country context variables, for each unit increase in the maternal health policy score, the odds of ANC4+>85% increased by 37% (95% confidence interval (CI) = 1.13-1.64) and the odds of all ANC4+, institutional deliveries and PNC>85% by 31% (95% CI = 1.07-1.60). Conclusions Despite the availability of supportive structures and free maternity service access policies, there is a dire need for stronger policy support for clinical guidelines and practice regulations, as well as national reporting and review systems for maternal health. A more favorable policy environment for maternal health can improve adoption of evidence-based interventions and increase utilization of maternal health services in LMICs. [ABSTRACT FROM AUTHOR]

Background Prolonged labour intensifies labour pain, and failure to address labour pain may lead to abnormal labour and augments the usage of operative interventions. Prolonged labour is common among women, resulting in maternal morbidity, increased caesarean section (CS) rates, and postpartum complications. It may bring forth negative birth experiences that may increase the preference for CS. There is a dearth of evidence concerning the effectiveness of breathing exercises on the duration of labor. As per our knowledge, this is the first systematic review and meta-analysis on the effect of breathing exercises on the duration of labor. This systematic review and meta-analysis aimed to appraise the evidence concerning the effectiveness of breathing exercises on the duration of labour. Methods Electronic databases MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Web of Science, SCOPUS, and ClinicalKey were searched for randomized controlled trials, quasi-experimental studies published in the English language between January 2005 to March 2022 that reported on the effectiveness of breathing exercises on the duration of labour. Duration of labour was the primary analysed outcome. The secondary outcomes assessed were anxiety, duration of pain, APGAR scores, episiotomy, and mode of delivery. Meta-analysis was done using RevMan v5.3. Results The reviewed trials involved 1418 participants, and the study participants ranged from 70 to 320. The mean gestational weeks of the participants among the reported trials was 38.9 weeks. Breathing exercise shortened the duration of the intervention group's second stage of labour compared with the control group. Conclusions Breathing exercise is a beneficial preventive intervention in shortening the duration of second stage of labour. [ABSTRACT FROM AUTHOR]

Background: Although a number of intermediate transport initiatives have been used in some developing countries, available evidence reveals a dearth of local knowledge on the effect of these rural informal transport mechanisms on access to maternal health care services, the cost of implementing such schemes and their scalability. This paper, attempts to provide insights into the functioning of the informal transport markets in facilitating access to maternal health care. It also demonstrates the role that higher institutions of learning can play in designing projects that can increase the utilization of maternal health services. Objectives: To explore the use of intermediate transport mechanisms to improve access to maternal health services, with emphasis on the benefits and unintended consequences of the transport scheme, as well as challenges in the implementation of the scheme. Methods: This paper is based on the pilot phase to inform a quasi experimental study aimed at increasing access to maternal health services using demand and supply side incentives. The data collection for this paper included qualitative and quantitative methods that included focus group interviews, review of project documents and facility level data. Results: There was a marked increase in attendance of antenatal, and delivery care services, with the contracted transporters playing a leading role in mobilizing mothers to attend services. The project also had economic spillover effects to the transport providers, their families and community generally. However, some challenges were faced including difficulty in setting prices for paying transporters, and poor enforcement of existing traffic regulations. Conclusions and implications: The findings indicate that locally existing resources such as motorcycle riders, also known as “boda boda” can be used innovatively to reduce challenges caused by geographical inaccessibility and a poor transport network with resultant increases in the utilization of maternal health services. However, care must be taken to mobilize the resources needed and to ensure that there is enforcement of laws that will ensure the safety of clients and the transport providers themselves. [ABSTRACT FROM AUTHOR]

Background: A physiological breech birth is one in which the woman is encouraged to remain active throughout her labor and able to assume the position of her choice for the birth. Use of this strategy within the United Kingdom National Health Service has led to the use of innovative maneuvers to relieve obstruction when women give birth in upright positions, for example, kneeling or standing. This includes use of the face‐to‐pubes rotational maneuver to relieve extended nuchal arm(s). In this paper, we report a case where the face‐to‐pubes rotational maneuver was used to relieve bilateral nuchal arm entrapment in a breech birth. Methods: Single‐case study. We aimed to generate an in‐depth understanding of how this maneuver works and how professionals decide to use it by exploring its use in a real‐life context. Results: The face‐to‐pubes rotational maneuver appears to be an effective method of relieving nuchal arm entrapment when used by experienced hands. In cases of bilateral nuchal arm entrapment, elevation to a higher station may be necessary to dis‐impact the arms above the pelvic inlet before the fetus can be rotated. After face‐to‐pubes rotation and release of arms, the head should be realigned in an occiput anterior position for delivery. Conclusion: The face‐to‐pubes rotational maneuver can be taught for resolution of nuchal arms in an upright position. Parents should be informed of the availability or not of a specialist midwife trained in physiological breech birth, as this may be important to their decision‐making. [ABSTRACT FROM AUTHOR]

Objective: to map the current knowledge on recommendations for labor, childbirth, and newborn (NB) care in the context of the novel coronavirus. Method: scoping review of papers identified in databases, repositories, and reference lists of papers included in the study. Two researchers independently read the papers' full texts, extracted and analyzed data, and synthesized content. Results: 19 papers were included, the content of which was synthesized and organized into two conceptual categories: 1) Recommendations concerning childbirth with three subcategories -- Indications to anticipate delivery, Route of delivery, and Preparation of the staff and birth room, and 2) Recommendations concerning postpartum care with four categories -- Breastfeeding, NB care, Hospital discharge, and Care provided to NB at home. Conclusion: prevent the transmission of the virus in the pregnancy-postpartum cycle, assess whether there is a need to interrupt pregnancies, decrease the circulation of people, avoid skin-to-skin contact and water births, prefer epidural over general anesthesia, keep mothers who tested positive or are symptomatic isolated from NB, and encourage breastfeeding. Future studies are needed to address directed pushing, instrumental delivery, delayed umbilical cord clamping, and bathing NB immediately after birth. [ABSTRACT FROM AUTHOR]

In this column, the editor of The Journal of Perinatal Education describes the contents of this issue, which offer a broad range of resources, research, and inspiration for childbirth educators in their efforts to promote normal birth. [ABSTRACT FROM AUTHOR]

Background: The most recent reports on global trends in neonatal mortality continue to show alarmingly slow progress on improvements in neonatal mortality rates, with sub-Saharan Africa still lagging behind. This emphasised the urgent need to innovatively employ alternative solutions that take into account the intricate complexities of neonatal health and the health systems in which the various strategies operate.Methods: In our first paper, we empirically explored the causes of the stagnating neonatal mortality in Uganda using a dynamic synthesis methodology (DSM) approach. In this paper, we completed the last three stages of DSM, which involved the development of a quantitative (simulation) model, using STELLA modelling software. We used statistical data to populate the model. Through brainstorming sessions with stakeholders, iterations to test and validate the model were undertaken. The different strategies and policy interventions that could possibly lower neonatal mortality rates were tested using what-if analysis. Sensitivity analysis was used to determine the strategies that could have a great impact on neonatal mortality.Results: We developed a neonatal health simulation model (NEOSIM) to explore potential interventions that could possibly improve neonatal health within a health system context. The model has four sectors, namely population, demand for services, health of the mothers and choices of clinical care. It tests the effects of various interventions validated by a number of Ugandan health practitioners, including health education campaigns, free delivery kits, motorcycle coupons, kangaroo mother care, improving neonatal resuscitation and labour management skills, and interventions to improve the mothers health, i.e. targeting malaria, anaemia and tetanus. Among the tested interventions, the package with the highest impact on reducing neonatal mortality rates was a combination of the free delivery kits in a setting where delivery services were free and motorcycle coupons to take women to hospital during emergencies.Conclusions: This study presents a System Dynamics model with a broad and integrated view of the neonatal health system facilitating a deeper understanding of its current state and constraints and how these can be mitigated. A tool with a user friendly interface presents the dynamic nature of the model using 'what-if' scenarios, thus enabling health practitioners to discuss the consequences or effects of various decisions. Key findings of the research show that proposed interventions and their impact can be tested through simulation experiments thereby generating policies and interventions with the highest impact for improved healthcare service delivery. [ABSTRACT FROM AUTHOR]

Background: Knowledge of the aggregate effects of multiple socioeconomic vulnerabilities is important for shedding light on the determinants of growing health inequalities and inequities in maternal healthcare. Objective: This paper describes patterns of inequity in maternal healthcare utilization and analyzes associations between inequity and multiple socioeconomic vulnerabilities among women in Vietnam. Design: This is a repeated cross-sectional study using data from the Vietnam Multiple Indicator Cluster Surveys 2000, 2006, and 2011. Two maternal healthcare indicators were selected: (1) skilled antenatal care and (2) skilled delivery care. Four types of socioeconomic vulnerabilities -- low education, ethnic minority, poverty, and rural location -- were assessed both as separate explanatory variables and as composite indicators (combinations of three and four vulnerabilities). Pairwise comparisons and adjusted odds ratios were used to assess socioeconomic inequities in maternal healthcare. Results: In all three surveys, there were increases across the survey years in both the proportions of women who received antenatal care by skilled staff (68.6% in 2000, 90.8% in 2006, and 93.7% in 2011) and the proportions of women who gave birth with assistance from skilled staff (69.9% in 2000, 87.7% in 2006, and 92.9% in 2011). The receipt of antenatal care by skilled staff and birth assistance from skilled health personnel were less common among vulnerable women, especially those with multiple vulnerabilities. Conclusions: Even thoughVietnam has improved its coverage of maternal healthcare on average, policies should target maternal healthcare utilization among women with multiple socioeconomic vulnerabilities. Both multisectoral social policies and health policies are needed to tackle multiple vulnerabilities more effectively by identifying those who are poor, less educated, live in rural areas, and belong to ethnic minority groups. [ABSTRACT FROM AUTHOR]

Background: This paper critically reviews published tools and indicators currently used to measure maternity care performance within Europe, focusing particularly on whether and how current approaches enable systematic appraisal of processes of minimal (or non-) intervention in support of physiological or "normal birth". The work formed part of COST Actions IS0907: "Childbirth Cultures, Concerns, and Consequences: Creating a dynamic EU framework for optimal maternity care" (2011-2014) and IS1405: Building Intrapartum Research Through Health - an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth (BIRTH) (2014-). The Actions included the sharing of country experiences with the aim of promoting salutogenic approaches to maternity care.Methods: A structured literature search was conducted of material published between 2005 and 2013, incorporating research databases, published documents in english in peer-reviewed international journals and indicator databases which measured aspects of health care at a national and pan-national level. Given its emergence from two COST Actions the work, inevitably, focused on Europe, but findings may be relevant to other countries and regions.Results: A total of 388 indicators were identified, as well as seven tools specifically designed for capturing aspects of maternity care. Intrapartum care was the most frequently measured feature, through the application of process and outcome indicators. Postnatal and neonatal care of mother and baby were the least appraised areas. An over-riding focus on the quantification of technical intervention and adverse or undesirable outcomes was identified. Vaginal birth (no instruments) was occasionally cited as an indicator; besides this measurement few of the 388 indicators were found to be assessing non-intervention or "good" or positive outcomes more generally.Conclusions: The tools and indicators identified largely enable measurement of technical interventions and undesirable health (or pathological medical) outcomes. A physiological birth generally necessitates few, or no, interventions, yet most of the indicators presently applied fail to capture (a) this phenomenon, and (b) the relationship between different forms and processes of care, mode of birth and good or positive outcomes. A need was identified for indicators which capture non-intervention, reflecting the reality that most births are low-risk, requiring few, if any, technical medical procedures. [ABSTRACT FROM AUTHOR]

Background This study aimed to explore the relationship between women's empowerment and utilization of maternity care for married Afghan women aged 15–49 y in Afghanistan, assessing the convergence validity of the Survey-based Women's Empowerment Index in Afghanistan (SWEI-A). Methods The study used data from the 2015 Afghanistan Demographic Health Survey to examine the association of different domains of women's empowerment with the utilization of maternity care using multilevel Poisson regression at both individual and community levels. Results The utilization of maternity services was considerably higher among women with high scores compared with those with low scores in almost all domains of the SWEI-A, except for property owning, in which women with high scores appeared to have lower rates of utilization of such services compared with those with low scores. At the community level, those communities with high participation of women in the labor force were less likely to have adequate antenatal care (ANC), institutional delivery and postnatal care (PNC). Individual-level literacy was associated with higher utilization of ANC, institutional delivery and PNC, contrary to community-level literacy. Conclusions Except for property owning, the high score in almost all other domains was associated with higher utilization of maternity care, which indicates an acceptable level of convergence validity for the developed index (i.e. the SWEI-A) in measuring women's empowerment among married Afghan women aged 15–49 y. [ABSTRACT FROM AUTHOR]

Aims: To establish a comprehensive understanding of the roles of midwives and the challenges they encounter in the prevention, diagnosis and management of postpartum haemorrhage (PPH) following normal vaginal delivery. Design: We conducted a scoping review following the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis for Scoping Reviews (PRISMA‐ScR) recommendations. Methods: We considered studies related to the roles of midwives and the challenges they encounter in the prevention, diagnosis and management of PPH during vaginal delivery. We excluded guidelines, consensuses, abstracts of meetings and non‐English language studies. Databases, including the Cochrane Library, PubMed, Web of Science, Ovid, Medline, Embase, JBI EBP and BIOSIS Previews, were searched on January 1, 2023, with no time limitations. Results: We included 28 publications. Midwives play important roles in the prevention, diagnosis and management of postpartum haemorrhage during vaginal delivery. In the prevention of PPH, midwives' roles include identifying and managing high‐risk factors, managing labour and implementing skin‐to‐skin contact. In the diagnosis of PPH, midwives' roles include early recognition and blood loss estimation. In the management of PPH, midwives are involved in mobilizing other professional team members, emergency management, investigating causes, enhancing uterine contractions, the repair of perineal tears, arranging transfers and preparation for surgical intervention. However, midwives face substantial challenges, including insufficient knowledge and skills, poor teamwork skills, insufficient resources and the need to deal with their negative emotions. Midwives must improve their knowledge, skills and teamwork abilities. Health care system managers and the government should give full support to midwives. Future research should focus on developing clinical practice guidelines for midwives for preventing, diagnosing and managing postpartum haemorrhage. [ABSTRACT FROM AUTHOR]

Background: Mistreatment during childbirth is a growing concern worldwide, especially in developing countries, such as Iran. In response, we launched a comprehensive implementation research (IR) project to reduce mistreatment during childbirth and enhance positive birth experiences in birth facilities. This study identified the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth using the Consolidated Framework for Implementation Research (CFIR). Methods: An exploratory qualitative study, involving 30 in-depth interviews, was conducted between July 2022 and February 2023. Participants included a purposive sample of key stakeholders at different levels of the health system (macro: Ministry of Health and Medical Education; meso: universities of medical sciences and health services; and micro: hospitals) with sufficient knowledge, direct experience, and/or collaboration in the implementation of the studied interventions. Interviews were transcribed verbatim and coded using directed qualitative content analysis (CFIR constructs) in MAXQDA 18. Results: The identified challenges were: (1) individual level (childbirth preparation classes: e.g., adaptability, design quality and packaging, cosmopolitanism; presence of birth companions: e.g., patient needs and resources, structural characteristics, culture); (2) healthcare provider level (integrating respectful maternity care into in-service training: e.g., relative priority, access to knowledge and information, reflecting and evaluating); (3) hospital level (evaluating the performance of maternity healthcare providers: e.g., executing, external policies and incentives); and (4) national health system level (implementation of pain relief during childbirth guidelines: e.g., networks and communications, patient needs and resources, executing, reflecting and evaluating). Conclusions: This study provides a clear understanding of the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth and highlights potential implications for policy makers and practitioners of maternal health programs. We encourage them to take the lessons learned from this study and revise their current programs and policies regarding the quality of maternity care by focusing on the identified challenges. Plain English summary: Evidence suggests that mistreatment during childbirth is a growing concern worldwide, especially in developing countries, such as Iran. In this qualitative study, through 30 in-depth interviews with key stakeholders at different levels of the health system (macro: Ministry of Health and Medical Education; meso: universities of medical sciences and health services; and micro: hospitals), we identified the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth using the Consolidated Framework for Implementation Research (CFIR). The data were analyzed using directed content analysis and a deductive approach in MAXQDA 18 software. The identified challenges were: (1) individual level (childbirth preparation classes: e.g., adaptability; presence of birth companions: e.g., patient needs and resources); (2) healthcare provider level (integrating respectful maternity care into in-service training: e.g., relative priority); (3) hospital level (evaluating the performance of maternity healthcare providers: e.g., executing, external policies and incentives); and (4) national health system level (implementation of pain relief childbirth guidelines: e.g., networks and communications). This study provides a clear understanding of the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth; and highlights potential implications for policy makers and practitioners of maternal health programs. [ABSTRACT FROM AUTHOR]

Background: No systematic review has explored the causes of and factors associated with maternal mortality in the context of Iran. This study reviewed determinants and causes of maternal mortalities during pregnancy, delivery and the puerperium using the International Classification of Diseases-Maternal Mortality (ICD-MM), introduced by the World Health Organization. Methods: A systematic electronic search of all the studies that identified causes and/or determinants of maternal deaths in any part of Iran or in the whole country were included, without any restriction of time or language of studies. To identify the studies to include in this study, a combination of hand searching and bibliographies was also conducted. These sources and citations yielded a total of 653 articles; nevertheless, only 29 articles met the inclusion criteria, hence, required data were extracted, summarized, and grouped together from these papers and are reported in the tables. Results: Amongst the 29 studies published between 2003 and 2017 in Iran, 24 studies were cross-sectional. Overall, 4633 deaths were reviewed, and 2655 (58%) of the cases included the data on the causes of death generally. According to the ICD-MM, a total of 69.9, 20.6, and 5.2% of the mortalities were due to direct, indirect and unspecified causes respectively and 4.3% of the causes were not clear in several studies. The leading direct and indirect causes of death were identified as hemorrhage (30.7%) and hypertensive disorders (17.1%) and circulatory system diseases (8.1%) respectively. Several factors including gravidity, type of delivery, socio-economic status of mothers, locations of birth, death and maternity care venues were found in the original studies as the most important determinant of maternal mortalities in Iran. Conclusions: This study, provided an updated summary of evidences on the causes and determinants of maternal death in Iran, which is critically important for the development of interventions and reduction of the burden of maternal mortality and morbidities. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to describe a quality improvement (QI) intervention in primary health facilities providing childbirth care in rural Southern Tanzania. Design/methodology/approach A QI collaborative model involving district managers and health facility staff was piloted for 6 months in 4 health facilities in Mtwara Rural district and implemented for 18 months in 23 primary health facilities in Ruangwa district. The model brings together healthcare providers from different health facilities in interactive workshops by: applying QI methods to generate and test change ideas in their own facilities; using local data to monitor improvement and decision making; and health facility supervision visits by project and district mentors. The topics for improving childbirth were deliveries and partographs. Findings Median monthly deliveries increased in 4 months from 38 (IQR 37-40) to 65 (IQR 53-71) in Mtwara Rural district, and in 17 months in Ruangwa district from 110 (IQR 103-125) to 161 (IQR 148-174). In Ruangwa health facilities, the women for whom partographs were used to monitor labour progress increased from 10 to 57 per cent in 17 months. Research limitations/implications The time for QI innovation, testing and implementation phases was limited, and the study only looked at trends. The outcomes were limited to process rather than health outcome measures. Originality/value Healthcare providers became confident in the QI method through engagement, generating and testing their own change ideas, and observing improvements. The findings suggest that implementing a QI initiative is feasible in rural, low-income settings. [ABSTRACT FROM AUTHOR]

Despite its reduction over the last decade, the maternal mortality rate in Uganda remains high, due to in part a lack of access to maternal health care. In an effort to increase access to care, a quasi-experimental trial using vouchers was implemented in Eastern Uganda between 2009 and 2011. Findings from the trial reported a dramatic increase in pregnant women's access to institutional delivery. Sustainability of such interventions, however, is an important challenge. While such interventions are able to successfully address immediate access barriers, such as lack of financial resources and transportation, they are reliant on external resources to sustain them and are not designed to address the underlying causes contributing to women's lack of access, including those related to gender. In an effort to examine ways to sustain the intervention beyond external financial resources, project implementers conducted a follow-up qualitative study to explore the root causes of women's lack of maternal health care access and utilization. Based on emergent findings, a gender analysis of the data was conducted to identify key gender dynamics affecting maternal health and maternal health care. This paper reports the key gender dynamics identified during the analysis, by detailing how gender power relations affect maternal health care access and utilization in relation to: access to resources; division of labour, including women's workload during and after pregnancy and lack of male involvement at health facilities; social norms, including perceptions of women's attitudes and behaviour during pregnancy, men's attitudes towards fatherhood, attitudes towards domestic violence, and health worker attitudes and behaviour; and decision-making. It concludes by discussing the need for integrating gender into maternal health care interventions if they are to address the root causes of barriers to maternal health access and utilization and improve access to and use of maternal health care in the long term. [ABSTRACT FROM AUTHOR]

Background: QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania.Methods: This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider's perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios.Results: Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes.Conclusions: Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system.Trial Registration: Registered clinical trial at www.clinicaltrials.gov ( NCT01409824 ). Registered May 2009. [ABSTRACT FROM AUTHOR]

Internally displaced women are underserved by health schemes and policies, even as they may face greater risk of violence and unplanned pregnancies, among other burdens. There are an estimated 450,000 internally displaced persons in India, but they are not formally recognised as a group. Displacement has been a common feature in India's northeast region. This paper examines reproductive and maternal health (RMH) care-seeking among Bru displaced women in India. The study employed qualitative methodology: four focus group discussions (FGDs) were held with 49 displaced Bru women aged 18–45 between June and July 2018; three follow-up interviews with FGD participants and five in-depth interviews with community health workers (Accredited Social Health Activists – ASHAs) in camps for Bru displaced people in the Indian state of Tripura. All interviewees gave written or verbal informed consent; discussions were conducted in the local dialect, recorded, and transcribed. Data were indexed deductively from a dataset coded using grounded approaches. Most women were unaware of many of the RMH services provided by health facilities; very few accessed such care. ASHAs had helped increase institutional deliveries over the years. Women were aware of temporary contraceptive methods as well as medical abortion, but lacked awareness of the full range of contraceptive options. Challenges in accessing RMH services included distance of facilities from camps, and multiple costs (for transport, medicines, and informal payments to facility staff). The study highlighted a need for comprehensive intervention to improve RMH knowledge, attitudes, and practices among displaced women and to reduce access barriers. [ABSTRACT FROM AUTHOR]

Background: High maternal mortality rates still today remain a significant public health concern in South Asian countries. The majority of maternal deaths occur during pregnancy, and these deaths may typically be avoided by ensuring that women have access to reliable maternity care such as antenatal care (ANC) and facility delivery. The objectives of this research were to assess socioeconomic disparities in the utilization of health care services by mothers and to determine the factors influencing this utilization among women aged 15 to 49 in five South Asian countries. Methods: For this study, nationally representative data from the Demographic and Health Survey (DHS) were analyzed. This research included a total of 262,531 women between the ages of 15 and 49. To determine the likely causes of maternal health care utilization, simple bivariate statistics and binary logistic regression were applied, and decomposition analysis and the concentration curve were used to quantify disparity (Lorenz curve). Results: ANC and institutional delivery were both prevalent in 59.27% and 86.52% of cases, respectively. Among the five nations, Maldives has the greatest ANC (96.83%) and institutional delivery (99.39%), while Bangladesh has the lowest ANC (47.01%) and institutional delivery (49.81%). Women's and husbands' education, household wealth status, BMI, and urban residents are the most important factors influencing maternal health service utilization, whereas higher education level, affluent wealth quintiles, and place of residence are the major contributors to socioeconomic inequalities in access to maternal health care that favor the wealthy. Conclusion: Maternal health care services must be utilized properly in order to promote optimal health and prevent maternal mortality. Several socioeconomic and sociodemographic variables of the individual population, as well as policy issues, all have an impact on maternal mortality. This research recommends for concerted action to enhance how successfully women use maternity care services. [ABSTRACT FROM AUTHOR]

Introduction: The utilization of the maternal and newborn health services has increased, but mere increase in utilization of services does not ensure that quality services are being provided. The aim of the study was to assess the quality of maternal and newborn services and their impact on maternal and neonatal outcome at a primary health center of Western Rajasthan in India. Materials and Methods: An exploratory study was undertaken at a conveniently selected primary health center providing 24-hour delivery services. Information regarding the availability of services was collected from the available medical officer in charge using an Indian Public Health Standards (IPHS) Proforma. Assessment of quality of services was performed by using WHO standards of care based on assessment of quality of maternal and newborn services tool by the perspectives of the provider as well as the mothers utilizing the services. 36 mothers who delivered at the selected PHC were interviewed. Results: All basic obstetric care services were available at the selected primary health centers including the 24 × 7 delivery services. The assessment of quality by provider's perspective revealed that the system of referral could be improved. Quality of maternal and newborn services assessment revealed that the practice of skin to skin contact between the mother and newborn just after the delivery was not being followed and few (30%) mothers informed that they could not start breastfeeding within 1 hours of birth. 47% mothers reported that they were not given the freedom to ask questions during delivery. Maternal and newborn outcome revealed that all mothers (100%) had a normal vaginal delivery, and 22% mothers had an episiotomy. All (100%) newborns cried immediately after birth, and average birthweight was 2.89 kg. Conclusion: PHCs are the first point of contact of mothers and healthcare delivery system. Assessment of quality of services is an important tool for quality assurance. Inclusion of evidence-based practices like skin-to-skin contact and early initiation of breastfeeding is important to improve the maternal and newborn well-being. [ABSTRACT FROM AUTHOR]

This updated edition of Care Practice Paper #2 presents the evidence for the benefits of allowing freedom of movement in labor. Physiologic and anatomical principles that support the benefits of movement are explained. The authors review common obstacles to movement in labor, including the routine use of interventions that inhibit women's ability to walk or change position. Women are encouraged to plan to be active in labor and to select care providers and birth settings that provide the full range of options for using movement in labor. [ABSTRACT FROM AUTHOR]

Copyright of African Journal of Reproductive Health is the property of Women's Health & Action Research Centre and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The concept of the ‘risk society’ has focused on growing uncertainties about the benefits of scientific innovation and the reliability of professional judgement. Paradoxically, this has gone hand in hand with reductions in the actual risk associated with many activities and is often accompanied by demands for a technological fix. These contradictory impulses are especially evident in maternity care. While maternal and infant mortality rates have fallen, risk conscious patients are increasingly concerned about the possibility of professional mistake or malpractice. As a result, further categories of risk are created for organizations and professionals, particularly in relation to expensive litigation. Against this background, the paper reports on an ethnographic study of two delivery suites in which a computerized decision support system will be implemented. In the paper, we attempt to highlight some of the intricacies of work processes in delivery suites, specifically involving decision-making, risk, uncertainty, professional autonomy and medical knowledge. Our findings suggest a range of complexities that may considerably complicate the implementation of the computerized decision support system when it finally emerges and becomes embedded in delivery suites. [ABSTRACT FROM AUTHOR]

Background: Data cleaning is an important quality assurance in data linkage research studies. This paper presents the data cleaning and preparation process for a large-scale cross-jurisdictional Australian study (the Smoking MUMS Study) to evaluate the utilisation and safety of smoking cessation pharmacotherapies during pregnancy.Methods: Perinatal records for all deliveries (2003-2012) in the States of New South Wales (NSW) and Western Australia were linked to State-based data collections including hospital separation, emergency department and death data (mothers and babies) and congenital defect notifications (babies in NSW) by State-based data linkage units. A national data linkage unit linked pharmaceutical dispensing data for the mothers. All linkages were probabilistic. Twenty two steps assessed the uniqueness of records and consistency of items within and across data sources, resolved discrepancies in the linkages between units, and identified women having records in both States.Results: State-based linkages yielded a cohort of 783,471 mothers and 1,232,440 babies. Likely false positive links relating to 3703 mothers were identified. Corrections of baby's date of birth and age, and parity were made for 43,578 records while 1996 records were flagged as duplicates. Checks for the uniqueness of the matches between State and national linkages detected 3404 ID clusters, suggestive of missed links in the State linkages, and identified 1986 women who had records in both States.Conclusions: Analysis of content data can identify inaccurate links that cannot be detected by data linkage units that have access to personal identifiers only. Perinatal researchers are encouraged to adopt the methods presented to ensure quality and consistency among studies using linked administrative data. [ABSTRACT FROM AUTHOR]

Background: Efforts to take forward universal health coverage require innovative approaches in fragile settings, which experience particularly acute human resource shortages and poor health indicators. For maternal and newborn health, it is important to innovate with new partnerships and roles for Traditional Birth Attendants (TBAs) to promote maternal health. We explore perspectives on programmes in Somaliland and Sierra Leone which link TBAs to health centres as part of a pathway to maternal health care. Our study aims to understand the perceptions of communities, stakeholder and TBAs themselves who have been trained in new roles to generate insights on strategies to engage with TBAs and to promote skilled birth attendance in fragile affected settings.Methods: A qualitative study was carried out in two chiefdoms in Bombali district in Sierra Leone and the Maroodi Jeex region of Somaliland. Purposively sampled participants consisted of key players from the Ministries of Health, programme implementers, trained TBAs and women who benefitted from the services of trained TBAs. Data was collected through key informants and in-depth interviews and focus group discussions. Data was transcribed, translated and analyzed using the framework approach. For the purposes of this paper, a comparative analysis was undertaken reviewing similarities and differences across the two different contexts.Results: Analysis of multiple viewpoints reveal that with appropriate training and support it is possible to change TBAs practices so they support pregnant women in new ways (support and referral rather than delivery). Participants perceived that trained TBAs can utilize their embedded and trusted community relationships to interact effectively with their communities, help overcome barriers to acceptability, utilization and contribute to effective demand for maternal and newborn services and ultimately enhance utilization of skilled birth attendants. Trained TBAs appreciated cordial relationship at the health centres and feeling as part of the health system. Key challenges that emerged included the distance women needed to travel to reach health centers, appropriate remuneration of trained TBAs and strategies to sustain their work.Conclusion: Our findings highlight the possible gains of the new roles and approaches for trained TBAs through further integrating them into the formal health system. Their potential is arguably critically important in promoting universal health coverage in fragile and conflict affected states (FCAS) where human resources are additionally constrained and maternal and newborn health care needs particularly acute. [ABSTRACT FROM AUTHOR]

Purpose: Women of Haitian nationality comprise a sizeable proportion of all women seeking labor and delivery services in a public hospital in Dominican Republic (DR), along the central border of Haiti. The purpose of this paper is to better understand and address the needs of Haitian women receiving labor and delivery services in this border region. Design/methodology/approach: The authors conducted a mixed-methods study to identify personal motivations, demographic characteristics, and migration history of women seeking labor and delivery services at a public hospital. Findings: The majority of women (83 percent) were born in Haiti but spoke Spanish (74 percent) and were long-term residents of the DR (mean 7.8 years). While many women reported they felt they had a positive experience delivering at the public hospital, some described feeling unwelcome or resented. Research limitations/implications: The study sample was small and from one hospital. Future studies could explore the differences in experiences among Haitian women who are long-term residents of the DR and those whose presence is more transient. Practical implications: Women residing on both sides of the border would likely benefit from coordinated efforts by the Haitian and DR Ministries of Health to strengthen referral services to and from either country. Social implications: Hospital staff and services in the DR should consider the unique needs of this population, which makes critical contributions to workforce and culture in the DR. Originality/value: This study is the first to assess labor and delivery service seeking practices and experiences within this population. [ABSTRACT FROM AUTHOR]

Background: A community health programme in Narok County in Kenya aimed to improve skilled birth assistance during childbirth through two demand side interventions. First, traditional birth attendants (TBAs) were co-opted into using their influence to promote use of skilled birth attendants (SBAs) at health facilities during delivery, and to accompany pregnant women to health facilities in return for a Ksh500 (Approximately USD5 as of August 2016) cash incentive for each pregnant mother they accompanied. Secondly, a free Motherpack consisting of a range of baby care items was given to each mother after delivering at a health facility. This paper estimates the impact of these two interventions on trends of facility deliveries over a 36-month period here.Methods: Dependency or inferred causality was estimated between reorientation of TBAs and provision of Motherpacks with changes in facility delivery numbers. The outcome variable consists of monthly facility delivery data from 28 health facilities starting from January 2013 to December 2015 obtained from the District Health Information Systems 2 (DHIS2). Data were collected on the 13th, 14th or 15th of each month, resulting in a total of 35 collections, over 35 months. The intervention data consisted of the starting month for each of the two interventions at each of the 28 facilities. A negative binomial generalized linear model framework is applied to model the relationship as all variables were measured as count data and were overdispersed. All analyses were conducted using R software.Findings: During the 35 months considered, a total of 9095 health facility deliveries took place, a total of 408 TBAs were reached, and 2181 Motherpacks were distributed. The reorientation of TBAs was significant (p = 0.009), as was the provision of Motherpacks (p = .0001). The number of months that passed since the start of the intervention was also found to be significant (p = 0.033). The introduction of Motherpacks had the greatest effect on the outcome (0.2), followed by TBA intervention (0.15). Months since study start had a much lower effect (0.05).Conclusion: Collaborating with TBAs and offering basic commodities important to mothers and babies (Motherpacks) immediately after delivery at health facilities, can improve the uptake of health facility delivery services in poor rural communities that maintain a strong bias for TBA assisted home delivery. [ABSTRACT FROM AUTHOR]

Background: The evaluation of payment for performance (P4P) programmes has focused mainly on understanding contributions to health service coverage, without unpacking causal mechanisms. The overall aim of the paper is to test the causal pathways through which P4P schemes may (or may not) influence maternal care outcomes.Methods: We used data from an evaluation of a P4P programme in Tanzania. Data were collected from a sample of 3000 women who delivered in the 12 months prior to interview and 200 health workers at 150 health facilities from seven intervention and four comparison districts in Tanzania in January 2012 and in February 2013. We applied causal mediation analysis using a linear structural equation model to identify direct and indirect effects of P4P on institutional delivery rates and on the uptake of two doses of an antimalarial drug during pregnancy. We first ran a series of linear difference-in-difference regression models to test the effect of P4P on potential mediators, which we then included in a linear difference-in-difference model evaluating the impact of P4P on the outcome. We tested the robustness of our results to unmeasured confounding using semi-parametric methods.Results: P4P reduced the probability of women paying for delivery care (-4.5 percentage points) which mediates the total effect of P4P on institutional deliveries (by 48%) and on deliveries in a public health facility (by 78%). P4P reduced the stock-out rate for some essential drugs, specifically oxytocin (-36 percentage points), which mediated the total effect of P4P on institutional deliveries (by 22%) and deliveries in a public health facility (by 30%). P4P increased kindness at delivery (5 percentage points), which mediated the effect of P4P on institutional deliveries (by 48%) and on deliveries in a public health facility (by 49%). P4P increased the likelihood of supervision visits taking place within the last 90 days (18 percentage points), which mediated 15% of the total P4P effect on the uptake of two antimalarial doses during antenatal care (IPT2). Kindness during deliveries and the probability of paying out of pocket for delivery care were the mediators most robust to unmeasured confounding.Conclusions: The effect of P4P on institutional deliveries is mediated by financing and human resources factors, while uptake of antimalarials in pregnancy is mediated by governance factors. Further research is required to explore additional and more complex causal pathways. [ABSTRACT FROM AUTHOR]

Background: Facility-based births have been promoted as the main strategy to reduce maternal and neonatal death risks at global scale. To improve birth outcomes, it is critical that health facilities provide quality care. Using a framework to assess quality of care, this paper examines health workers' perceptions about access to facility birth; the effectiveness of the care provided and obstacles to quality birth care in a rural area of Burkina Faso. Methods: A qualitative study was conducted in 2011 in the Banfora Region, Burkina Faso. Participant observations were carried out in four different health centres for a period of three months; more than 30 deliveries were observed. In-depth interviews were conducted with 12 frontline health workers providing birth care and with two staff of the local health district management team. Interview transcripts and field notes were analysed thematically. Results: Health workers in this rural area of Burkina Faso provided birth care in a context of limited financial resources, insufficient personnel and poorly equipped facilities; the quality of the birth care provided was severely compromised. Health workers tended to place the responsibility for poor quality of care on infrastructural limitations and patient behaviour, while our observational data also identified missed opportunities that would not demand additional resources throughout the process of care like early initiation of breastfeeding and skin-to-skin contact after birth. Health workers felt disempowered, having limited abilities to prevent and treat birth complications, and resorted to alternative and potentially harmful strategies. Conclusions: We found poor quality of care at birth, missed opportunities, and health worker disempowerment in rural health facilities of Banfora, Burkina Faso. There is an urgent need to provide health workers with the necessary tools to prevent and handle birth complications, and to ensure that existing low cost life-saving interventions in maternal and new-born health are appropriately used and integrated into the daily routines in maternity wards at all levels. [ABSTRACT FROM AUTHOR]

Background: Auxiliary Midwives (AMWs) are community health volunteers supporting the work of midwives, especially maternal and child health services in hard to-reach areas in Myanmar. This paper assessed the contributions of AMW to maternal and child health services, factors influencing their productivity and their willingness to serve the community.Method: The study applied quantitative cross-sectional survey using census method. Total of 1,185 AMWs belonging to three batches: trained prior to 2000, between 2000 and 2011, and in 2012, from 21 townships of 17 states and regions in Myanmar participated in the study. Multiple logit regression was used to examine the impact of age, marital status, education, domicile, recruitment pattern and 'batch of training', on AMW's confidence level in providing care, and their intention to serve the community more than 5 years.Results: All AMWs were able to provide essential maternal and child health services including antenatal care, normal delivery and post-natal care. They could identify and refer high-risk pregnancies to larger health facilities for proper management. On average, 9 deliveries, 11 antenatal and 9 postnatal cases were performed by an AMW during the six months prior to this study. AMWs had a comparative advantage for longer service in hard-to-reach villages where they lived, spoke the same dialect as the locals, understood the socio-cultural dimensions, and were well accepted by the community. Despite these contributions, 90 % of the respondents expressed receiving no adequate supervision, refresher training, replenishment of the AMW kits and transportation cost. AMWs in the elder age group are significantly more confident in taking care of the patients than those in the younger groups. Over 90 % of the respondents intended to stay more than five years in the community. The confidence in catering services appeared to have significant association with a longer period of stay in AMW jobs as evidenced by the odds ratio of 3.5, compared to those reporting unconfident.Conclusions: Comprehensive support system and national policy are needed to sustain and strengthen the contributions of AMWs, in sharing the workload of midwives, particularly in hard-to-reach areas of Myanmar. [ABSTRACT FROM AUTHOR]

Background: Kenya's high maternal mortality ratio can be partly explained by the low proportion of women delivering in health facilities attended by skilled birth attendants (SBAs). Many women continue to give birth at home attended by family members or traditional birth attendants (TBAs). This is particularly true for pastoralist women in Laikipia and Samburu counties, Kenya. This paper investigates the socio-demographic factors and cultural beliefs and practices that influence place of delivery for these pastoralist women.Methods: Qualitative data were collected in five group ranches in Laikipia County and three group ranches in Samburu County. Fifteen in-depth interviews were conducted: seven with SBAs and eight with key informants. Nineteen focus group discussions (FGDs) were conducted: four with TBAs; three with community health workers (CHWs); ten with women who had delivered in the past two years; and two with husbands of women who had delivered in the past two years. Topics discussed included reasons for homebirths, access and referrals to health facilities, and strengths and challenges of TBAs and SBAs. The data were translated, transcribed and inductively and deductively thematically analysed both manually and using NVivo.Results: Socio-demographic characteristics and cultural practices and beliefs influence pastoralist women's place of delivery in Laikipia and Samburu counties, Kenya. Pastoralist women continue to deliver at home due to a range of factors including: distance, poor roads, and the difficulty of obtaining and paying for transport; the perception that the treatment and care offered at health facilities is disrespectful and unfriendly; lack of education and awareness regarding the risks of delivering at home; and local cultural values related to women and birthing.Conclusions: Understanding factors influencing the location of delivery helps to explain why many pastoralist women continue to deliver at home despite health services becoming more accessible. This information can be used to inform policy and program development aimed at increasing the proportion of facility-based deliveries in challenging settings. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 pandemic led to some of the most drastic changes in clinical care delivery ever seen in the United States. Almost overnight, providers of prenatal care adopted virtual visits and reduced visit schedules. These changes stood in stark contrast to the 12 to 14 in-person prenatal visit schedule that had been previously recommended for almost a century. As maternity care providers consider what prenatal care delivery changes we should maintain following the acute pandemic, we may gain insight from understanding the evolution of prenatal care delivery guidelines. In this paper, we start by sketching out the relatively unstructured beginnings of prenatal care in the 19th century. Most medical care fell within the domain of laypeople, and childbirth was a central feature of female domestic culture. We explore how early discoveries about "toxemia" created the groundwork for future prenatal care interventions, including screening of urine and blood pressure-which in turn created a need for routine prenatal care visits. We then discuss the organization of the medical profession, including the field of obstetrics and gynecology. In the early 20th century, new data increasingly revealed high rates of both infant and maternal mortalities, leading to a greater emphasis on prenatal care. These discoveries culminated in the first codification of a prenatal visit schedule in 1930 by the Children's Bureau. Surprisingly, this schedule remained essentially unchanged for almost a century. Through the founding of the American College of Obstetricians and Gynecologists, significant technological advancements in laboratory testing and ultrasonography, and calls of the National Institutes of Health Task Force for changes in prenatal care delivery in 1989, prenatal care recommendations continued to be the same as they had been in 1930-monthly visits until 28 weeks' gestation, bimonthly visits until 36 weeks' gestation, and weekly visits until delivery. However, coronavirus disease 2019 forced us to change, to reconsider both the need for in-person visits and frequency of visits. Currently, as we transition from the acute pandemic, we should consider how to use what we have learned in this unprecedented time to shape future prenatal care. Lessons from a century of prenatal care provide valuable insights to inform the next generation of prenatal care delivery. [ABSTRACT FROM AUTHOR]

The current study was designed to further knowledge of the immediate, short and long-term effects of Caesarean delivery for both the woman and her baby. A study group of 50 low-risk primigravidae of normal stature delivered by emergency Caesarean section were compared with a closely matched control group of 50 primigravidae delivered vaginally. The study generated a large amount of both quantitative and qualitative data. From the analysis of the comments made by the women in both the study and control groups at the time of both the hospital and home interviews, it was apparent that there were a number of deficiencies in the care received. This paper examines some of the issues related to the delivery of midwifery care round the themes of lack of realistic preparation for labour, delivery and parenthood; lack of support and conflicting advice from midwives, especially in the postnatal wards; failure of communication between women and staff, and it was apparent that this occurred in all areas from antenatal care to the postnatal wards. [ABSTRACT FROM AUTHOR]

Introduction: The utilization of facility delivery is crucial to achieve sustainable development goals by reducing maternal and neonatal deaths. This study aimed to compare the distributions and determinants of childbirth in health facilities in urban and rural regions of Bangladesh. Methods: Cross-sectional data from the 2017-2018 Bangladesh Demographic and Health Survey were analyzed. Multilevel logistic regression was applied. Results: A total of 4 751 women were included in the analyses. Only 50% of childbirths took place in health facilities, 63.4% and 44.6% in urban and rural regions, respectively. Overall, the odds of the association between facility delivery and the studied factors were similar. Multiparous women had significantly lower odds of facility delivery in both rural (adjusted odds ratio [AOR] = 0.3, 95% confidence interval [CI]: 0.2 to 0.5) and urban (AOR = 0.2, 95% CI: 0.1 to 0.5) regions. In both regions, women with higher education levels, highly educated husbands, antenatal care (ANC), and higher wealth indexes had significantly higher odds of facility delivery. Conclusion: Several common associated factors were identified. However, differences were observed regarding distributions of these factors. The differences in facility delivery utilization could result from lower ANC utilization, socioeconomic status, and transportation facilities in rural regions than urban regions; therefore, improving these conditions could increase facility delivery in these regions. [ABSTRACT FROM AUTHOR]

Background: Pregnant women in urban poor societies are vulnerable groups. Due to low financial capacity, there are obstacles to accessing delivery in an institution for poor women in urban areas. The study analyses factors associated with the delivery place among pregnant women in urban poor society in Indonesia. Materials and Methods: The study analyzed secondary data from the 2017 Indonesian Demographic and Health Survey (IDHS). A total of 1,562 samples were childbearing-age women (15–49 years) who gave birth in an urban poor society in Indonesia in the last 5 years. The study examined some variables, such as delivery place, age, education, employment, marital status, parity, insurance, knowledge of pregnancy danger, antenatal care (ANC), the autonomy of health, and family finance autonomy. The study employed binary logistic regression in the final stage. Results: The results show that age is associated with the place of delivery. The higher the education, the higher the possibility for delivery in an institution. Being employed and having partners are protective factors for women in institution delivery. The likelihood of giving birth in a medical facility decreases as more children are born alive. In addition, having health insurance, thorough ANC visits, knowledge of pregnancy danger symptoms, and health autonomy are protective factors for pregnant women having deliveries in medical facilities. On the contrary, pregnant women who rely solely on family financing have a higher chance of delivering in a medical facility. Conclusion: The study concluded that 10 variables were associated with pregnant women's delivery in Indonesia's urban poor society: age, education, employment, marital, parity, insurance, pregnancy danger knowledge, ANC, health autonomy, and family finance autonomy. [ABSTRACT FROM AUTHOR]