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Background More than a third of pregnant women in Africa use medicinal plants (hereafter, ‘herbs’) during pregnancy, yet little is known about herb use among urban African women, or about the potential impact on newborns. Methods This cross-sectional study of 504 women giving birth at an urban government hospital in Kumasi, Ghana (May–July 2018) collected data via chart reviews and maternal interviews. Data were analyzed using conditional logistic regression. Results Of 380 singleton births with complete data, 102 mothers (26.84%) reported using herbs during pregnancy and/or delivery. Herb users and non-users did not differ significantly across a range of sociodemographic variables. Controlling for age, education, neonatal birthweight and household running water (socioeconomic status (SES) indicator), herb-using women were twice as likely to have their newborn admitted to the hospital (odds ratio (OR) = 2.05; confidence interval (CI) 95% 1.17, 3.60) and four times as likely to bear a child with a low Apgar score (OR = 4.09; CI 95% 1.66, 10.07) compared with non-users. Conclusion Urban-dwelling Ghanaian women from diverse backgrounds use herbs during pregnancy. Maternal herb use was associated with poor neonatal outcomes, regardless of the baby’s birthweight and mother’s age, education or SES, suggesting the importance of educating all women about the possible negative impacts of herb use during pregnancy and delivery.

Background: While the nexus of migration and health outcomes is well acknowledged, the effect of rural-urban migration on use of sexual and reproductive health (SRH) services has received less attention. We assessed the effect of rural-rural migration on the use of SRH services while controlling for confounding and whether there is a difference in the use of SRH services among migrant and non-migrant street children and young adults.Methods: Data were collected among 513 street children and young adults aged 12 - 24 years using face‐to‐face interviews using venue-based time-space sampling (VBTS). Using STATA 16.00, multivariate logistic regression analysis was performed to identify factors associated with SRH services use, with rural-urban migration status as the main predictor. We defined migrants as street children and young adults aged 12 - 24 years who migrated from rural districts and settled in Kampala city for a period of not more than 24 months preceding the survey.Results: Overall, 18.13% of the street children and young adults had ever used contraception/family planning, 45.89% had ever tested for HIV and knew their status while 34.70% had ever been screened for sexually transmitted infections (STIs). Migrant street children and young adults had reduced odds of using SRH services (HIV testing, use of FP and screening for STIs compared to non-migrant street children and young adults (aOR=0.59, 95%CI 0.36 - 0.97). Other factors associated with use of SRH services among street children and young adults include age (aOR=4.51; 95%CI 2.78 - 7.33), schooling status (aOR=0.34; 95%CI - 1.830 0.15-0.76), knowledge of place of care (aOR=3.37,95%CI 2.04 - 5.34) and access to SRH information (aOR=2.7, 95%CI 1.67 - 4.53). Conclusion: Access to and use of SRH services is low among migrant street children and adults compared to the non-migrant street children and young adults and is independently associated with rural-urban migration status, age, schooling status, knowledge of place of SRH care and access to SRH information. Our findings call for the need to design and implement multi-dimensional interventions to increase use of SRH services among street children and young adults while taking into consideration their migration patterns.

INTRODUCTION: Sickle cell disease (SCD) stigma is a major community health issue. The challenges of caring for someone with SCD can be isolating and overwhelming. We explored stigma and its related factors for caregivers of pediatric patients with SCD in Kumasi, Ghana. METHODS: Guided by the Ecological Systems Theory, we used in-depth interviews with a semi-structured guide to learn about the perception of stigmatization for Ghanaian caregivers of patients with SCD. RESULTS: Overall, participants were knowledgeable about SCD. We identified three overarching themes including: 1) Blame for SCD; 2) Public misconception about SCD, and; 3) Shame for financial burden of SCD. DISCUSSION: Findings demonstrate the need to design a SCD stigma reduction program for caregivers, their families and the community. Providers need to consider SCD stigma and interaction with multiple ecological levels including the family and community, health care system, culture, and health policy in Ghana. Findings can be used as a catalyst to explore the reduction of stigmatization in other sub-Saharan countries.

Background Although under-five (U5) mortality in Uganda has dropped over the past two decades, rates in urban slum neighborhoods remain high. As part of a broader verbal and social autopsy study of U5 deaths, this study explored the perspectives of volunteer community health workers, called Village Health Teams (VHTs), on why children under five in Kampala’s informal settlements are still dying despite living in close proximity to nearby health facilities. Methods This exploratory, qualitative study took place between January and March 2020 in the Rubaga division of Kampala, Uganda. VHTs from the slums of Kawaala and Nankulabye parishes, both located near a large government health center, were interviewed by a trained local interviewer to determine their perceptions of barriers to care-seeking and attribution for U5 childhood deaths. All interviews were audiotaped, transcribed into English, imported into NVivo V 12.0 and thematically analyzed using the Attride-Stirling framework. Results 20 VHTs were interviewed, yielding two global themes, the first focusing on VHTs perceptions of their role in the community to promote positive health outcomes, and the second focusing on VHTs’ perceptions of how prompt care-seeking is disincentivized. Within the latter theme, three inter-related sub-themes emerged: disincentives for care-seeking at the health system level, which can drive negative beliefs held by families about the health system, and in turn, drive incentives for alternative health behaviors, which manifest as “incentivized delays” to care-seeking. Discussion This study illustrates VHT perspectives on the complex interactions between health system disincentives and the attitudes and behaviors of families with a sick child, as well as the reinforcing nature of these factors. Findings suggest a need for multi-pronged approaches that sensitize community members, engage community and health system leadership, and hold providers accountable for providing high-quality care. VHTs have enormous potential to foster improvement if given adequate resources, training, and support.

Purpose: To explore the impact of the COVID-19 pandemic on pregnant women’s anxiety and identify factors most strongly associated with greater changes in anxiety.Methods: An anonymous, online, survey of pregnant women (distributed April 3 - 24, 2020) included a modified Pregnancy-Related Anxiety Scale (PRAS) reflecting respondents’ perception of pregnancy anxiety before COVID-19 and a current assessment of pregnancy-related anxiety. The difference between these scores was used as the outcome variable. Data were analysed using bivariate and multivariate linear regression analyses. Results: 2,740 pregnant women from 47 states completed the survey. 25.8% (N=706) stopped in-person visits, 15.2% used video visits (N=415), and 31.8% (N=817) used phone visits for prenatal care as a result of COVID-19. Those planning a hospital birth dropped from 2641 (96.4%) to 2400 (87.7%) following COVID-19. More than half of women reported increased stress about food running out (59.2%, N=1622), losing a job or household income (63.7%, N=1745), or loss of childcare (56.3%, N=1543). More than a third reported increasing stress about conflict between household members (37.5%, N=1028), and 93% (N=2556) reported increased stress about getting infected with COVID-19. Slightly less than half of respondents (either selves or family members) were healthcare workers (41.4%, N=1133) or worked in essential services (45.5%, N=1246). In multivariate analysis, those reporting higher agreement with COVID-19-related stressors had greater changes in pre- to post-COVID-19 pregnancy-related anxiety.Conclusions: The COVID-19 pandemic is profoundly affecting pregnant women’s mental health, and factors independent of pregnancy appear to be driving changes in pregnancy-specific anxiety.

BackgroundGlobal health experiences are an increasingly popular component of medical student curricula. There is little research on the impact of international medical electives embedded within long-standing, sustainable partnerships. Our research explores the University of Michigan medical student elective experience in Ghana within the context of the Ghana-Michigan collaborative.MethodsStudy participants are University of Michigan medical students who completed an international elective in Ghana between March 2006 and June 2017. Post-elective reports were completed by students, including a description of the experience, highlights, disappointments, and the impact of the experience on interest in future international work and future practice of medicine. A retrospective thematic analysis of reports was carried out using NVivo 12 (QSR International, Melbourne, Australia).ResultsA total of 57 reports were analyzed. Benefits of the elective experience included building cross-cultural relationships, exposure to different healthcare environments, hands-on clinical and surgical experience, and exposure to different patient populations. Ninety-five percent of students planned to engage in additional international work in the future. Students felt that the long-standing bidirectional exchange allowed them to build cross-cultural relationships and be incorporated as a trusted part of the local clinical team. The partnership modeled collaboration, and many students found inspiration for the direction of their own careers.ConclusionsEmbedding clinical rotations within a well-established, sustained partnerships provides valuable experiences for trainees by modeling reciprocity, program management by local physicians, and cultural humility—all of which can help prepare learners to ethically engage in balanced, long-term partnerships in the future.

Objective To explore the incidence and factors associated with maternal near-miss. Design Cross-sectional study with an embedded case-control study. Setting Three tertiary referral hospitals in southern Ghana. Population All women admitted to study facilities with pregnancy-related complications or for birth. Methods An adapted version of the WHO Maternal Near Miss Screening Tool was used to identify maternal near-miss cases. These were compared with unmatched controls (uncomplicated deliveries) in a ratio of 1:2. Main outcome measures Incidence of maternal near-miss, maternal near-miss to maternal mortality ratio, and cause of and factors associated with maternal near-miss. Results Out of 8433 live births, 288 maternal near-miss cases and 62 maternal deaths were identified. In all, 454 healthy controls were recruited for comparison. Maternal near-miss and maternal death incidence ratios were 34.2 (95% CI 30.2-38.1) and 7.4 (95% CI 5.5-9.2) per 1000 live births, respectively with a maternal near-miss to mortality ratio of 4.6:1. Cause of near-miss was pre-eclampsia/eclampsia (41.0%), haemorrhage (12.2%), maternal sepsis (11.1%) and ruptured uterus (4.2%). A major factor associated with maternal near-miss was maternal fever within the 7 days before birth (OR 5.95, 95%CI 3.754-9.424). Spontaneous onset of labour was protective against near-miss (OR 0.09 95% CI 0.057-0.141). Conclusion For every maternal death, there were nearly five maternal near-misses. Women having a fever in the 7 days before delivery were six times more likely to experience a near-miss than women not having fever. Tweetable abstract Maternal near-miss exceeds maternal death by 5:1, with the leading cause of maternal near-miss was pre-eclampsia/eclampsia.

Background While the nexus of migration and health outcomes is well acknowledged, the effect of rural-urban migration on uptake of sexual and reproductive health (SRH) services has received less attention. We assessed the effect of rural-rural urban migration on uptake of SRH services and whether there is a difference in uptake of SRH services among migrant and non-migrant street children. Methods Data were collected among 513 street children aged 12-24 years using face‐to‐face interviews. Participants were recruited by venue-based time-space sampling (VBTS). Using STATA 16.00, we performed multivariate binary logistic regression to identify correlates of SRH service uptake with migration status as the main predictor while controlling for confounding. In this study, migrants are defined as children who had moved to settle in the city for at least 24 months preceding the survey. Results Overall, two-thirds (66.82%) of children had moved to the city in the last 2 years, 20% in the last 3-5 years and 13.18% in 6 years or longer. Only 18.13% of the street children had ever used contraception/family planning, 45.89% had ever tested for HIV and knew their status while 34.70% had ever been screened for sexually transmitted infections. Multivariate analysis shows that migrant street children had reduced odds of using sexual and reproductive health services (HIV testing, use of contraception and screening for STIs) compared to the lifelong native street children (aOR=0.59, 95%CI 0.36- 0.97). Other factors associated with use of SRH services among street children include age (aOR=4.51; 95%CI 2.78-7.33), schooling status (aOR=0.34; 95%CI -1.830 0.15-0.76), knowledge of place of care (OR=3.37,95%CI 2.04-5.34) and access to SRH education information (aOR=2.7, 95%CI 1.67- 4.53). Conclusion Rural-urban migration is associated with low SRH service uptake. Access to and use of SRH services among migrant street children is low compared to non-migrant street children. Our findings point to the need for urban health systems to design effective interventions to improve equitable access to and use of quality SRH services among street children while taking into consideration their migration patterns.

The emergence of COVID-19 has presented challenges for pregnant women around the world, including disruptions in antenatal care (ANC), heightened anxiety during pregnancy, and concerns regarding safe delivery. The present study sought to determine how pregnant women in Ghana were affected by COVID-19.

Maternity waiting homes (MWHs) in Liberia promote facility‐based delivery to reduce maternal mortality. However, women often must bring their own food and supplies to MWHs, which makes food insecurity a barrier to the utilisation of MWHs. Consumption of edible indigenous insects is a common practice and has notable nutritional benefits but has not been studied in Liberia as a potential solution to food insecurity at MWHs. The purpose of this study is to (a) examine the acceptability of insect consumption in the context of Liberian beliefs, (b) identify species commonly consumed by pregnant women in Liberia, and (c) examine the feasibility of harvesting insects as food and income generation for women staying at MWHs. Focus groups were conducted at 18 healthcare facilities in Liberia. Participants included chiefs, community leaders, women of reproductive age, traditional birth attendants, women staying at MWHs, and male partners. Focus group participants identified many different species of insects consumed by pregnant women in the community as well as the perceived health impacts of insect consumption. They also described their own experiences with insect hunting and consumption and the perceived marketability of insects, particularly palm weevil larvae. The results of these discussions demonstrate that insect consumption is an acceptable practice for pregnant women in rural Liberia. These findings suggest that it is feasible to further explore the use of palm weevil larvae as dietary supplementation and income generation for women staying at MWHs in Liberia.

Background For every newborn who dies within the first month, as many as eight more suffer life-threatening complications but survive (termed ‘neonatal near-misses’ (NNM)). However, there is no universally agreed-upon definition or assessment tool for NNM. This study sought to describe the development of the Neonatal Near-Miss Assessment Tool (NNMAT) for low-resource settings, as well as findings when implemented in Ghana. Methods This prospective, observational study was conducted at two tertiary care hospitals in southern Ghana from April – July 2015. Newborns with evidence of complications and those admitted to the NICUs were screened for inclusion using the NNMAT. Incidence of suspected NNM at enrollment and confirmed near-miss (surviving to 28 days) was determined and compared against institutional neonatal mortality rates. Suspected NNM cases were compared with newborns not classified as a suspected near-miss, and all were followed to 28 days to determine odds of survival. Confirmed near-misses were those identified as suspected near-misses at enrollment who survived to 28 days. The main outcome measures were incidence of NNM, NNM:mortality ratio, and factors associated with NNM classification. Results Out of 394 newborns with complications, 341 (86.5%) were initially classified as suspected near-misses at enrollment using the NNMAT, with 53 (13.4%) being classified as a non-near-miss. At 28-day follow-up, 68 (17%) had died, 52 (13%) were classified as a non-near-miss, and 274 were considered confirmed near-misses. Those newborns with complications who were classified as suspected near-misses using the NNMAT at enrollment had 12 times the odds of dying before 28 days than those classified as non-near-misses. While most confirmed near-misses qualified as NNM via intervention-based criteria, nearly two-thirds qualified based on two or more of the four NNMAT categories. When disaggregated, the most predictive elements of the NNMAT were gestational age Conclusions This research suggests that the NNMAT is an effective tool for assessing neonatal near-misses in low-resource settings. We believe this approach has significant systems-level, continuous quality improvement, clinical and policy-level implications.

Neonatal morbidity and mortality remain a significant challenge in Ghana. Given the relationship between care-seeking and understanding of illness, this study aimed to explore mothers' perceptions of the cause of illness and/or death in Northern Ghana. All neonatal deaths and near-misses (babies who survived a life-threatening complication) in 2015 and 2016 were identified through a community - and facility-based surveillance system. Mothers of the deceased or ill infants participated in open narrative qualitative interviews. Narratives that included discussion of whether the mother understood what caused the baby's illness or death were analysed. Interviews with 155 mothers included discussion of their perception of the cause of newborn illness or death. Of the 155 interviews, 108 interviews involved mothers whose babies died, and 47 interviews involved mothers whose newborns survived a life-threatening illness, a neonatal 'near-miss'. Very few expressed a clear understanding of the cause of death or illness. Those mothers who did not understand were either not told or did not understand the cause of illness or death. Newborn health outcomes may be improved by increased maternal awareness and understanding of neonatal illnesses. Future interventions need to address communication issues that impair mothers' understanding, facilitate recognition of danger signs, and prompt timely care-seeking.

Objective: To explore if and how women perceived their prenatal care to have changed as a result of COVID-19 and the impact of those changes on pregnant women. Design: Qualitative analysis of open-ended prompts included as part of an anonymous, online, cross-sectional survey of pregnant women in the United States. Setting: Online survey with participants from 47 states within the U.S. Participants: Self-identified pregnant women recruited through Facebook, Twitter, and other online sources. Measurements and findings: An anonymous, online survey of pregnant women (distributed April 3 - 24, 2020) included an open-ended prompt asking women to tell us how COVID-19 had affected their prenatal care. Open-ended narrative responses were downloaded into Excel and coded using the Attride-Sterling Framework. 2519 pregnant women from 47 states responded to the survey, 88.4% of whom had at least one previous birth. Mean age was 32.7 years, mean weeks pregnant was 24.3 weeks, and mean number of prenatal visits at the point of the survey was 6.5. Predominant themes of the open narratives included COVID-19’s role in creating structural changes within the healthcare system (reported spontaneously by 2075 respondents), behavioral changes among both pregnant women and their providers (reported by 429 respondents), and emotional consequences for women who were pregnant (reported by 503 respondents) during the pandemic. Changes resulting from COVID-19 varied widely by provider, and women's perceptions of the impact on quality of care ranged from perceiving care as extremely compromised to perceiving it to be improved as a result of the pandemic. Key conclusions and Implications for practice: Women who are pregnant during the COVID-19 pandemic have faced enormous upheaval as hospitals and healthcare providers have struggled to meet the simultaneous and often competing demands of infection prevention, pandemic preparedness, high patient volumes of extremely sick patients, and the needs of ‘non-urgent’ pregnant patients. In some settings, women described very few changes, whereas others reported radical changes implemented seemingly overnight. While infection rates may drive variable responses, these inconsistencies raise important questions regarding the need for local, state, national, or even global recommendations for the care of pregnant women during a global pandemic such as COVID-19.

Sexual coercion refers to strategies that result in an individual engaging in sexual activity against his or her will. Ecological factors influence the way sexual interactions occur; however, the relationship between these factors and sexual coercion has not been explored among university students in Ghana. The purpose of this study was to examine sexual coercion among university students in Ghana by specifically examining individual-level factors (age, gender, sexual debut, age differential with first partner, being in an intimate relationship, history of abortion, and past experiences with transactional sex) and the experience of forced and coerced sex. Residential students at the University of Cape Coast were invited to participate and completed a survey on a tablet computer. Questions included demographics; sexual and reproductive health experiences and knowledge; and attitudes and experiences with abortion. Bivariate and multivariate analyses were used to examine individual-level factors associated with experiences of sexual coercion and forced sex. There were 480 females and 556 males that completed the survey; 26.3 and 16.4% reported having had intercourse either because they were forced or coerced, or when they were “very unwilling”. These students were more likely to be female (OR 3.5), to have had an abortion (OR 2.9), and to have engaged in transactional sex (OR 1.9). Many University of Cape Coast students are experiencing forced or coerced sex. Programs targeting both female and male students as both victims and perpetrators of sexual violence in this population are sorely needed. Primary prevention of sexual violence is one promising field.

Objective To examine the prevalence of maternal near-miss (MNM) and its associated risk factors in a community setting in Central Uganda. Methods A cross-sectional research design employing multi-stage sampling collected data from women aged 15–49 years in Rakai, Uganda, who had been pregnant in the 3 years preceding the survey, conducted between August 10 and December 31, 2013. Additionally, in-depth interviews were conducted. WHO-based disease and management criteria were used to identify MNM. Binary logistic regression was used to predict MNM risk factors. Content analysis was performed for qualitative data. Results Survey data were collected from 1557 women and 40 in-depth interviews were conducted. The MNM prevalence was 287.7 per 1000 pregnancies; the majority of MNMs resulted from hemorrhage. Unwanted pregnancies, a history of MNM, primipara, pregnancy danger signs, Banyakore ethnicity, and a partner who had completed primary education only were associated with increased odds of MNM (all P Conclusions MNM morbidity is a significant burden in Central Uganda. The present study demonstrated higher MNM rates compared with studies employing organ-failure MNM-diagnostic criteria. These findings illustrate the need to look beyond mortality statistics when assessing maternal health outcomes. Concerted efforts to increase supervised deliveries, access to emergency obstetric care, and access to contraceptives are warranted.

Objective This study explored providers’ perspectives and behavior regarding respectful maternity care, including knowledge, attitudes, and practices. Design Mixed-methods cross-sectional study combining quantitative survey data, qualitative interviews, and observations of labor and delivery across four health facilities Setting Government health facilities in rural northern Ghana Participants 43 front-line maternity care providers completed a survey of practice patterns before a quality of care training. We then used purposive and convenience sampling to recruit a sub-sample for in-depth interviews (N=17), and convenience sampling and self-selection to observe approximately half (N=8) providing clinical care. Measurements and findings We calculated descriptive statistics from quantitative data and used the framework approach for qualitative analysis. Observational data were examined using the CHANGE Project's Assessment Tools for Caring Providers. We utilized split frame methodology to make comparisons across data sources. Quantitative survey results (N=43) indicate most providers report explaining procedures to women (89.5%), involving women and families in care decisions (84.1%), and covering or screening women for privacy (81.5%). At the same time, 38.9% reported they have shouted at, scolded, insulted, threatened, or talked rudely to a woman, and 26.4% said they have treated a woman differently because of her personal attributes. Qualitative interview data (N=17) suggested that providers can articulate a vision of respectful care, aspire to offer respectful care, and recognize they do not always meet those aspirations. Among those (N=8) volunteering to be observed, introductions and explanations for procedures were rare, privacy screening was infrequent, and participants were observed slapping, scolding, and restraining women in labor, often associated with patient non-compliance to provider instructions. Key conclusions Even among providers knowledgeable about respectful maternity care and who agreed to be observed providing delivery care, disrespect and abuse were present. Implications for practice Further research and programmatic efforts are needed to address the gap between knowledge and behavior.

Background: Person-centred maternity care (PCMC) is maternity care that is responsive to and respectful of women's needs and values. It is a key dimension of quality, capturing the experience of interpersonal dimensions of care. Poor PCMC contributes to high maternal mortality not only directly but also indirectly through decreased demand for services. Although there is growing recognition of the importance of PCMC to maternal and child health outcomes, there is a paucity of data on interventions that aim to integrate a person-centred approach to maternity care. In this study, we aimed to evaluate the effect of an integrated simulation training on provision of PCMC. Methods: The pilot PCMC training project was launched in a rural district in Northern Ghana in April, 2017. To improve quality of care, including PCMC, we integrated specific components of such care, emphasising dignity and respect, communication and autonomy, and supportive care, into a simulation training to improve identification and management of obstetric and neonatal emergencies. 43 providers in the district participated in two 2-day trainings led by PRONTO international trainers. Six providers were then trained as simulation facilitators, and they led refresher sessions every month for 4 months at the five highest-volume delivery facilities in the district. We conducted surveys at baseline and endline with women who had recently given birth to assess their experiences of care using a 24-item version of the 30-item PCMC scale. Findings: We included data from 215 baseline surveys, conducted in March and April, 2017, and 318 surveys at endline in November, 2017. Women at endline reported higher PCMC scores than did women at baseline. The average PCMC score increased from 35·9 (SD 6·3) at baseline to 51·5 (12·9) at endline, a change of 43% (p

Highlights • Mothers caring for newborns have a maternal dualism between cultural and health system obligations. • Traditional newborn protective rituals were identified to help nurses provide health education. • Family and community expressed a strong need to protect the newborn using traditional belief systems., Background - Far too many newborns die or face serious morbidity in Zambia, as in many other sub-Saharan African countries. New knowledge is needed to enhance our understanding of newborn care and the cultural factors influencing the ways mothers seek newborn care. This study adds to the literature about rural Zambians’ cultural beliefs and practices related to newborn care and health-seeking practices that influence maternal-newborn health. Objective - The goal of this study was to describe the factors associated with newborn care in rural Zambia. Design - Sixty focus groups were conducted. Each group contained a minimum of 8 and maximum of 12 participants. Recruitment was conducted orally by word of mouth through the nurse in charge at the health facilities and village chiefs. Setting – Data were collected between June and August 2016 in 20 communities located in Zambia's rural Lundazi (Eastern province), Mansa, and Chembe (Luapula province) Districts. Participants - The study included community members (n = 208), health workers (n = 225), and mothers with infants younger than 1-year-old (n = 213). Findings - The following themes emerged. From mothers with infants, the dominant theme concerned traditional and protective newborn rituals. From community members, the dominant theme was a strong sense of family and community to protect the newborn, and from health workers, the major theme was an avoidance of shame. A fourth theme, essential newborn care, was common among all groups. Key conclusions – Together the themes pointed toward a maternal dualism for mothers in rural Zambia. Mothers with infants in rural Zambia likely experience a dualistic sense of responsibility to satisfy both cultural and health system expectations when caring for their newborns. Mothers are pulled to engage in traditional protective newborn care rituals while at the same time being pushed to attend ANC and deliver at the health facility. These findings can be used to understand how mothers care for their newborns to develop interventions aimed at improving maternal-child health outcomes. Implications for practice - There were findings about the culture-specific prevention of cough, care of the umbilical cord, and early introduction of traditional porridge that carry implications for nursing practice. There is an obvious need to reinforce the importance of partner testing for STIs during routine ANC even though there is a desire to preserve dignity.

Objective Rates of maternal and neonatal death remain high in the Global South, especially in Sub-Saharan Africa. In addition, indicators vary significantly by geography. This study aimed to understand what communities in northern Ghana with frequent maternal and newborn deaths or near deaths (near-misses) perceive to be the causes. As part of a larger study, four communities in Ghana's Northern Region were identified as areas with high concentrations of deaths and near-misses of mothers and babies. Design Stakeholders were interviewed using in-depth interviews (IDIs) and focus-group discussions (FGDs). Field workers conducted 12 FGDs and 12 IDIs across a total of 126 participants. Setting This exploratory descriptive study was conducted in the East Mamprusi District in the Northern Region of Ghana, in the communities of Jawani, Nagboo, Gbangu and Wundua. Participants FGDs were led by trained field workers and attended by traditional chiefs and their elders, members of women's groups, and traditional birth attendants in each of the four study communities. IDIs, or one-on-one interviews, were conducted with traditional healers who manage maternal and neonatal cases, community health nurses, and midwives. Measurements and findings Qualitative data were audio-recorded, transcribed, and thematically analyzed using the Attride-Sterling analytical framework. Discussions focused on where blame should be attributed for the negative outcomes of mothers and babies – with blame either being directed at the actions or inactions of the mothers (behavioral), or at the larger factors associated with poverty (situational) that necessitate mothers’ behavior. For example, some respondents blamed women for their poor diets, while others blamed the lack of money or household support to buy nutritious foods. Blame was rarely attributed to the fathers despite local gender norms of males being the household decision-makers with regard to spending and care-seeking. Key conclusions These findings contribute to a small but growing body of literature on the blaming of mothers for their own deaths and those of their newborns – a phenomenon also described in high-income countries – and is supported by blame attribution theories that explain the self-protective nature of victim-blaming. Implications for practice These results carry important implications for education and intervention design related to maternal and neonatal mortality, including more focused efforts at incorporating men and the larger community. More research is warranted on blame attribution for these adverse outcomes and its effects on the victims.

Background Few evidence-based interventions exist on how to improve respectful maternity care (RMC) in low-resource settings. We sought to evaluate the effect of an integrated simulation-based training on provision of RMC. Methods The pilot project was in East Mamprusi District in northern Ghana. We integrated specific components of RMC, emphasizing dignity and respect, communication and autonomy, and supportive care, into a simulation training to improve identification and management of obstetric and neonatal emergencies. Forty-three providers were trained. For evaluation, we conducted surveys at baseline (N = 215) and endline (N = 318) 6 months later, with recently delivered women to assess their experiences of care using the person-centered maternity care scale. Higher scores on the scale represent more respectful care. Results Compared to the baseline, women in the endline reported more respectful care. The average person-centered maternity care score increased from 50 at baseline to 72 at endline, a relative increase of 43%. Scores on the subscales also increased between baseline and endline: 15% increase for dignity and respect, 87% increase for communication and autonomy, and 55% increase for supportive care. These differences remained significant in multivariate analysis controlling for several potential confounders. Conclusions The findings suggest that integrated provider trainings that give providers the opportunity to learn, practice, and reflect on their provision of RMC in the context of stressful emergency obstetric simulations have the potential to improve women's childbirth experiences in low-resource settings. Incorporating such trainings into preservice and in-service training of providers will help advance global efforts to promote RMC.

Background Globally, three million girls are at risk of female genital mutilation (FGM) and an estimated 200 million girls and women in the world have undergone FGM. While the overall prevalence of FGM in Ghana is 4%, studies have shown that the overall prevalence in the Upper East Region is 38%, with Bawku municipality recording the highest at 82%. Methods This study used a cross-sectional design with a quantitative approach: a survey with women of reproductive age (15–49). Results Among all respondents, 830 women who participated in the study, 61% reported having undergone FGM. Of those circumcised, 66% indicated their mothers influenced it. Three quarters of the women think FGM could be stopped through health education. Women who live in the Pusiga district (AOR: 1.66; 95% CI: 1.16–2.38), are aged 35–49 (AOR: 4.24; 95% CI: 2.62–6.85), and have no formal education (AOR: 2.78; 95% CI: 1.43–5.43) or primary education (AOR: 2.10; 95% CI: 1.03–4.31) were more likely to be circumcised relative to those who reside in Bawku Municipal, are aged 15–24, and had tertiary education. Likewise, married women (AOR: 3.82; 95% CI: 2.53–5.76) were more likely to have been circumcised compared with unmarried women. At a site-specific level, factors associated with FGM included age and marital status in Bawku, and age, marital status, and women’s education in Pusiga. Conclusion Female Genital Mutilation is still being practiced in the Bawku Municipality and the Pusiga District of northern Ghana, particularly among women with low socio-economic status. Implementing interventions that would provide health education to communities and promote girl-child education beyond the primary level could help end the practice.

OBJECTIVE To explore basic and comprehensive emergency obstetric service provision across four districts in rural northern Ghana, and whether women were more likely to deliver at facilities with more skilled care. METHODS Field workers geo-coded all health facilities in East Mamprusi, Sissala East, Kassena Nankana Municipal, and Kassena Nankana West districts, and administered surveys to assess providers and emergency obstetric care available. Data were also prospectively collected on delivery locations of women and neonates who died, or nearly died (near misses), between September 1, 2015 and April 30, 2017. RESULTS There were 14 physicians for a population of nearly 360 000 women. Six (6%) facilities could provide basic emergency care, and 3 (3%) could provide comprehensive care. Services were distributed unequally, with 6 (67%) of the emergency facilities located in the least populated district. Among the sample of women and neonates who died or nearly died, 175 (39%) delivered at locations unable to provide basic emergency services. CONCLUSION Access to emergency obstetric and neonatal care was distributed inequitably across these districts, suggesting the need to revisit geographic placement of facilities relative to population. The study also raised the question of how to ensure facilities are equipped to respond to emergencies.

Background Community interventions are often created by researchers, non-profit organisations, or other community outsiders and launched in communities with minimal input from the community members themselves. In addition, these are often blanket interventions, or generic programming offered across varied communities that do not take into account the unique needs of each community. The PREventing Maternal And Neonatal Death (PREMAND) project in rural northern Ghana hypothesised that the root causes of maternal and neonatal deaths and near-misses would vary based on each community's unique geographic, social, and cultural factors, and that interventions to address these issues should be driven by the community members and tailored to their specific needs. Methods PREMAND is a three-phase project beginning with sociocultural audits of near-misses and verbal and social autopsies of deaths of mothers and babies in four districts in Ghana. Semi-structured qualitative interviews about each event are also conducted and transcribed. Data are then mapped to demonstrate where clusters of events are located and to determine which five communities are experiencing the highest numbers of deaths and near-deaths. Lastly, data and maps generated by PREMAND are presented to community leaders and elders through large community meetings. Communities are provided with small seed grants (US$2000) to generate their own solutions based on the data presented and their own experiences as experts on their own communities. Findings The community intervention stage is still underway, but preliminary results indicate that all five identified communities have planned unique interventions, and two of the communities have completed their interventions. One community plumbed water to a local health facility where deliveries occur, and another purchased and retrofitted a motor ambulance for emergency transport. All of the communities have committed to putting forth their own funds so that they can undertake bigger projects than seed money will allow. Interpretation Preliminary results from the community intervention phase demonstrate that, when provided with basic information about the problem and a small amount of resources to develop their own solutions, community members are motivated to enact change, develop unique solutions specific to their own needs, and even contribute their own time and funds to improve their communities. Funding USAID Ghana.

Previous research suggests that care-seeking in rural northern Ghana is often governed by a woman's husband or compound head. This study was designed to explore the role grandmothers (typically a woman's mother-in-law) play in influencing maternal and newborn healthcare decisions. In-depth interviews were conducted with 35 mothers of newborns, 8 traditional birth attendants and local healers, 16 community leaders and 13 healthcare practitioners. An additional 18 focus groups were conducted with stakeholders such as household heads, compound leaders and grandmothers. In this region, grandmothers play many roles. They may act as primary support providers to pregnant mothers, care for newborns following delivery, preserve cultural traditions and serve as repositories of knowledge on local medicine. Grandmothers may also serve as gatekeepers for health-seeking behaviour, especially with regard to their daughters and daughters-in-law. This research also sheds light on the potential gap between health education campaigns that target mothers as autonomous decision-makers, and the reality of a more collectivist community structure in which mothers rarely make such decisions without the support of other community members.

Objective the objective of this study is to understand the barriers final year midwifery students face when deciding to practice in a rural, deprived area. Design a cross-sectional study design using a computer based structured survey. Setting 15 of the 16 publicly funded midwifery colleges across all ten regions in Ghana. Participants a national sample of final-year midwifery students from publically funded midwifery colleges in Ghana. Measurements basic frequencies and percentages were calculated for the variables cited as the top three factors motivating participants to study midwifery stratified by student type (post-basic verses diploma) and program location (urban, peri-urban, and rural). Odds ratios were calculated using separate logistic regression models to analyze the relationship between students' experience with rural communities and how it affected their willingness to work in a rural area following graduation. Findings eight hundred and fifty-six midwifery students ( N = 856) completed a computerised survey for a response rate of 91.8%. The top motivation to study midwifery was a ‘desire to help others'. Over half (55%) of participants reported they will ‘definitely work' (11%) or ‘were likely to work' (44%) in a deprived area. When examined by student type and location of school, the top reason cited by participants was 'to serve humanity'. Those born in a rural area, currently living in a rural area, or under obligation to return to a rural or peri-urban area had greater odds of being willing to work in a deprived area after graduation. Key conclusions findings from our study are unique in that they examine the distinct motivational factors from a national sample of midwifery students about to join the workforce. Regardless of the type of student or the location of the school, midwifery students in Ghana were highly motivated by altruistic values. Strategies to address the rural shortage of midwifery providers in Ghana is presented. Implication for practice understanding the factors that motivate midwifery students to work in rural, deprived areas will help develop effective policy interventions affecting practice.

PROBLEM International medical electives typically represent a unidirectional flow of students from economically advantaged countries in the global "North" to resource-poor nations in the global "South." Little is known about the impact of bilateral exchanges on students from less affluent nations. APPROACH Since 2007, students from the University of Michigan Medical School (UMMS) and medical schools in Ghana have engaged in a bilateral clinical exchange program. A 45-item online survey was distributed to all 73 Ghanaian medical students who had rotated at UMMS from 2008 to 2010 to assess perspectives on the value and impact of their participation. OUTCOMES Incoming Ghanaian students outnumbered outgoing UMMS students 73 to 33 during the study period. Of eligible Ghanaian students, 70% (51/73) participated in the survey, with 40 of 51 providing valid data on at least 50% of questions. Ninety-seven percent (37/38) reported that the UMMS rotation was valuable to their medical training, 90% (35/39) reported changes in how they approach patient care, and 77% (24/31) reported feeling better equipped to serve patients in their home community. Eighty-five percent of students (28/33) felt more inclined to pursue training opportunities outside of their home country after their rotation at UMMS. NEXT STEPS More studies are needed to determine the feasibility of bidirectional exchanges as well as the short-term and long-term impact of rotations on students from underresourced settings and their hosts in more resource-rich environments.

Objective: to explore community and health-care provider attitudes towards maltreatment during delivery in rural northern Ghana, and compare findings against The White Ribbon Alliance's seven fundamental rights of childbearing women. Design: a cross-sectional qualitative study using in-depth interviews and focus groups. Setting: the Kassena-Nankana District of rural northern Ghana between July and October 2010. Participants: 128 community members, including mothers with newborn infants, grandmothers, household heads, compound heads, traditional healers, traditional birth attendants, and community leaders, as well as 13 formally trained health-care providers. Measurements and findings: 7 focus groups and 43 individual interviews were conducted with community members, and 13 individual interviews were conducted with health-care providers. All interviews were transcribed verbatim and entered into NVivo 9.0 for analysis. Despite the majority of respondents reporting positive experiences, unprompted, maltreatment was brought up in 6 of 7 community focus groups, 14 of 43 community interviews, and 8 of 13 interviews with health-care providers. Respondents reported physical abuse, verbal abuse, neglect, and discrimination. One additional category of maltreatment identified was denial of traditional practices. Key conclusions: maltreatment was spontaneously described by all types of interview respondents in this community, suggesting that the problem is not uncommon and may dissuade some women from seeking facility delivery. Implications for practice: provider outreach in rural northern Ghana is necessary to address and correct the problem, ensuring that all women who arrive at a facility receive timely, professional, nonjudgmental, high-quality delivery care.

Aim: Encouraging women to deliver in facility settings is one strategy to improve maternal and neonatal outcomes in the developing world. However, in much of sub-Saharan Africa, fewer than half of pregnant women deliver in health facilities. Fear of maltreatment during labor and delivery has been shown to be one barrier to facility delivery, yet previous studies have focused solely on reports from women, rarely seeking insights from practicing midwives. Method: All seven practicing midwives from a rural hospital in Ghana and ten pregnant women seeking antenatal care from the same hospital were recruited to participate in in-depth interviews regarding their perceptions of care during labor and delivery. A semi-structured interview tool and qualitative field interviewing approach were utilized. All interviews were audio taped, transcribed, and analyzed using NVivo 9.0. Results: Respondents described situations that precipitate abuse during facility deliveries, yet not all abuse was seen as acceptable. Two overarching themes emerged: 1) The interaction between midwives and their patients is analogous to a mother/daughter relationship, including both a knowledge imbalance and the need for disciplinary action when necessary; and 2) Midwives feel a strong sense of responsibility for the delivery outcomes and as a result, they will do whatever it takes to deliver a live baby to a healthy mother. Hitting, yelling, and neglecting women were reported as common occurrences in the labor and delivery ward. However, each was undertaken to encourage women to do what was needed to deliver safely. Conclusion: These findings suggest that the issue of patient maltreatment in low-resource labor and delivery settings is complex and may be undertaken in what is perceived to be the laboring woman’s best interest. The exploration of alternative strategies to facilitate labor and delivery is warranted, as well as the provision of adequate support and resources for practicing midwives in rural settings.

OBJECTIVE: To determine whether facility delivery is related to compliance with recommended infant immunizations particularly those that occur weeks or months after delivery. METHODS: In a retrospective analysis multivariate logistic regression was used to assess data from the 2011 Ethiopia Demographic and Health Survey (EDHS) to determine the strongest correlates of facility delivery. These correlates were then used along with facility delivery itself to determine the relationship between facility delivery and infant immunization. RESULTS: In total 3334 women delivered a newborn 12-24months before the 2011 EDHS: 90.2% (3007) delivered at home and 9.8% (327) delivered in a facility. Education wealth status urban residence and number of children under 5years living in the household were the factors most strongly associated with facility delivery. When facility delivery and its strongest correlates were entered into multivariate logistic regression models with infant immunizations as the outcome facility delivery was significantly associated with increased likelihood of DPT-HepB-Hib polio and measles vaccination and increased likelihood of being fully immunized (all P

SummaryThis study aimed to explore pregnant women's attitudes towards the inclusion of a lay companion as a source of social support during labour and delivery in rural central Ghana. Quantitative demographic and pregnancy-related data were collected from 50 pregnant women presenting for antenatal care at a rural district hospital and analysed using STATA/IC 11.1. Qualitative attitudinal questions were collected from the same women through semi-structured interviews; data were analysed using NVivo 9.0. Twenty-nine out of 50 women (58%) preferred to have a lay companion during facility-based labour and delivery, whereas 21 (42%) preferred to deliver alone with the nurses in a facility. Women desiring a companion were younger, had more antenatal care visits, had greater educational attainment and were likely to be experiencing their first delivery. Women varied in the type of companion they prefer (male partner vs female relative). What was expected in terms of social support differed based upon the type of companion. Male companions were expected to provide emotional support and to ‘witness her pain’. Female companions were expected to provide emotional support as well as instrumental, informational and appraisal support. Three qualitative themes were identified that run counter to the inclusion of a lay helper: fear of an evil-spirited companion, a companion not being necessary or helpful, and being ‘too shy’ of a companion. This research challenges the assumption of a unilateral desire for social support during labour and delivery, and suggests that women differ in the type of companion and type of support they prefer during facility deliveries. Future research is needed to determine the direction of the relationship – whether women desire certain types of support and thus choose companions they believe can meet those needs, or whether women desire a certain companion and adjust their expectations accordingly.

article i nfo Objective: To determine the types of access to care most strongly associated with facility-based delivery among women in Ghana. Methods: Data relating to the "5 As of Access" framework were extracted from the 2008 Ghana Demographic Health Survey and analyzed using multivariate logistic regression. Results: In all, 55.5% of a weighted sample of 1102 women delivered in a healthcare facility, whereas 45.5% delivered at home. Affordability was the strongest access factor associated with delivery location, with health insurance coverage tripling the odds of facility delivery. Availability, accessibility (except urban residence), acceptabil- ity, and social access variables were not significant factors in the final models. Social access variables, includ- ing needing permission to seek healthcare and not being involved in decisions regarding healthcare, were associated with a reduced likelihood of facility-based delivery when examined individually. Multivariate analysis suggested that these variables reflected maternal literacy, health insurance coverage, and household wealth, all of which attenuated the effects of social access. Conclusion: Affordability was an important deter- minant of facility delivery in Ghana—even among women with health insurance—but social access variables had a mediating role.

Background: Social, cultural, and behavioral factors are often potent upstream contributors to maternal, neonatal, and child mortality, especially in low- and middle-income countries (LMICs). Social autopsy is one method of identifying the impact of such factors, yet it is unclear how social autopsy methods are being used in LMICs. Objective: This study aimed to identify the most common social autopsy instruments, describe overarching findings across populations and geography, and identify gaps in the existing social autopsy literature. Methods: A systematic search of the peer-reviewed literature from 2005 to 2016 was conducted. Studies were included if they were conducted in an LMIC, focused on maternal/neonatal/infant/child health, reported on the results of original research, and explicitly mentioned the use of a social autopsy tool. Results: Sixteen articles out of 1950 citations were included, representing research conducted in 11 countries. Five different tools were described, with two primary conceptual frameworks used to guide analysis: Pathway to Survival and Three Delays models. Studies varied in methods for identifying deaths, and recall periods for respondents ranged from 6 weeks to 5+ years. Across studies, recognition of danger signs appeared to be high, while subsequent care-seeking was inconsistent. Cost, distance to facility, and transportation issues were frequently cited barriers to care-seeking, however, additional barriers were reported that varied by location. Gaps in the social autopsy literature include the lack of: harmonized tools and analytical methods that allow for cross-study comparisons, discussion of complexity of decision making for care seeking, qualitative narratives that address inconsistencies in responses, and the explicit inclusion of perspectives from husbands and fathers. Conclusion: Despite the nascence of the field, research across 11 countries has included social autopsy methods, using a variety of tools, sampling methods, and analytical frameworks to determine how social factors impact maternal, neonatal, and child health outcomes.

To explore community understanding of perinatal illness in northern Ghana.A cross-sectional descriptive study design.253 community members participated in in-depth interviews and focus group discussions, including women with newborn infants, grandmothers and health care providers. Four overarching themes emerged: (1) Local understanding of illness affects treatment practices. Respondents recognized danger signs of illness spanning antenatal to early neonatal periods. Understanding of causation often had a distinctly local flavor, and thus treatment sometimes differed from mainstream recommendations; (2) Mothers are frequently blamed for their infant's illness; (3) Healthcare decisions regarding infant care are often influenced by community members aside from the infant's mother and (4) Confidence in healthcare providers is issue-specific, and many households use a blended approach to meet their health needs.Despite widespread recognition of danger signs and reported intentions to treat ill infants through the formal health care system, traditional approaches to perinatal illness remain common. Interventions need to be aligned with community perceptions if they are to succeed.

This study explored the relationship between facility-based delivery and infant immunizations in sub-Saharan Africa, controlling for economic development indicators. Publically available data were collected and imported into Stata 11.0 for descriptive, correlation, and regression analyses. Facility delivery was significantly associated with full vaccination and BCG immunization in children aged 12-23 months. Facility delivery was associated with full vaccination (p

Objective: This study assessed the perception of risk of cervical cancer and existence of risk factors for cervical cancer based on five known risk factors among women attending the Tamale Teaching Hospital in Tamale, Ghana. Methods: A consecutive sample of 300 women was interviewed using a semi structured questionnaire to inquire about risk factors and perception of risk of cervical cancer. Specific risk factors that were explored included early coitarche, multiple sexual partners, polygamous relationships, history of smoking, and having a current partner who had multiple sexual partners. Results: Sixty-one per cent of women reported that they had no personal risk for cervical cancer. 27% of respondents were in polygamous relationships, and of those, more than half didn’t think they were at an increased risk of cervical cancer. 2 women had a total of ≥ 5 sexual partners in their lifetime and neither believed they were at any risk for cervical cancer. 23% said their current partner had had at least 2 sexual partners in his lifetime, and of those, (61%) thought they were at no risk for cervical cancer. 46% of respondents reported not having any of the risk factors listed in the study. 23% of respondents reported having one risk factor while 21% had two risk factors and 11% had three or more risk factors. Conclusion: Women’s perception of personal risk for cervical cancer is lower than their actual risk based on the five behavioural risk factors assessed and a lack of knowledge of the personal factors for the disease Funding: This project was supported by NIH Research Training Grant #R25 TW009345 funded by the Fogarty International Centre, in partnership with several NIH Institutes (NIMH, NIGMS, NHLBI, OAR and OWH) Keywords: Cervical Cancer, Risk, Perceptions, Northern Ghana

Summary In this Series we document the substantial progress in the reduction of maternal mortality and discuss the current state of science in reducing maternal mortality. However, maternal health is also powerfully influenced by the structures and resources of societies, communities, and health systems. We discuss the shocks from outside of the field of maternal health that will influence maternal survival including economic growth in low-income and middle-income countries, urbanisation, and health crises due to disease outbreaks, extreme weather, and conflict. Policy and technological innovations, such as universal health coverage, behavioural economics, mobile health, and the data revolution, are changing health systems and ushering in new approaches to affect the health of mothers. Research and policy will need to reflect the changing maternal health landscape.

To improve maternal health requires action to ensure quality maternal health care for all women and girls, and to guarantee access to care for those outside the system. In this paper, we highlight some of the most pressing issues in maternal health and ask: what steps can be taken in the next 5 years to catalyse action toward achieving the Sustainable Development Goal target of less than 70 maternal deaths per 100?000 livebirths by 2030, with no single country exceeding 140? What steps can be taken to ensure that high-quality maternal health care is prioritised for every woman and girl everywhere? We call on all stakeholders to work together in securing a healthy, prosperous future for all women. National and local governments must be supported by development partners, civil society, and the private sector in leading efforts to improve maternal–perinatal health. This effort means dedicating needed policies and resources, and sustaining implementation to address the many factors influencing maternal health-care provision and use. Five priority actions emerge for all partners: prioritise quality maternal health services that respond to the local specificities of need, and meet emerging challenges; promote equity through universal coverage of quality maternal health services, including for the most vulnerable women; increase the resilience and strength of health systems by optimising the health workforce, and improve facility capability; guarantee sustainable finances for maternal–perinatal health; and accelerate progress through evidence, advocacy, and accountability.This is the sixth in a Series of six papers about maternal health.

Despite global attention, high levels of maternal mortality continue to plague many low- and middle-income settings. One important way to improve the care of women in labour is to increase the proportion of women who deliver in a health facility. However, due to poor quality of care, including being disrespected and abused, women are reluctant to come to facilities for delivery care. The current study sought to examine disrespectful and abusive treatment towards labouring women from the perspective of midwifery students who were within months of graduation. Key Messages •Midwifery students in Ghana’s public midwifery schools report witnessing and participating in many forms of disrespect and abuse during deliveries as part of their education. While they are clear as to why respectful care is important and necessary, they are able to justify and explain reasons for disrespectful and abusive care. This poor treatment of labouring women was explicitly and tacitly supported by these students’ teachers and preceptors. •All study materials and methods were reviewed and approved by the Ghana Health Service Ethical Review Committee, the Kwame Nkrumah University of Science and Technology Committee on Publication and Human Ethics, and the University of Michigan Institutional Review Board. •This research was made possible through a grant from the African Studies Center, University of Michigan. For this study, we conducted focus groups with final year midwifery students at 15 public midwifery training colleges in all 10 of Ghana’s regions. Focus group discussions were recorded and transcribed. A multi-disciplinary team of researchers from the US and Ghana analysed the qualitative data. While students were able to talk at length as to why respectful care is important, they were also able to recount times when they both witnessed and participated in disrespectful and abusive treatment of labouring women. The themes which emerged from these data are: 1) rationalization of disrespectful and abusive care; 2) the culture of blame and; 3) no alternative to disrespect and abuse. Although midwifery students in Ghana’s public midwifery schools highlight the importance of providing high-quality, patient-centred respectful care, they also report many forms of disrespect and abuse during childbirth. Without better quality care, including making care more humane, the use of facility-based maternity services in Ghana is likely not to improve. This study provides an important starting point for educators, researchers, and policy makers to re-think how the next generation of healthcare providers needs to be prepared to provide high-quality, respectful care to women during labour and delivery in low-resource settings.

Although the past decade has brought global reductions in maternal, infant and child mortality, many low-resource settings have failed to make significant gains relative to their high-income counterparts. In Ghana, nearly 50% of under-five mortality in 2014 could be attributed to deaths during the first 28 days after birth. This article analyses the data across a mixed-methods study of the factors impacting maternal and neonatal care in northern Ghana. The stillbirth and neonatal death study (SANDS) was conducted in 2010 and included both quantitative (N = 20 497) and qualitative data collection (N = 253) to explore the issues associated with the continuum of reproductive health care. Findings were compared against an adaptation of the WHO/UNICEF framework for integrated maternal and newborn care and used to generate concrete recommendations for clinicians, policymakers and programmers across the continuum of care, from pregnancy through delivery and postnatal care. SANDS elucidated epidemiological trends: 40% of neonatal deaths occurred on the first day after birth, and the leading causes of early neonatal mortality were birth asphyxia/injury, infection and complications of prematurity. Qualitative data reflect findings along two axes-community to facility-based care, and pre-pregnancy through the postnatal period. Resulting recommendations include the need to improving clinicians' understanding of and sensitization to local traditional practices, the need for policies to better address quality of care and coordination of training efforts, and the need for comprehensive, integrated programmes that ensure continuity of care from pre-pregnancy through the post-partum period. SANDS illustrates complex medical-social-cultural knowledge, attitudes and practices that span the reproductive period in rural northern Ghana. Data illustrate that not only are the first few days of life critical in infant survival but also there are significant social and cultural barriers to ensuring that mothers and their newborns are cared for in a timely, evidence-based manner.

Incontinence-inducing delivery injuries, such as obstetric fistula and anal-sphincter tears, are devastating sequelae of prolonged and obstructed labor, and can only be repaired through surgery. Such injuries are most prevalent in settings where delays and limitations in accessing emergency obstetric services are common [1, 2]. The 2011 Demographic and Health Survey of Uganda [3] estimated that 2% of Ugandan women have experienced obstetric fistula and resulting trans-vaginal urine or fecal incontinence. This article is protected by copyright. All rights reserved.

Background: Women comprise 75% of the health workforce in many countries and the majority of students in academic global health tracks but are underrepresented in global health leadership. This study aimed to elucidate prevailing attitudes, perceptions, and beliefs of women and men regarding opportunities and barriers for women’s career advancement, as well as what can be done to address barriers going forward. Methods: This was a convergent mixed-methods, cross-sectional, anonymous, online study of participants, applicants, and those who expressed an interest in the Women Leaders in Global Health Conference at Stanford University October 11–12, 2017. Respondents completed a 26-question survey regarding beliefs about barriers and solutions to addressing advancement for women in global health. Findings: 405 participants responded: 96.7% were female, 61.6% were aged 40 or under, 64.0% were originally from high-income countries. Regardless of age or country of origin, leading barriers were: lack of mentorship, challenges of balancing work and home, gender bias, and lack of assertiveness/confidence. Proposed solutions were categorized as individual or meta-level solutions and included senior women seeking junior women for mentorship and sponsorship, junior women pro-actively making their desire for leadership known, and institutions incentivizing mentorship and implementing targeted recruitment to improve diversity of leadership. Interpretation: This study is the first of its kind to attempt to quantify both the barriers to advancement for women leaders in global health as well as the potential solutions. While there is no shortage of barriers, we believe there is room for optimism. A new leadership paradigm that values diversity of thought and diversity of experience will benefit not only the marginalized groups that need to gain representation at the table, but ultimately the broader population who may benefit from new ways of approaching long-standing, intractable problems.

Objective To identify demographic and psychological factors that predict satisfaction or dissatisfaction with outcomes among patients undergoing facial plastic surgery. Methods All patients presenting to the Center for Facial Cosmetic Surgery at the University of Michigan between January 1, 2007, and January 1, 2008, were asked to participate. Patients answered an initial baseline survey consisting of demographic information and an assessment of their baseline level of optimism/pessimism in addition to a surgery-specific outcome questionnaire both preoperatively and 4 to 6 months postoperatively. Results Fifty-one patients (mean [SD] age, 53 [13.0]; 69% female; 98% white) participated. Patients over the mean age of 53 years were more satisfied with their results than those under the mean age ( P = .01). Patients currently being treated for depression were more satisfied with surgical outcomes than those not being treated ( P = .05). No correlation was identified between baseline optimism/pessimism or other baseline factors and patients' perceived surgical outcomes. Surgeons were decidedly less positive in their assessment of the outcome than patients. Conclusion Despite a priori hypotheses that patients treated for depression might be more pessimistic and rate their satisfaction lower than other patients, patients treated for depression show a trend toward greater satisfaction from facial plastic surgical procedures than those not treated for depression.