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Background: Poor reproductive, maternal, newborn, child, and adolescent health outcomes in Nigeria can be attributed to several factors, not limited to low health service coverage, a lack of quality care, and gender inequity. Providers' gender-discriminatory attitudes, and men's limited positive involvement correlate with poor utilization and quality of services. We conducted a study at the beginning of a large family planning (FP) and maternal, newborn, child, and adolescent health program in Kogi and Ebonyi States of Nigeria to assess whether or not gender plays a role in access to, use of, and delivery of health services., Methods: We conducted a cross-sectional, observational, baseline quality of care assessment from April-July 2016 to inform a maternal and newborn health project in health facilities in Ebonyi and Kogi States. We observed 435 antenatal care consultations and 47 births, and interviewed 138 providers about their knowledge, training, experiences, working conditions, gender-sensitive and respectful care, and workplace gender dynamics. The United States Agency for International Development's Gender Analysis Framework was used to analyze findings., Results: Sixty percent of providers disagreed that a woman could choose a family planning method without a male partner's involvement, and 23.2% of providers disagreed that unmarried clients should use family planning. Ninety-eight percent believed men should participate in health services, yet only 10% encouraged women to bring their partners. Harmful practices were observed in 59.6% of deliveries and disrespectful or abusive practices were observed in 34.0%. No providers offered clients information, services, or referrals for gender-based violence. Sixty-seven percent reported observing or hearing of an incident of violence against clients, and 7.9% of providers experienced violence in the workplace themselves. Over 78% of providers received no training on gender, gender-based violence, or human rights in the past 3 years., Conclusion: Addressing gender inequalities that limit women's access, choice, agency, and autonomy in health services as a quality of care issue is critical to reducing poor health outcomes in Nigeria. Inherent gender discrimination in health service delivery reinforces the critical need for gender analysis, gender responsive approaches, values clarification, and capacity building for service providers.

Maternal Child Survival Program (MCSP) worked in Ebonyi and Kogi States between 2014 to 2018 to improve quality of maternal, child and newborn health care. A formative assessment was conducted in selected health facilities to examine the quality of care received by mothers and their newborns at all stages of normal birth on the day of birth. Health providers attending deliveries at 13 facilities in the two states were observed by trained health professionals. Forty health facilities with a high volume of at least 50 Antenatal Care visits per month and deliveries were purposively selected from 120 quality improvement health facilities. Screening for danger signs at admission was conducted for only 10.5% cases in labor and providers adhered to most recommended infection prevention standards but only washed hands before birth in 19.5% of cases. Chlorhexidine gel was applied to the newborn's umbilical stump in only 2% cases while partograph was used in 32% of the cases. No newborns received the full package of essential care. Potentially harmful practices were observed especially holding newborn babies upside down in 32% cases. Improved provider training and mentoring in high-quality care on the day of birth and strengthened supportive supervision may help to reduce maternal and newborn morbidity and mortality.

This analysis seeks to identify strengths and gaps in the existing facility capacity for intrapartum and immediate postpartum fetal and neonatal care, using data collected as a part of Malawi's Helping Babies Breath program evaluation. From August to September 2012, the Maternal and Child Health Integrated Program (MCHIP) conducted a cross-sectional survey in 84 Malawian health facilities to capture current health facility service availability and readiness and health worker capacity and practice pertaining to labor, delivery, and immediate postpartum care. The survey collected data on availability of equipment, supplies, and medications, and health worker knowledge and performance scores on intrapartum care simulation and actual management of real clients at a subset of facilities. We ran linear regression models to identify predictors of high simulation performance of routine delivery care and management of asphyxiated newborns across all facilities surveyed. Key supplies for infection prevention and thermal care of the newborn were found to be missing in many of the surveyed facilities. At the health center level, 75% had no clinician trained in basic emergency obstetric care or newborn care and 39% had no midwife trained in the same. We observed that there were no proportional increases in available transport and staff at a facility as catchment population increased. In simulations of management of newborns with breathing problems, health workers were able to complete a median of 10 out of 16 tasks for a full-term birth case scenario and 20 out of 30 tasks for a preterm birth case scenario. Health workers who had more years of experience appeared to perform worse. Our study provides a benchmark and highlights gaps for future evaluations and studies as Malawi continues to make strides in improving facility-based care. Further progress in reducing the burden of neonatal and fetal death in Malawi will be partly predicated on guaranteeing properly equipped and staffed facilities in addition to ensuring the presence of skilled health workers.

Decisions made at the household level, for example, to seek antenatal care or breastfeed, can have a direct impact on the health of mothers and newborns. The SMART Community-based Initiatives program in Egypt worked with community development associations to encourage better household decision-making by training community health workers to disseminate information and encourage healthy practices during home visits, group sessions, and community activities with pregnant women, mothers of young children, and their families. A quasi-experimental design was used to evaluate the program, with household surveys conducted before and after the intervention in intervention and comparison areas. Survey questions asked about women's knowledge and behaviors related to maternal and newborn care and child nutrition and, at the endline, exposure to SMART activities. Exposure to program activities was high in intervention areas of Upper Egypt: 91% of respondents reported receiving home visits and 84% attended group sessions. In Lower Egypt, these figures were 58% and 48%, respectively. Knowledge of danger signs related to pregnancy, delivery, and newborn illness increased significantly more in intervention than comparison areas in both regions (with one exception in Lower Egypt), after controlling for child's age and woman's education; this pattern also occurred for two of five behaviors (antenatal care visits and consumption of iron-folate tablets). Findings suggest that there may have been a significant dose-response relationship between exposure to SMART activities and certain knowledge and behavioral indicators, especially in Upper Egypt. The findings demonstrate the ability of civil society organizations with minimal health programming experience to increase knowledge and promote healthy behaviors among pregnant women and new mothers. The SMART approach offers a promising strategy to fill gaps in health education and counseling and strengthen community support for behavior change.

Background: Pregnant women and infants are particularly vulnerable to malaria. National malaria in pregnancy (MIP) programs in Malawi, Senegal, and Zambia were reviewed to identify promising strategies that have helped these countries achieve relatively high coverage of MIP interventions as well as ongoing challenges that have inhibited further progress., Methods: We used a systematic case study methodology to assess health system strengths and challenges in the 3 countries, including desk reviews of available reports and literature and key informant interviews with national stakeholders. Data were collected between 2009 and 2011 and analyzed across 8 MIP health systems components: (1) integration of programs and services, (2) policy, (3) commodities, (4) quality assurance, (5) capacity building, (6) community involvement, (7) monitoring and evaluation, and (8) financing. Within each program area, we ranked degree of scale up across 4 stages and synthesized the findings in a MIP table of analysis to reveal common themes related to better practices, remaining bottlenecks, and opportunities to accelerate MIP coverage, strengthen MIP programs, and improve results., Findings: Each of the 3 countries has malaria policies in place that reflect current MIP guidance from the World Health Organization. The 3 countries successfully integrated MIP interventions into a platform of antenatal care services, but coordination at the national level was disjointed. All 3 countries recognized the importance of having a MIP focal person to ensure collaboration and planning at the national level, but only Malawi had appointed one. Commodity stockouts were frequent due to problems at all levels of the logistics system, from quantification to distribution. Lack of support for quality assurance and weak monitoring and evaluation mechanisms across all 3 countries affected optimal coverage., Conclusions: MIP programs should address all 8 interconnected MIP health systems areas holistically, in the context of a health systems approach to building successful programs. The MIP table of analysis can be a useful tool for other malaria-endemic countries to review their programs and improve MIP outcomes.

Background: Ethiopia is one of the ten countries with the highest number of neonatal deaths globally, and only 1 in 10 women deliver with a skilled attendant. Promotion of essential newborn care practices is one strategy for improving newborn health outcomes that can be delivered in communities as well as facilities. This article describes newborn care practices reported by recently-delivered women (RDWs) in four regions of Ethiopia., Methods: We conducted a household survey with two-stage cluster sampling to assess newborn care practices among women who delivered a live baby in the period 1 to 7 months prior to data collection., Results: The majority of women made one antenatal care (ANC) visit to a health facility, although less than half made four or more visits and women were most likely to deliver their babies at home. About one-fifth of RDWs in this survey had contact with Health Extension Workers (HEWS) during ANC, but nurse/midwives were the most common providers, and few women had postnatal contact with any health provider. Common beneficial newborn care practices included exclusive breastfeeding (87.6%), wrapping the baby before delivery of the placenta (82.3%), and dry cord care (65.2%). Practices contrary to WHO recommendations that were reported in this population of recent mothers include bathing during the first 24 hours of life (74.7%), application of butter and other substances to the cord (19.9%), and discarding of colostrum milk (44.5%). The results suggest that there are not large differences for most essential newborn care indicators between facility and home deliveries, with the exception of delayed bathing and skin-to-skin care., Conclusions: Improving newborn care and newborn health outcomes in Ethiopia will likely require a multifaceted approach. Given low facility delivery rates, community-based promotion of preventive newborn care practices, which has been effective in other settings, is an important strategy. For this strategy to be successful, the coverage of counseling delivered by HEWs and other community volunteers should be increased.

Background: As low-income countries strive to meet targets for Millennium Development Goals 4 and 5, there is growing need to track coverage and quality of high-impact peripartum interventions. At present, nationally representative household surveys conducted in low-income settings primarily measure contact with the health system, shedding little light on content or quality of care. The objective of this study is to validate the ability of women in Mozambique to report on facility-based care they and their newborns received during labor and one hour postpartum., Methods and Findings: The study involved household interviews with women in Mozambique whose births were observed eight to ten months previously as part of a survey of the quality of maternal and newborn care at government health facilities. Of 487 women whose births were observed and who agreed to a follow-up interview, 304 were interviewed (62.4%). The validity of 34 indicators was tested using two measures: area under receiver operator characteristic curve (AUC) and inflation factor (IF); 27 indicators had sufficient numbers for robust analysis, of which four met acceptability criteria for both (AUC >0.6 and 0.75

Maternal mortality is a global burden, with more than 500,000 women dying each year due to pregnancy and childbirth-related complications. Birth-preparedness and complication readiness is a comprehensive strategy to improve the use of skilled providers at birth, the key intervention to decrease maternal mortality. Birth-preparedness and complication readiness include many elements, including: (a) knowledge of danger signs; (b) plan for where to give birth; (c) plan for a birth attendant; (d) plan for transportation; and (e) plan for saving money. The 2003 Burkina Faso Demographic and Health Survey indicated that only 38.5% of women gave birth with the assistance of a skilled provider. The Maternal and Neonatal Health Program of JHPIEGO implemented a district-based model service-delivery system in Koupéla, Burkina Faso, during 2001-2004, to increase the use of skilled providers during pregnancy and childbirth. In 2004, a cross-sectional survey with a random sample of respondents was conducted to measure the impact of birth-preparedness and complication readiness on the use of skilled providers at birth. Of the 180 women who had given birth within 12 months of the survey, 46.1% had a plan for transportation, and 83.3% had a plan to save money. Women with these plans were more likely to give birth with the assistance of a skilled provider (p=0.07 and p=0.03 respectively). Controlling for education, parity, average distance to health facility, and the number of antenatal care visits, planning to save money was associated with giving birth with the assistance of a skilled provider (p=0.05). Qualitative interviews with women who had given birth within 12 months of the survey (n=30) support these findings. Most women saved money for delivery, but had less concrete plans for transportation. These findings highlight how birth-preparedness and complication readiness may be useful in increasing the use of skilled providers at birth, especially for women with a plan for saving money during pregnancy.

Background: Tanzania has a maternal mortality ratio of 556 per 100,000 live births, representing 21% of all deaths of women of reproductive age. Hemorrhage, mostly postpartum hemorrhage (PPH), is estimated to cause at least 25% of maternal deaths in Tanzania. In 2008, the Ministry of Health, Community Development, Gender, Elderly and Children launched interventions to improve efforts to prevent PPH. Competency-based training for skilled birth attendants and ongoing quality improvement prioritized the practice of active management of the third stage of labor (AMTSL).Methods: A cross-sectional study was conducted in 52 health facilities in Tanzania utilizing direct observations of women during labor and delivery. Observations were conducted in 2010 and, after competency-based training and quality improvement interventions in the facilities, in 2012. A total of 489 deliveries were observed in 2010 and 558 in 2012. Steps for AMTSL were assessed using a standardized structured observation checklist that was based on World Health Organization guidelines.Results: The proportion of deliveries receiving all three AMTSL steps improved significantly by 19 percentage points (p < 0.001) following the intervention, with the most dramatic increase occurring in health centers and dispensaries (47.2 percentage point change) compared to hospitals (5.2 percentage point change). Use of oxytocin for PPH prevention rose by 37.1 percentage points in health centers and dispensaries but remained largely the same in hospitals, where the baseline was higher. There was substantial improvement in the timely provision of uterotonics (within 3 min of birth) across all facilities (p = 0.003). Availability of oxytocin, which was lower in health centers and dispensaries than hospitals at baseline, rose from 73 to 94% of all facilities.Conclusion: The quality of PPH prevention increased substantially in facilities that implemented competency-based training and quality improvement interventions, with the most dramatic improvement seen at lower-level facilities. As Tanzania continues with efforts to increase facility births, it is imperative that the quality of care also be improved by promoting use of up-to-date guidelines and ensuring regular training and mentoring for health care providers so that they adhere to the guidelines for care of women during labor. These measures can reduce maternal and newborn mortality. [ABSTRACT FROM AUTHOR]