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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]

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]

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]

Large scale investment in the National Rural Health Mission is expected to increase the utilization and reduce the cost of maternal care in public health centres in India. The objective of this paper is to examine recent trends in the utilization and cost of hospital based delivery care in the Empowered Action Group (EAG) states of India. The unit data from the District Level Household Survey 3, 2007-2008 is used in the analyses. The coverage and the cost of hospital based delivery at constant price is analyzed for five consecutive years preceding the survey. Descriptive and multivariate analyses are used to understand the socio-economic differentials in cost and utilization of delivery care. During 2004-2008, the utilization of delivery care from public health centres has increased in all the eight EAG states. Adjusting for inflation, the household cost of delivery care has declined for the poor, less educated and in public health centres in the EAG states. The cost of delivery care in private health centres has not shown any significant changes across the states. Results of the multivariate analyses suggest that time, state, place of residence, economic status; educational attainment and delivery characteristics of mother are significant predictors of hospital based delivery care in India. The study demonstrates the utility of public spending on health care and provides a thrust to the ongoing debate on universal health coverage in India. [ABSTRACT FROM AUTHOR]

Introduction: Community health worker (CHW) interventions have been utilized to address barriers that prevent pregnant women from delivering in health facilities in low- and middle-income countries (LMICs). The objective of this research was to assess the programmatic factors that increase the likelihood of health facility delivery within a large digital health-supported CHW program in Zanzibar, Tanzania. Methods: This study included 36,693 women who were enrolled in the Safer Deliveries program with a live birth between January 1, 2017 and July 31, 2019. We assessed whether long-term enrollment, recency of CHW pregnancy visit prior to delivery, and number of routine home pregnancy visits were associated with an increased likelihood of health facility delivery compared to home delivery. We used Chi-squared tests to assess bivariate relationships and performed logistic regression analyses to assess the association between each programmatic variable and health facility delivery, adjusting for relevant confounders. Results: We found that long-term enrollment was significantly associated with increased likelihood of health facility delivery, with the strongest relationship among women with a previous home delivery (OR = 1.4, 95%CI [1.0,1.7]). Among first-time mothers, two or more pregnancy visits by a CHW was positively associated with health facility delivery (OR = 1.8, 95%CI [1.2, 2.7]). Recent pregnancy visit by a CHW was positively associated with health facility delivery, but was not significant at the α = 0.05 level. Discussion: In this program, we found evidence that at least two routine home pregnancy visits, longer length of enrollment in the program, and recency of home visit to the delivery date were strategies to increase health facility delivery rates among enrolled mothers. Maternal and child health programs should undertake similar evaluations to improve program delivery. [ABSTRACT FROM AUTHOR]

Purpose: With the aim of characterizing the gastrointestinal (GI) microbiota and contextually determine how different prenatal, perinatal, and postnatal factors affected its composition in early childhood, infants were enrolled in a longitudinal-prospective study named "A.MA.MI." (Alimentazione MAmma e bambino nei primi MIlle giorni; NCT04122612, October 2019). Methods: Forty-five fecal samples were collected at 12 months of infants' age, identified as the 3rd follow-up (T3). The evaluated variables were pre-gestational weight and weight gain during pregnancy, delivery mode, feeding, timing of weaning, and presence/absence of older siblings. Fecal alpha and beta-diversities were analyzed. Noteworthy, to determine the impact of the influencing factors, multivariate analyses were conducted. Results: At T3, all prenatal and perinatal variables did not result to be significant whereas, among the postnatal variables, type of milk-feeding and weaning showed the greatest contribution in shaping the microbiota. Although aged 1 year, infants exclusively breastfed until 6 months were mainly colonized by Lactobacillaceae and Enterobacteriaceae. Differently, Bacteroidaceae characterized the microbiota of infants that were never breastfed in an exclusive way. Moreover, although an early introduction of solid foods determined higher values of Faith's PD, high abundances of Ruminococcaceae and Faecalibacterium mainly associated with infants weaned after the 4th month of age. Conclusion: The microbial colonization during the first year of life is likely affected by a simultaneous effect of multiple variables playing a significant role at different times. Therefore, these data contribute to add evidence concerning the complex multifactorial interaction between GI microbiota and various stimuli affecting infants during the early stages of life. [ABSTRACT FROM AUTHOR]

Background and Objectives: Concern about mistreatment and abuse during childbirth care is growing, and evidence suggests that many women worldwide experience mistreatment during childbirth. The study aimed to assess the prevalence of abused women during labor, types of abuse, rate of satisfaction with birth care among abused women, and associated sociodemographic and obstetric factors with mistreatment and abuse in the delivery room. Methods: A cross-sectional study was conducted with data from 1196 women who experienced a vaginal delivery at least once within the past year in a public health setting in Erbil city, Kurdistan Region, Iraq. The author developed a questionnaire after a comprehensive review of the literature. Data were collected through direct interviews with the sample. Frequency, percentage, and chi-square tests were used for data analysis. Results: About half of the study sample (49.9%) mentioned that they experienced mistreatment and/or abuse during labor and delivery. The most experienced type of mistreatment and abuse were as follows: lack of privacy (84.6%), patient-blaming (58.5), purposeful neglect (51.6%), abandonment of care, and detention in facilities (43.9%), Non-consented care (42.9%). The rate of physical and verbal abuse was 24.3% and 29.8%, respectively. There was a highly significant association between parity and general satisfaction with birth care with experiencing abuse (P = 0.006, P ≤ 0.001). Conclusions: Mistreatment and abuse of women during childbirth are present among Kurdish women, leading to generally non-satisfaction with birth care, and exploring the reasons behind why health care providers mistreatment and abuse women during childbirth is critical. [ABSTRACT FROM AUTHOR]

Introduction: Clinical experiences expose learners to the patient perspective, which can have a lasting impact on students' professional identity. However, in busy clinical settings where opportunities for reflection may be limited, listening to patients' stories is often neglected. We used a reflection assignment to augment a new maternal-child health integrated curriculum. Methods: Medical students completed a brief assignment from their session in the neonatal intensive care unit (NICU), which included reflective writing, between fall 2016 and summer 2017. The Depth of Reflection rubric was used to score reflections on a scale: "Knowledge and Comprehension" (Level I), "Analysis" (Level II), and "Synthesis and Evaluation" (Level III). A constant comparison method based on grounded theory elicited prenatal and postnatal themes from medical students' reflective writing. Results: All students completed narratives (n = 166); 70% (n = 116) achieved a Depth of Reflection of Level II or III. Six overarching themes emerged: (1) Conception, Pregnancy, and Delivery Experiences; (2) Positive Support Structures; (3) Barriers and Stressors to Care; (4) Future Plans; (5) Unexpected Complications; and (6) Student Career and Professional Considerations. Discussion: Reflections from a novel and brief integrated maternal-child health experience demonstrated high levels on the Depth of Reflection scale. This experience exposed students to core themes central to a family's pregnancy and perinatal experience. Professional identity formation also emerged as a theme. Reflective writing assignments in a busy NICU can facilitate exploration of medical students' knowledge of maternal-child health patient experiences. [ABSTRACT FROM AUTHOR]

Depression affects 1 in 7 women during the perinatal period. Women with vitamin D deficiency may be at an increased risk for depression. This study investigated the relationship between maternal and cord blood 25-hydroxyvitamin D (25OHD) and maternal depressive symptoms over the perinatal period. Study objectives were to examine variations and relationships between maternal and cord blood vitamin D levels and maternal depressive symptoms over the perinatal period. At a large medical center in southern California, pregnant women (N = 126) were recruited for this longitudinal cohort study. Depressive symptoms (Edinburgh Postnatal Depression Screen, EPDS) and vitamin D status (25OHD) were measured at three time points in the perinatal period: time 1 (T1; N = 125) EPDS and 25OHD were collected in early pregnancy; time 2 (T2; N = 96) EPDS was conducted in the third trimester with blood collected at time of delivery; and time 3 (T3; N = 88) was collected postpartum. A significant inverse relationship between vitamin D status and depressive symptoms was observed between 25OHD and EPDS scores at all time points in this sample (T1 = − 0.18, P = 0.024; T2 = − 0.27, P = 0.009; T3 = − 0.22, P = 0.019). This association remained after controlling for confounders. Low cord blood 25OHD levels were inversely associated with higher EPDS scores in the third trimester (r = − 0.22, P = 0.02). Clinicians may want to consider screening women diagnosed with vitamin D deficiency for depression and vice versa. Vitamin D may represent an important biomarker for pregnant and postpartum women diagnosed with depression. Further studies examining underlying mechanisms and supplementation are needed. [ABSTRACT FROM AUTHOR]

HIV-related stigma compromises both HIV prevention and treatment and has recently been described as a barrier to utilization of skilled childbirth services in sub-Saharan Africa. This study uses the 2011 Uganda Demographic Health Survey to estimate the associations between HIV-related stigma, measured both at the individual and community level, and use of facility delivery among women. Consistent with theoretical predictions, higher levels of stigma are associated with reduced likelihood of facility delivery. The negative relationship between stigma and facility delivery is especially pronounced when stigma is measured at the community level, highlighting the importance of understanding the proximate context of HIV-related stigma and its potential effects on behavior. Reducing the stigma of HIV will be critical to achieving the twin goals of reducing overall maternal mortality and preventing mother-to-child HIV transmission. [ABSTRACT FROM AUTHOR]

Unlabelled: Decisions at the limits of viability about initiating care are challenging. We aimed to investigate physicians' preferences on treatment decisions, against the background of the 2010 Dutch guideline offering active care from 24(+0/7) weeks of gestational age (GA). Obstetricians' and neonatologists' opinions were compared. An online survey was conducted amongst all perinatal professionals (n = 205) of the 10 Dutch level III perinatal care centers. Response rate was 60 % (n = 122). Comfort care was mostly recommended below 24(+0/7) weeks and intensive care over 26(+0/7) weeks. The professional views varied most at 24 and 25 weeks, with intensive care recommended but comfort care at parental request optional being the median. There was a wide range in perceived lowest limits of GA for interventions as a caesarian section and a neonatologist present at birth. Obstetricians and neonatologists disagreed on the lowest limit providing chest compressions and administering epinephrine for resuscitation. The main factors restricting active treatment were presence of congenital disorders, "small for gestational age" fetus, and incomplete course of corticosteroids.Conclusion: There was a wide variety in individually preferred treatment decisions, especially when aspects were not covered in the Dutch guideline on perinatal practice in extreme prematurity. Furthermore, obstetricians and neonatologists did not always agree.What Is Known: • Cross-cultural differences exists in the preferred treatment at the limits of viability • In the Netherlands since 2010, intensive care can be offered starting at 24 (+0/7)   weeks gestation What is new: • There was a wide variety in preferred treatment decisions at the limits of viability especially when aspects were not covered in the Dutch national guideline on perinatal practice in extreme prematurity. [ABSTRACT FROM AUTHOR]

Objectives This study aims to explore the association between women's autonomy and skilled attendance during pregnancy and delivery in Nepal. Methods We adopt data from the Nepal Demographic and Health Survey (NDHS, ). We include only married women who gave birth in the 5 years preceding the survey (N = 4148). Women's autonomy was assessed on the basis of four indicators of decision making: healthcare, visiting friends or relatives, household purchases and spending earned money. Each indicator was dichotomized (yes/no) and then summarized into a single variable to measure overall autonomy. Next, we measured health attendance (skilled vs. unskilled) during antenatal and delivery care. The association between women's autonomy and skilled attendance was analysed using a logistic regression model. Results Most women had a medium (40 %) and high (35 %) level of overall autonomy. The proportion of women accessing skilled providers during antenatal and delivery care was 51 and 36 %. Women with autonomy in healthcare, visiting friends or relatives, making household purchases and spending money earned were associated with a higher likelihood of receiving care from skilled providers during antenatal care and delivery. An elevated probability of access to skilled attendance during antenatal (aOR 1.33; 95 % CI 1.10-1.59) and delivery care (aOR 1.38; 95 % CI 1.12-1.70) was reported among women with higher levels of overall autonomy. Conclusion Women's autonomy was significantly associated with the maternal health care utilization by skilled attendants. This study will provide insights for policy makers to develop strategies in improving maternal health. [ABSTRACT FROM AUTHOR]

Based on previous findings showing both better birth outcomes in migrant than in Spanish women and different rates of medical intervention according to mother's origin, we hypothesize that mode of delivery decisions to solve similar problems differ according to ethnic origin. Ethnic differences for maternal characteristics, medical intervention, and mode of delivery were evaluated in 16,589 births from a Maternity Hospital in Madrid (Spain). Multinomial logistic regression analysis was used to evaluate the effect of mother's ethnic origin on the mode of delivery, adjusting for mother's age, parity, gestational age, birth weight, and epidural anesthesia. Compared with the Spanish mothers, the risk of having a Caesarean section is significantly higher in Latin Americans and significantly lower for the Chinese. Both low birth weight and macrosomic deliveries are at higher risk for Caesarean section. The interventionist system characterizing Spain is being extended to all ethnic groups and, at the same time, different medical interventions are applied to similar problems depending on women's ethnic origin. Obstetric interventions might be contributing to the increasing trend of low birth weight and late preterm/early full term deliveries (37-38 weeks) observed in Spain. Behavioral and cultural values of the women and of the health care providers may contribute to systematic differences in labor management and mode of delivery. [ABSTRACT FROM AUTHOR]

The purpose of this qualitative study was to document and explore the maternity health care needs and the barriers to accessing maternity health services from the perspective of immigrant Muslim women living in St. John’s, Canada. A purposive approach was used in recruiting six individuals to participate in in-depth semi-structured interviews. Data were analyzed using a two-step process of content analysis. Three metathemes were identified and compared to previous research on maternity health and the care needs of immigrant women. Women experienced discrimination, insensitivity and lack of knowledge about their religious and cultural practices. Health information was limited or lacked the cultural and religious specificity to meet their needs during pregnancy, labor and delivery, and postpartum phases. There were also significant gaps between existing maternity health services and women’s needs for emotional support, and culturally and linguistically appropriate information. This gap was further complicated by the functional and cultural adjustments associated with immigration. Maternity health care information and practices designed to meet the needs of mainstream Canadian-born women lacked the flexibility to meet the needs of immigrant Muslim women. Recommendations for change directed at decision makers include improving access to culturally and linguistically appropriate maternity and health related information, developing the diversity responsiveness of health care providers and the organizations where they work and establishing social support networks and partnerships with immigrant communities. Changes that address the needs of immigrant Muslim women have the potential to create more inclusive and responsive maternity health services for all Canadian women. [ABSTRACT FROM AUTHOR]

This article focuses on family choices about pregnancy-related care, and the use of childhood immunization in Guatemala. In Guatemala, as in many countries, the public and the private sectors developed alongside and generally in isolation from several other preexisting medical belief and treatment systems. Although the use of government health services and private formal practitioners appears to have grown over the past two decades, the use of formal medical services is still low relative to other Latin American countries, and traditional providers remain a common source of treatment. Guatemalan families typically are poor and have limited access to health services. Among the family's social and economic characteristics, the respondent's education is related most consistently to use of prenatal care, delivery assistance, and immunization. More highly educated women are both more likely to use any kind of care and more likely to use formal care and to have their children immunized completely. Mothers who have worked outside the household are also more likely to use formal delivery care and to have their children immunized fully. The effects of the husband's characteristics are mostly consistent with hypothesized relationships. In particular, women whose husbands completed at least some secondary school are much more likely than others to seek formal pre-natal and delivery care, and their children are more likely to have received at least some immunizations.