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Abstract Optimal maternal nutrition, including adequate intake and status of essential micronutrients, is important for the health of women and developing infants. Currently, the World Health Organization (WHO) Antenatal care recommendations for a positive pregnancy experience recommend daily iron and folic acid (IFA) supplementation as the standard of care. The use of multiple micronutrient supplements (MMS) is recommended in the context of rigorous research as more evidence was needed regarding the impact of switching from IFA supplements to MMS, including evaluation of critical clinical maternal and perinatal outcomes, acceptability, feasibility, sustainability, equity and cost‐effectiveness. WHO convened a technical consultation of key stakeholders to discuss research priorities with the objective of providing guidance and clarity to donors, implementers and researchers about this recommendation. The overarching principles of the research agenda include the use of clinical indicators and impact measures that are applicable across studies and settings and the inclusion of outcomes that are important to women. Future studies should consider using standardized protocols based on current best practices to measure critical outcomes such as gestational age (GA) and birthweight (BW) in studies. As GA and BW are influenced by multiple factors, more research is needed to understand the biological impact pathways, and how initiation and considerations for timing of MMS influence these outcomes. A set of core clinical indicators was agreed upon during the technical consultation. For implementation research, the Evidence‐to‐Decision framework was used as a resource for discussing components of implementation research. The implementation research questions, key indicators and performance measures will depend on country‐specific context and bottlenecks that require further research and improved solutions to enable the successful implementation of iron‐containing supplements.

Introduction There are limited global data on ectopic pregnancy (EP) and molar pregnancy (MP), making it important to understand their epidemiology and management across different regions. Our study aimed to describe their prevalence for both conditions, severity of their complications and management among women in selected health facilities across 17 countries in Africa and Latin America and the Caribbean (LAC).Methods This is a secondary analysis of the WHO multi-country survey on abortion. Data were collected from 280 healthcare facilities across 11 countries in Africa and 6 in LAC. Sociodemographic information, signs and symptoms, management and clinical outcomes were extracted from medical records. Facility-level data on post-abortion care (PAC) capabilities were also collected, and facilities were classified accordingly. χ2 or Fisher’s exact tests were used to compare categorical data.Results The total number of women with EP and MP across both regions was 9.9% (2 415/24 424) where EP accounted for 7.8% (1 904/24 424) and MP for 2.1% (511/24 424). EP presented a higher severity of complications than MP. At admission, 49.8% of EP had signs of peritoneal irritation. The most common surgical management for EP was laparotomy (87.2%) and for MP, uterine evacuation (89.8%). Facilities with higher scores in infrastructure and capability to provide PAC more frequently provided minimal invasive management using methotrexate/other medical treatment (34.9%) and laparoscopy (5.1%).Conclusion In Africa and LAC, EP and MP cause significant maternal morbidity and mortality. The disparity in the provision of good quality care highlights the need to strengthen the implementation of evidence-based recommendations in the clinical and surgical management of EP and MP.

The Health Equity Leadership & Exchange Network states that “health equity exists when all people, regardless of race, sex, sexual orientation, disability, socioeconomic status, geographic location, or other societal constructs, have fair and just access, opportunity, and resources to achieve their highest potential for health.” It is clear from the wide discrepancies in maternal and infant mortalities, by race, ethnicity, location, and social and economic status, that health equity has not been achieved in pregnancy care. Although the most obvious evidence of inequities is in low-resource settings, inequities also exist in high-resource settings. In this presentation, based on the Global Pregnancy Collaboration Workshop, which addressed this issue, the bases for the differences in outcomes were explored. Several different settings in which inequities exist in high- and low-resource settings were reviewed. Apparent causes include social drivers of health, such as low income, inadequate housing, suboptimal access to clean water, structural racism, and growing maternal healthcare deserts globally. In addition, a question is asked whether maternal health inequities will extend to and be partially due to current research practices. Our overview of inequities provides approaches to resolve these inequities, which are relevant to low- and high-resource settings. Based on the evidence, recommendations have been provided to increase health equity in pregnancy care. Unfortunately, some of these inequities are more amenable to resolution than others. Therefore, continued attention to these inequities and innovative thinking and research to seek solutions to these inequities are encouraged.

Abstract Background When deciding whether to implement an intervention, decision-makers typically have questions on feasibility and acceptability and on factors affecting implementation. Descriptions of programme implementation and of policies and systems are rich sources of information for these questions. However, this information is often not based on empirical data collected using explicit methods. To use the information in unconventional source materials in syntheses or other decision support products, we need methods of assessing their strengths and limitations. This paper describes the development and content of the Assessing unConventional Evidence (ACE) tool, a new tool to assess the strengths and limitations of these sources. Methods We developed the ACE tool in four stages: first, we examined existing tools to identify potentially relevant assessment criteria. Second, we drew on these criteria and team discussions to create a first draft of the tool. Third, we obtained feedback on the draft from potential users and methodologists, and through piloting the tool in evidence syntheses. Finally, we used this feedback to iteratively refine the assessment criteria and to improve our guidance for undertaking the assessment. Results The tool is made up of 11 criteria including the purpose and context of the source; the completeness of the information presented; and the extent to which evidence is provided to support the findings made. Users are asked to indicate whether each of the criteria have been addressed. On the basis of their judgements for each criterion, users then make an overall assessment of the limitations of the source, ranging from no or very minor concerns to serious concerns. These assessments can then facilitate appropriate use of the evidence in decision support products. Conclusions Through focussing on unconventional source materials, the ACE tool fills an important gap in the range of tools for assessing the strengths and limitations of policy-relevant evidence and supporting evidence-informed decision-making.

Abstract Background The new WHO model for antenatal care (ANC) focuses on improving practice, organisation and delivery of ANC within health systems, which includes both clinical care and women’s experiences of care. The goal of this review is to identify tools and measures on women’s experiences of ANC. Methods We conducted a scoping review to identify tools and measures on women’s experiences of ANC. An iterative approach was used to review all tools in a series of four steps: (1) identify papers between 2007 and 2023; (2) identify the tools from these papers; (3) map relevant measures to conceptualizations of experiences of care, notably mistreatment of women and respectful maternity care and (4) identify gaps and opportunities to improve measures. Results Across the 36 tools identified, a total of 591 measures were identified. Of these, 292/591 (49.4%) measures were included and mapped to the typology of mistreatment of women used as a definition for women’s experiences care during ANC in this review, while 299/591 (44.9%) irrelevant measures were excluded. Across the included measures, the highest concentration was across the domains of poor rapport between women and providers (49.8%) followed by failure to meet professional standards of care (23.3%). Approximately, 13.9% of measures were around overall respectful care, followed by health systems (6.3%), and any physical or verbal abuse, stigma and/or discrimination (4.8%) . Conclusion This analysis provides an overview of the existing tools, gaps and opportunities to measure women’s experiences during ANC. Expanding beyond the childbirth period, these findings can be used to inform existing and future tools for research and monitoring measuring women’s experiences of ANC.

Abstract Background GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative Research) is a methodological approach to systematically and transparently assess how much confidence decision makers can place in individual review findings from qualitative evidence syntheses. The number of reviews applying GRADE-CERQual is rapidly expanding in guideline and other decision-making contexts. The objectives of this evaluation were, firstly, to describe the uptake of GRADE-CERQual in qualitative evidence synthesis by review authors and, secondly, to assess both reporting of and fidelity to the approach. Methods The evaluation had two parts. Part 1 was a citation analysis and descriptive overview of the literature citing GRADE-CERQual. Authors worked together to code and chart the citations, first by title and abstract and second by full text. Part 2 was an assessment and analysis of fidelity to, and reporting of, the GRADE-CERQual approach in included reviews. We developed fidelity and reporting questions and answers based on the most recent guidance for GRADE-CERQual and then used NVivo12 to document assessments in a spreadsheet and code full-text PDF articles for any concerns that had been identified. Our assessments were exported to Excel and we applied count formulae to explore patterns in the data. We employed a qualitative content analysis approach in NVivo12 to sub-coding all the data illustrating concerns for each reporting and fidelity criteria. Results 233 studies have applied the GRADE-CERQual approach, with most (n = 225, 96.5%) in the field of health research. Many studies (n = 97/233, 41.6%) were excluded from full fidelity and reporting assessment because they demonstrated a serious misapplication of GRADE-CERQual, for example interpreting it as a quality appraisal tool for primary studies or reviews. For the remaining studies that applied GRADE-CERQual to assess confidence in review findings, the main areas of reporting concern involved terminology, labelling and completeness. Fidelity concerns were identified in more than half of all studies assessed. Conclusions GRADE-CERQual is being used widely within qualitative evidence syntheses and there are common reporting and fidelity issues. Most of these are avoidable and we highlight these as gaps in knowledge and guidance for applying the GRADE-CERQual approach.

Introduction Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal deaths globally and require close monitoring of blood pressure (BP) to mitigate potential adverse effects. Despite the recognised need for research on self-monitoring of blood pressure (SMBP) among pregnant populations, there are very few studies focused on low and middle income contexts, which carry the greatest burden of HDPs. The study aims to understand the perceptions, barriers, and operational considerations for using a smartphone software application to perform SMBP by pregnant women in Lombok, Indonesia.Methods and analysis This study includes a combination of focus group discussions, in-depth interviews and workshop observations. Pregnant women will also be provided with a research version of the smartphone BP application to use in their home and subsequently provide feedback on their experiences. The study will include pregnant women with current or past HDP, their partners and the healthcare workers involved in the provision of antenatal care services within the catchment area of six primary healthcare centres. Data obtained from the interviews and observations will undergo thematic analyses using a combination of both inductive and deductive approaches.Ethics and dissemination The study was approved by the World Health Organization (WHO) and Human Reproduction Programme (HRP) Research Project Review Panel and WHO Ethical Review Committee (A65932) as well as the Health Research Ethics Committee, Faculty of Medicine, Universitas Mataram in Indonesia (004/UN18/F7/ETIK/2023).Findings will be disseminated through research publications and communicated to the Lombok district health offices. The analyses from this study will also inform the design of a subsequent impact evaluation.

Background Postpartum depression (PPD) is a leading cause of disability globally with estimated prevalence of approximately 20% in low-income and middle-income countries. This study aims to determine the prevalence and factors associated with PPD following mistreatment during facility-based childbirth.Method This secondary analysis used data from the community survey of postpartum women in Ghana, Guinea, Myanmar and Nigeria for the WHO study, ‘How women are treated during facility-based childbirth’. PPD was defined using the Patient Health Questionnaire (PHQ-9) tool. Inferential analyses were done using the generalised ordered partial proportional odds model.Results Of the 2672 women, 39.0% (n=1041) developed PPD. 42.2% and 5.2% of mistreated women developed minimal/mild PPD and moderate/severe PPD, respectively. 43.0% and 50.6% of women who experienced verbal abuse and stigma/discrimination, respectively developed minimal/mild PPD. 46.3% of women who experienced physical abuse developed minimal/mild PPD while 7.6% of women who experienced stigma/discrimination developed moderate/severe PPD. In the adjusted model, women who were physically abused, verbally abused and stigma/discrimination compared with those who were not were more likely to experience any form of PPD ((OR: 1.57 (95% CI 1.19 to 2.06)), (OR: 1.42 (95% CI 1.18 to 1.69)) and (OR: 1.69 (95% CI 1.03 to 2.78))), respectively. Being single and having higher education were associated with reduced odds of experiencing PPD.Conclusion PPD was significantly prevalent among women who experienced mistreatment during childbirth. Women who were single, and had higher education had lower odds of PPD. Countries should implement women-centred policies and programmes to reduce mistreatment of women and improve women’s postnatal experiences.

Objectives Digital adaptation kits (DAKs) distill WHO guidelines for digital use by representing them as workflows, data dictionaries and decision support tables. This paper aims to highlight key lessons learnt in coding data elements of the antenatal care (ANC) and family planning DAKs to standardised classifications and terminologies (CATs).Methods We encoded data elements within the ANC and family planning DAKs to standardised CATs from the WHO CATs and other freely available CATs.Results The coding process demonstrated approaches to refine the data dictionaries and enhance alignment between data elements and CATs.Discussion Applying CATs to WHO clinical and public health guidelines can ensure that recommendations are operationalised in a digital system with appropriate consistency and clarity. This requires a multidisciplinary team and careful review to achieve conceptual equivalence between data elements and standardised terminologies.Conclusion The systematic translation of guidelines into digital systems provides an opportunity for leveraging CATs; however, this approach needs further exploration into its implementation in country contexts and transition into machine-readable components.

# Background Globally, most maternal deaths occur during the first twenty-four hours after childbirth. Although different interventions have been implemented to improve maternal health care utilisation in Ethiopia, including immediate postnatal care, information regarding the change in immediate postnatal care utilisation over time is lacking. This study aimed to examine the trends of immediate postnatal care utilisation from the year 2011 to 2019 and to identify factors associated with immediate postnatal care utilisation using nationwide demographic and health survey data. # Methods The study was conducted using secondary data from Ethiopia Demographic and Health Survey (EDHS) in 2011 (n=4268), 2016 (n=4081), and 2019 (n=2159). The trend analysis was conducted using data from the three surveys, however, only the latest survey data were used for the analysis of factors associated with immediate postnatal care utilisation. Bivariable and multivariable logistic regression analysis was carried out to identify factors associated with immediate postnatal care utilisation. Odds ratio (OR) with a 95% confidence level (CI) was computed and adjustment was made to the survey design (i.e., weight, stratification, and clustering). # Results The percentage of women who received immediate postnatal check increased from 6.4% (95% CI=5.1-8.0) in 2011 to 16.3% (95% CI=14.3-19.0) in 2016 to 33.4 % (95% CI=28.6-39.0) in 2019. Moreover, health facility births and the percentage of women who had four or more antenatal care visits increased in this period. Having less than four (adjusted OR (aOR)=3.33; 95% CI=1.77-6.24) and greater than and equal to four antenatal care visits (aOR=7.19; 95% CI=3.80-13.56), and caesarean delivery (aOR=4.39; 95% CI=2.28-8.46) were factors positively associated with immediate postnatal care utilisation. On the other hand, giving birth at a health facility (aOR=0.04; 95% CI=0.02-0.07) was negatively associated with immediate postnatal care utilisation. # Conclusions The study showed consistent improvements in immediate postnatal care utilisation between 2011 and 2019. Despite the progress, the coverage remains low in Ethiopia, only reaching one-third of those who need it. More tailored and context-specific efforts across the continuum of maternal health care services are needed to improve the utilisation and quality of postnatal care.

Abstract Background The World Health Organization (WHO) recommends self-monitoring of blood pressure (SMBP) for hypertension management. In addition, during the COVID-19 response, WHO guidance also recommends SMBP supported by health workers although more evidence is needed on whether SMBP of pregnant individuals with hypertension (gestational hypertension, chronic hypertension, or pre-eclampsia) may assist in early detection of pre-eclampsia, increase end-user autonomy and empowerment, and reduce health system burden. To expand the evidence base for WHO guideline on self-care interventions, we conducted a systematic review of SMBP during pregnancy on maternal and neonatal outcomes. Methods We searched for publications that compared SMBP with clinic-based monitoring during antenatal care. We included studies measuring any of the following outcomes: maternal mortality, pre-eclampsia, long-term risk and complications, autonomy, HELLP syndrome, C-section, antenatal hospital admission, adverse pregnancy outcomes, device-related issues, follow-up care with appropriate management, mental health and well-being, social harms, stillbirth or perinatal death, birthweight/size for gestational age, and Apgar score. After abstract screening and full-text review, we extracted data using standardized forms and summarized findings. We also reviewed studies assessing values and preferences as well as costs of SMBP. Results We identified 6 studies meeting inclusion criteria for the effectiveness of SMBP, 6 studies on values and preferences, and 1 study on costs. All were from high-income countries. Overall, when comparing SMBP with clinic-monitoring, there was no difference in the risks for most of the outcomes for which data were available, though there was some evidence of increased risk of C-section among pregnant women with chronic hypertension. Most end-users and providers supported SMBP, motivated by ease of use, convenience, self-empowerment and reduced anxiety. One study found SMBP would lower health sector costs. Conclusion Limited evidence suggests that SMBP during pregnancy is feasible and acceptable, and generally associated with maternal and neonatal health outcomes similar to clinic-based monitoring. However, more research is needed in resource-limited settings. Systematic review registration PROSPERO CRD42021233839 .

Plain language summary Respectful maternity care is vital to achieving positive pregnancy and childbirth experiences for women and their families. Mistreatment of women during childbirth at facilities can negatively impact women’s future health seeking behaviors and utilization of maternal care services. The experiences and perspectives of doctors, midwives and nurses working in labour wards are vital in understanding how women are treated during childbirth, and what measures can be taken to prevent it. In this study, we explored the opinions of health workers and hospital administrators on how women are treated during childbirth to determine the gaps in the quality of maternal care in health facilities in Ghana. Participants expressed mixed feelings concerning mistreatment of women during childbirth. Most were aware of the occurrence of mistreatment in health facilities including physical and verbal abuse, and denial of preferred position for childbirth and companionship. The reasons provided for mistreatment included low staff capacity, high workload, non-compliance by women and poor attitudes towards health workers. Most health workers were against mistreatment during childbirth. Participants thought mistreatment could be minimized by improving staff skills, refresher training, and childbirth preparation education for women. Our study indicates the need to motivate, retrain or encourage health professionals to provide respectful care to women during childbirth to improve their experience of care. Further research to help implement better maternity care devoid of mistreatment in health facilities in Ghana is needed.

IntroductionThe World Health Organization (WHO) recommends treatment and management of gestational diabetes (GD) through lifestyle changes, including diet and exercise, and self-monitoring blood glucose (SMBG) to inform timely treatment decisions. To expand the evidence base of WHO's guideline on self-care interventions, we conducted a systematic review of SMBG among pregnant individuals with GD.SettingFollowing PRISMA guidelines, we searched PubMed, CINAHL, LILACS, and EMBASE for publications through November 2020 comparing SMBG with clinic-based monitoring during antenatal care (ANC) globally.Primary and secondary outcome measuresWe extracted data using standardized forms and summarized maternal and newborn findings using random effects meta-analysis in GRADE evidence tables. We also reviewed studies on values, preferences, and costs of SMBG.ResultsWe identified 6 studies examining SMBG compared to routine ANC care, 5 studies on values and preferences, and 1 study on costs. Nearly all were conducted in Europe and North America. Moderate-certainty evidence from 3 randomized controlled trials (RCTs) showed that SMBG as part of a package of interventions for GD treatment was associated with lower rates of preeclampsia, lower mean birthweight, fewer infants born large for gestational age, fewer infants with macrosomia, and lower rates of shoulder dystocia. There was no difference between groups in self-efficacy, preterm birth, C-section, mental health, stillbirth, or respiratory distress. No studies measured placenta previa, long-term complications, device-related issues, or social harms. Most end-users supported SMBG, motivated by health benefits, convenience, ease of use, and increased confidence. Health workers acknowledged SMBG's convenience but were wary of technical problems. One study found SMBG by pregnant individuals with insulin-dependent diabetes was associated with decreased costs for hospital admission and length of stay.ConclusionSMBG during pregnancy is feasible and acceptable, and when combined in a package of GD interventions, is generally associated with improved maternal and neonatal health outcomes. However, research from resource-limited settings is needed.Systematic Review RegistrationPROSPERO CRD42021233862.

Objective To identify current and emerging self-care interventions to improve maternity healthcare.Design Scoping review.Data sources MEDLINE, Embase, EmCare, PsycINFO, Cochrane CENTRAL/CDSR, CINAHL Plus (last searched on 17 October 2021).Eligibility criteria Evidence syntheses, interventional or observational studies describing any tool, resource or strategy to facilitate self-care in women preparing to get pregnant, currently pregnant, giving birth or post partum.Data extraction/synthesis Screening and data collection were conducted independently by two reviewers. Self-care interventions were identified based on predefined criteria and inductively organised into 11 categories. Characteristics of study design, interventions, participants and outcomes were recorded.Results We identified eligible 580 studies. Many included studies evaluated interventions in high-income countries (45%) and during antenatal care (76%). Self-care categories featuring highest numbers of studies were diet and nutrition (26% of all studies), physical activity (24%), psychosocial strategies (18%) and other lifestyle adjustments (17%). Few studies featured self-care interventions for sexual health and postpartum family planning (2%), self-management of medication (3%) and self-testing/sampling (3%). Several venues to introduce self-care were described: health facilities (44%), community venues (14%), digital platforms (18%), partner/peer support (7%) or over-the-counter products (13%). Involvement of health and community workers were described in 38% and 8% of studies, who supported self-care interventions by providing therapeutics for home use, training or counselling. The most common categories of outcomes evaluated were neonatal outcomes (eg, birth weight) (31%), maternal mental health (26%) and labour outcomes (eg, duration of labour) (22%).Conclusion Self-care interventions in maternal care are diverse in their applications, implementation characteristics and intended outcomes. Many self-care interventions were implemented with support from the health system at initial stages of use and uptake. Some promising self-care interventions require further primary research, though several are matured and up-to-date evidence syntheses are needed. Research on self-care in the preconception period is lacking.

Introduction Engaging the community as actors within reproductive, maternal, newborn and child health (RMNCH) programmes (referred to as ‘community blank’) has seen increased implementation in recent years. While evidence suggests these approaches are effective, terminology (such as ‘community engagement,’ ‘community participation,’ ‘community mobilisation,’ and ‘social accountability’) is often used interchangeably across published literature, contributing to a lack of conceptual clarity in practice. The purpose of this review was to describe and clarify varying uses of these terms in the literature by documenting what authors and implementers report they are doing when they use these terms.Methods Seven academic databases (PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Global Health), two grey literature databases (OAIster, OpenGrey) and relevant organisation websites were searched for documents that described ‘community blank’ terms in RMNCH interventions. Eligibility criteria included being published between 1975 and 1 October 2021 and reports or studies detailing the activities used in ‘community blank.’Results A total of 9779 unique documents were retrieved and screened, with 173 included for analysis. Twenty-four distinct ‘community blank’ terms were used across the documents, falling into 11 broader terms. Use of these terms was distributed across time and all six WHO regions, with ‘community mobilisation’, ‘community engagement’ and ‘community participation’ being the most frequently used terms. While 48 unique activities were described, only 25 activities were mentioned more than twice and 19 of these were attributed to at least three different ‘community blank’ terms.Conclusion Across the literature, there is inconsistency in the usage of ‘community blank’ terms for RMNCH. There is an observed interchangeable use of terms and a lack of descriptions of these terms provided in the literature. There is a need for RMNCH researchers and practitioners to clarify the descriptions reported and improve the documentation of ‘community blank’ implementation. This can contribute to a better sharing of learning within and across communities and to bringing evidence-based practices to scale. Efforts to improve reporting can be supported with the use of standardised monitoring and evaluation processes and indicators. Therefore, it is recommended that future research endeavours clarify the operational definitions of ‘community blank’ and improve the documentation of its implementation.

Despite global attention, physical and verbal abuse remains prevalent in maternity and newborn healthcare. We aimed to establish theoretical principles for interventions to reduce such abuse. We undertook a mixed methods systematic review of health and social care literature (MEDLINE, SocINDEX, Global Index Medicus, CINAHL, Cochrane Library, Sept 29th 2020 and March 22nd 2022: no date or language restrictions). Papers that included theory were analysed narratively. Those with suitable outcome measures were meta-analysed. We used convergence results synthesis to integrate findings. In September 2020, 193 papers were retained (17,628 hits). 154 provided theoretical explanations; 38 were controlled studies. The update generated 39 studies (2695 hits), plus five from reference lists (12 controlled studies). A wide range of explicit and implicit theories were proposed. Eleven non-maternity controlled studies could be meta-analysed, but only for physical restraint, showing little intervention effect. Most interventions were multi-component. Synthesis suggests that a combination of systems level and behavioural change models might be effective. The maternity intervention studies could all be mapped to this approach. Two particular adverse contexts emerged; social normalisation of violence across the socio-ecological system, especially for 'othered' groups; and the belief that mistreatment is necessary to minimise clinical harm. The ethos and therefore the expression of mistreatment at each level of the system is moderated by the individuals who enact the system, through what they feel they can control, what is socially normal, and what benefits them in that context. Interventions to reduce verbal and physical abuse in maternity care should be locally tailored, and informed by theories encompassing all socio-ecological levels, and the psychological and emotional responses of individuals working within them. Attention should be paid to social normalisation of violence against 'othered' groups, and to the belief that intrapartum maternal mistreatment can optimise safe outcomes.

Labouring women may be subjected to physical and verbal abuse that reflects dynamics of power, described as Mistreatment of Women (MoW). This Critical Interpretive Synthesis on power and MoW consolidates current research and advances theory and practice through inter-disciplinary literature exploration. The review was undertaken in 3 phases. Phase 1 consisted of topic scoping; phase 2 entailed exploration of key power-related drivers emerging from the topic scoping; and phase 3 entailed data synthesis and analysis, with a particular focus on interventions. We identified 63 papers for inclusion in Phase 1. These papers utilized a variety of methods and approaches and represented a wide range of geographic regions. The power-related drivers of mistreatment in these articles span multiple levels of the social ecological model, including intrapersonal (e.g. lack of knowledge about one’s rights), interpersonal (e.g. patient-provider hierarchy), community (e.g. widespread discrimination against indigenous women), organizational (e.g. pressure to achieve performance goals), and law/policy (e.g. lack of accountability for rights violations). Most papers addressed more than one level of the social-ecological model, though a significant minority were focused just on interpersonal factors. During Phase 1, we identified priority themes relating to under-explored power-related drivers of MoW for exploration in Phase 2, including lack of conscientization and normalization of MoW; perceptions of fitness for motherhood; geopolitical and ethnopolitical projects related to fertility; and pressure to achieve quantifiable performance goals. We ultimately included 104 papers in Phase 2. The wide-ranging findings from Phase 3 (synthesis and analysis) coalesce in several key meta-themes, each with their own evidence-base for action. Consistent with the notion that research on power can point us to “drivers of the drivers,” the paper includes some intervention-relevant insights for further exploration, including as relating to broader social norms, health systems design, and the utility of multi-level strategies.

Recent years have demonstrated an increase in caesarean section (CS) in most countries worldwide with considerable concern for the potential consequences. In 2015, WHO proposed the use of Robson classification as a global standard for assessing, monitoring and comparing CS rates. Currently, there is no standardized method to assess CS in Myanmar. The aim of this study was to explore health provider's perceptions about the feasibility, acceptability and readiness to implement the Robson classification in public hospitals across Myanmar. Ten maternities were purposively chosen, including all five teaching hospitals (tertiary referral hospital-level) affiliated to each medical university in Myanmar, which provide maternal and newborn care services, and district/township hospitals. Face-to-face in-depth interviews (IDI) with healthcare providers and facility administrators were conducted using semi-structured discussion guides. Facility and medical records systems were also assessed. We used the thematic analysis approach and Atlas.ti qualitative analysis software. A total of 67 IDIs were conducted. Most participants had willingness to implement Robson classification if there were sufficient human resources and training. Limited human resources, heavy workloads, and infrastructure resources were the major challenges described that may hinder implementation. The focal person for data entry, analysis, or reporting could be differed according to the level of facility, availability of human resources, and ability to understand medical terms and statistics. The respondents mentioned the important role of policy enforcement for the sustainability of data collection, interpretation and feedback. The optimal review interval period could therefore differ according to the availability of responsible persons, and the number of births. However, setting a fixed schedule according to the specific hospital for continuous monitoring of CS rate is required. In Myanmar, implementation of Robson classification is feasible while key barriers mainly related to human resource and training must be addressed to sustain.

Women greatly value and benefit from the presence of someone they trust to support them throughout labour and childbirth ('labour companion of choice'). Labour companionship improves maternal and perinatal outcomes, including enhancing physiological labour and birth experiences. Despite clear benefits, implementation is slow. We conducted a scoping review to assess coverage and models of labour companionship, including quantitative studies reporting coverage of labour companionship in any level health facility globally. We searched MEDLINE, CINAHL, and Global Health from 1 January 2010-14 December 2021. We extracted data on study design, labour companionship coverage, timing and type of companions allowed, and recoded data into categories for comparison across studies. We included data from a maternal health sentinel network of hospitals in Latin America, using descriptive statistics to assess coverage among 120,581 women giving birth in these sites from April 2018-April 2022. In the scoping review, we included 77 studies from 27 countries. There was wide variation in the coverage of labour companionship: almost one-third of studies reported coverage less than 40%, and one-third of studies reported coverage between 40-80%. Husbands or partners were the most frequent companion (37.7%, 29/77), followed by family member or friend (gender not specified) (32.5%, 25/77), family member or friend (female-only) (13.0%, 10/77). Across nine sentinel hospitals in five Latin American countries, there was variation in coverage, with no companion at any time ranging from 14.9%-93.8%. Despite the well-known benefits and factors affecting implementation of labour companionship, more work is needed to improve equitable coverage. Concerted efforts are needed to engage with communities, health workers, health managers, and policy-makers to establish policies, address implementation barriers, and integrate data on coverage into perinatal records and quality processes to ensure that all women have access. Harmonized reporting of labour companionship would greatly enhance understanding at global level.

Effective interpersonal communication is essential to provide respectful and quality maternal and newborn care (MNC). This scoping review mapped, categorized, and analysed strategies implemented to improve interpersonal communication within MNC up to 42 days after birth. Twelve bibliographic databases were searched for quantitative and qualitative studies that evaluated interventions to improve interpersonal communication between health workers and women, their partners or newborns' families. Eligible studies were published in English between January 1st 2000 and July 1st 2020. In addition, communication studies in reproduction related domains in sexual and reproductive health and rights were included. Data extracted included study design, study population, and details of the communication intervention. Communication strategies were analysed and categorized based on existing conceptualizations of communication goals and interpersonal communication processes. A total of 138 articles were included. These reported on 128 strategies to improve interpersonal communication and were conducted in Europe and North America (n = 85), Sub-Saharan Africa (n = 12), Australia and New Zealand (n = 10), Central and Southern Asia (n = 9), Latin America and the Caribbean (n = 6), Northern Africa and Western Asia (n = 4) and Eastern and South-Eastern Asia (n = 2). Strategies addressed three communication goals: facilitating exchange of information (n = 97), creating a good interpersonal relationship (n = 57), and/or enabling the inclusion of women and partners in the decision making (n = 41). Two main approaches to strengthen interpersonal communication were identified: training health workers (n = 74) and using tools (n = 63). Narrative analysis of these interventions led to an update of an existing communication framework. The categorization of different forms of interpersonal communication strategy can inform the design, implementation and evaluation of communication improvement strategies. While most interventions focused on information provision, incorporating other communication goals (building a relationship, inclusion of women and partners in decision making) could further improve the experience of care for women, their partners and the families of newborns.

Abstract Background Increasingly, WHO recommendations are defined by context-specific factors and WHO is developing strategies to ensure that recommendations are successfully adapted and implemented at country level. This manuscript describes the development of a toolkit to support governments to adapt the WHO recommendations on antenatal care (ANC) for a positive pregnancy experience for their context in a systematic manner. Methods The toolkit was developed in three steps. It was created with input from methodologists and regional implementation experts (Step 1) followed by a user-testing phase (Step 2), implemented during country stakeholder meetings. User testing consisted of stakeholder interviews that were transcribed, and data was categorised according to the content analysis method. Suggestions for toolkit improvement and issues identified during the interviews were assessed as serious, moderately serious or minor/cosmetic. Results A total of 22 stakeholders – comprising five Ministry of Health (MoH) consultants, four MoH policy-makers, and 13 advisors/implementers – from Burkina Faso, India, Rwanda and Zambia participated in user-testing interviews during stakeholder meetings held in each country between August 2018 and February 2019. Most stakeholders had a medical or nursing background and half were women. Overall, responses to the toolkit were positive, with all stakeholders finding it useful and desirable. User testing interviews highlighted four serious, four moderately serious and five minor/cosmetic issues to be managed. These were addressed in the final step (Step 3), an updated version of the WHO ANC Recommendations Adaptation Toolkit, comprised of two main components – a baseline assessment tool with spreadsheets for data entry and a Slidedoc®, a dual-purpose document for reading and presentation, outlining the qualitative data that shaped the women-centred perspective of the guidelines, accompanied by an instruction manual detailing the components’ use. Conclusions The WHO ANC Recommendations Adaptation Toolkit was developed to support countries to systematically adapt the WHO ANC recommendations for country contexts. Using this approach, similar tools can be developed to support guideline implementation across different health domains and the continuum of care.

Abstract Background Improving the quality of maternal health care is critical to reduce mortality and improve women’s experiences. Mistreatment during childbirth in health facilities can be an important barrier for women when considering facility-based childbirth. Therefore, this study attempted to explore the acceptability of mistreatment during childbirth in Myanmar according to women and healthcare providers, and to understand how gender power relations influence mistreatment during childbirth. Methods A qualitative study was conducted in two townships in Bago Region in September 2015, among women of reproductive age (18–49 years), healthcare providers and facility administrators. Semi-structured discussion guides were used to explore community norms, and experiences and perceptions regarding mistreatment. Coding was conducted using athematic analysis approach and Atlas.ti. Results were interpreted using a gender analysis approach to explore how power dynamics, hierarchies, and gender inequalities influence how women are treated during childbirth. Results Women and providers were mostly unaccepting of different types of mistreatment. However, some provided justification for slapping and shouting at women as encouragement during labour. Different access to resources, such as financial resources, information about pregnancy and childbirth, and support from family members during labor might impact how women are treated. Furthermore, social norms around pregnancy and childbirth and relationships between healthcare providers and women shape women’s experiences. Both informal and formal rules govern different aspects of a woman’s childbirth care, such as when she is allowed to see her family, whether she is considered “obedient”, and what type of behaviors she is expected to have when interacting with providers. Conclusions This is the first use of gender analysis to explore how gender dynamics and power relations contribute to women’s experiences of mistreatment during childbirth. Both providers and women expected women to understand and “obey” the rules of the health facility and instructions from providers in order to have better experiences. In this way, deviation from following the rules and instructions puts the providers in a place where perpetrating acts of mistreatment were justifiable under certain conditions. Understanding how gender norms and power structures how women are treated during childbirth is critical to improve women’s experiences.

The progressive realisation of universal health coverage requires that health services are not only available and accessible, but also that they are rendered to the population in an acceptable, compassionate and respectful manner to deliver quality of care. Health workers’ competencies play a central role in the provision of compassionate and respectful care (CRC); but health workers’ behaviour is also influenced by the policy and governance environment in which they operate. The identification of relevant policy levers to enhance CRC therefore calls for actions that enable health workers to optimise their roles and fulfil their responsibilities.This paper aims at exploring the health workforce policy and management levers to enable CRC. Through an overview of selected country experiences, concrete examples are provided to illustrate the range of available policy options. Relevant interventions may span the individual, organisational, or system-wide level. Some policies are specific to CRC and may include, among others, the inclusion of relevant competencies in preservice and in-service education, supportive supervision and accountability mechanisms. Other relevant actions depend on a broader workforce governance approach, including policies that target health workforce availability, distribution and working conditions, or wider system -level factors, including regulatory and financing aspects.The selection of the appropriate system-wide and CRC-specific interventions should be tailored to the national and operational context in relation to its policy objectives and feasibility and affordability considerations. The identification of performance metrics and the collation and analysis of required data are necessary to monitor effectiveness of the interventions adopted.

Objectives Digital tools for decision-support and health records can address the protracted process of guideline adoption at local levels and accelerate countries’ implementation of new health policies and programmes. World Health Organization (WHO) launched the SMART Guidelines approach to support the uptake of clinical, public health, and data recommendations within digital systems. SMART guidelines are a package of tools that include Digital Adaptation Kits (DAKs), which distill WHO guidelines into a format that facilitates translation into digital systems. SMART Guidelines also include reference software applications known as digital modules. Methods This paper details the structured process to inform the adaptation of the WHO antenatal care (ANC) digital module to align with country-specific ANC packages for Zambia and Rwanda using the DAK. Digital landscape assessments were conducted to determine potential integrations between the ANC digital module and existing systems. A multi-stakeholder team consisting of Ministry of Health technical officers representing maternal health, HIV, digital health, and monitoring and evaluation at district and national levels was assembled to review existing guidelines to adapt the DAK. Results The landscape analysis resulted in considerations for integrating the ANC module into the broader digital ecosystems of both countries. Adaptations to the DAK included adding national services not reflected in the generic DAK and modification of decision support logic and indicators. Over 80% of the generic DAK content was consistent with processes for both countries. The adapted DAK will inform the customization of country-specific ANC digital modules. Conclusion Both countries found that coordination between maternal and digital health leads was critical to ensuring requirements were accurately reflected within the ANC digital module. Additionally, DAKs provided a structured process for gathering requirements, reviewing and addressing gaps within existing systems, and aligning clinical content.

We have limited understanding of the organisational issues at the health facility-level that impact providers and care as it relates to mistreatment in childbirth, especially in low- and middle-income countries (LMICs). By extension, it is not clear what types of facility-level organisational changes or changes in working environments in LMICs could support and enable respectful maternity care (RMC). While there has been relatively more attention to health system pressures related to shortages of staff and other resources as key barriers, other organisational challenges may be less explored in the context of RMC. This scoping review aims to consolidate evidence to address these gaps. We searched literature published in English between 2000-2021 within Scopus, PubMed, Google Scholar and ScienceDirect databases. Study selection was two-fold. Maternal health articles articulating an organisational issue at the facility- level and impact on providers and/or care in an LMIC setting were included. We also searched for literature on interventions but due to the limited number of related intervention studies in maternity care specifically, we expanded intervention study criteria to include all medical disciplines. Organisational issues captured from the non-intervention, maternal health studies, and solutions offered by intervention studies across disciplines were organised thematically and to establish linkages between problems and solutions. Of 5677 hits, 54 articles were included: 41 non-intervention maternal healthcare studies and 13 intervention studies across all medical disciplines. Key organisational challenges relate to high workload, unbalanced division of work, lack of professional autonomy, low pay, inadequate training, poor feedback and supervision, and workplace violence, and these were differentially influenced by resource shortages. Interventions that respond to these challenges focus on leadership, supportive supervision, peer support, mitigating workplace violence, and planning for shortages. While many of these issues were worsened by resource shortages, medical and professional hierarchies also strongly underpinned a number of organisational problems. Frontline providers, particularly midwives and nurses, suffer disproportionately and need greater attention. Transforming institutional leadership and approaches to supervision may be particularly useful to tackle existing power hierarchies that could in turn support a culture of respectful care.

Stigma and discrimination are fundamental causes of health inequities, and reflect privilege, power, and disadvantage within society. Experiences and impacts of stigma and discrimination are well-documented, but a critical gap remains on effective strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings. We aimed to address this gap by conducting a mixed-methods systematic review and narrative synthesis to describe strategy types and characteristics, assess effectiveness, and synthesize key stakeholder experiences. We searched MEDLINE, CINAHL, Global Health, and grey literature. We included quantitative and qualitative studies evaluating strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings. We used an implementation-focused narrative synthesis approach, with four steps: 1) preliminary descriptive synthesis, 2) exploration of relationships between and across studies, 3) thematic analysis of qualitative evidence, and 4) model creation to map strategy aims and outcomes. Of 8,262 articles screened, we included 12 articles from 10 studies. Nine articles contributed quantitative data, and all measured health worker-reported outcomes, typically about awareness of stigma or if they acted in a stigmatizing way. Six articles contributed qualitative data, five were health worker perspectives post-implementation and showed favorable experiences of strategies and beliefs that strategies encouraged introspection and cultural humility. We mapped studies to levels where stigma can exist and be confronted and identified critical differences between levels of stigma strategies aimed to intervene on and evaluation approaches used. Important foundational work has described stigma and discrimination in sexual and reproductive healthcare settings, but limited interventional work has been conducted. Healthcare and policy interventions aiming to improve equity should consider intervening on and measuring stigma and discrimination-related outcomes. Efforts to address mistreatment will not be effective when stigma and discrimination persist. Our analysis and recommendations can inform future intervention design and implementation research to promote respectful, person-centered care for all.

Abstract Self-care interventions and remote care offer innovative and equitable ways to strengthen access to sexual and reproductive health services. Self-isolation during COVID-19 provided the opportunity for obstetric facilities and healthcare providers to integrate and increase the usage of interventions for self-care and remote care for pregnant women and to improve the quality of care overall.

Abstract Background This is the third in a series of three papers describing the use of qualitative evidence syntheses (QES) to inform the development of clinical and health systems guidelines. WHO has recognised the need to improve its guideline methodology to ensure that decision-making processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable to end users. In addition to the standard data on effectiveness, WHO guidelines increasingly use evidence derived from QES to provide information on acceptability and feasibility and to develop important implementation considerations. Methods WHO convened a group drawn from the technical teams involved in formulating recent (2010–2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. As members of WHO guideline technical teams, our aim in this paper is to explore how we have used findings from QES to develop implementation considerations for these guidelines. Results For each guideline, in addition to using systematic reviews of effectiveness, the technical teams used QES to gather evidence of the acceptability and feasibility of interventions and, in some cases, equity issues and the value people place on different outcomes. This evidence was synthesised using standardised processes. The teams then used the QES to identify implementation considerations combined with other sources of information and input from experts. Conclusions QES were useful sources of information for implementation considerations. However, several issues for further development remain, including whether researchers should use existing health systems frameworks when developing implementation considerations; whether researchers should take confidence in the evidence into account when developing implementation considerations; whether qualitative evidence that reveals implementation challenges should lead guideline panels to make conditional recommendations or only point to implementation considerations; and whether guideline users find it helpful to have challenges pointed out to them or whether they also need solutions. Finally, we need to explore how QES findings can be incorporated into derivative products to aid implementation.

Abstract Background WHO has recognised the need to improve its guideline methodology to ensure that guideline decision-making processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable. To help achieve this, WHO guidelines now typically enhance intervention effectiveness data with evidence on a wider range of decision-making criteria, including how stakeholders value different outcomes, equity, gender and human rights impacts, and the acceptability and feasibility of interventions. Qualitative evidence syntheses (QES) are increasingly used to provide evidence on this wider range of issues. In this paper, we describe and discuss how to use the findings from QES to populate decision-making criteria in evidence-to-decision (EtD) frameworks. This is the second in a series of three papers that examines the use of QES in developing clinical and health system guidelines. Methods WHO convened a writing group drawn from the technical teams involved in its recent (2010–2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. Results We describe a step-wise approach to populating EtD frameworks with QES findings. This involves allocating findings to the different EtD criteria (how stakeholders value different outcomes, equity, acceptability and feasibility, etc.), weaving the findings into a short narrative relevant to each criterion, and inserting this summary narrative into the corresponding ‘research evidence’ sections of the EtD. We also identify areas for further methodological research, including how best to summarise and present qualitative data to groups developing guidelines, how these groups draw on different types of evidence in their decisions, and the extent to which our experiences are relevant to decision-making processes in fields other than health. Conclusions This paper shows the value of incorporating QES within a guideline development process, and the roles that qualitative evidence can play in integrating the views and experiences of relevant stakeholders, including groups who may not be otherwise represented in the decision-making process.

Abstract Background WHO has recognised the need to ensure that guideline processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable. Along with decision-making criteria that require findings from effectiveness reviews, WHO is increasingly using evidence derived from qualitative evidence syntheses (QES) to inform the values, acceptability, equity and feasibility implications of its recommendations. This is the first in a series of three papers examining the use of QES in developing clinical and health systems guidelines. Methods WHO convened a group of methodologists involved in developing recent (2010–2018) guidelines that were informed by QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. Our aim in this paper is to (1) describe and discuss how the findings of QES can inform the scope of a guideline and (2) develop findings for key guideline decision-making criteria. Results QES resulted in the addition of new outcomes that are directly relevant to service users, a stronger evidence base for decisions about how much effective interventions and related outcomes are valued by stakeholders in a range of contexts, and a more complete database of summary evidence for guideline panels to consider, linked to decisions about values, acceptability, feasibility and equity. Conclusions Rigorously conducted QES can be a powerful means of improving the relevance of guidelines, and of ensuring that the concerns of stakeholders, at all levels of the healthcare system and from a wide range of settings, are taken into account at all stages of the process.

Abstract Background An awareness campaign set to accompany the Global Maternal Sepsis Study (GLOSS) was launched in 2017. In order to better develop and evaluate the campaign, we sought to understand the factors that influence awareness of maternal sepsis by exploring healthcare providers’ knowledge, perception of enabling environments, and perception of severity of maternal sepsis. Methods We used a mixed-methods approach that included 13 semi-structured interviews to GLOSS regional and country coordinators and 1555 surveys of providers working in GLOSS participating facilities. Directed content analysis and grounded theory were used for qualitative analysis, based on a framework including four overarching themes around maternal health conditions, determinants of maternal health, barriers and facilitators to sepsis identification and management, plus 24 additional sub-topics that emerged during the interviews. Descriptive statistics for frequencies and percentages were used for the quantitative analysis; significance was tested using Pearson χ2. Logistic regressions were performed to adjust for selected variables. Results Analysis of interviews described limited availability of resources, poor quality of care, insufficient training and lack of protocols as some of the barriers to maternal sepsis identification and management. Analysis from the quantitative survey showed that while 92% of respondents had heard of maternal sepsis only 15% were able to correctly define it and 43% to correctly identify initial management. Provider confidence, perceived availability of resources and of a supportive environment were low (33%, 38%, and 48% respectively). Overall, the predictor that most explained awareness was training. Respondents from the survey and interviewees identified sepsis among the main conditions affecting women at their facilities. Conclusions Awareness on maternal sepsis, while acknowledged as important, remains low. Healthcare providers need resources and support to feel confident about the correct identification and management of sepsis, as a prerequisite for the improvement of awareness of maternal sepsis. Similarly, providers need to know about maternal sepsis and its severity to understand the importance of reducing sepsis-related mortality and morbidity. Awareness raising campaigns can help bring neglected maternal health conditions, such as sepsis, to the forefront of global and local agendas.

Abstract Background Estimates of pregnancies, abortions and pregnancy intentions can help assess how effectively women and couples are able to fulfil their childbearing aspirations. Abortion incidence estimates are also a necessary foundation for research on the safety of abortions performed and the consequences of unsafe abortion. Furthermore, periodic estimates of these indicators are needed to help inform policy and programmes. Methods We will develop a Bayesian hierarchical times series model which estimates levels and trends in pregnancy rates, abortion rates, and percentages of pregnancies and births unintended for each five-year period between 1990 and 2019. The model will be informed by data on abortion incidence and the percentage of births or pregnancies that were unintended. We will develop a data classification process to be applied to all available data. Model-based estimates and associated uncertainty will take account of data sparsity and quality. Our proposed approach will advance previous work in two key ways. First, we will estimate pregnancy and abortion rates simultaneously, and model the propensity to abort an unintended pregnancy, as opposed to modeling abortion rates directly as in prior work. Secondly, we will produce estimates that are reproducible at the country level by publishing the data inputs, data classification processes and source code. Discussion This protocol will form the basis for updated global, regional and national estimates of intended and unintended pregnancy rates, abortion rates, and the percent of unintended pregnancies ending in abortion, from 1990 to 2019.

Introduction While the use of folic acid pre-pregnancy and iron and folic acid (IFA) during pregnancy and postnatal have been demonstrated to be effective and are recommended interventions by WHO, ensuring individuals adhere to the supplementation regimen can be a challenge. Self-care interventions that support an individual’s ability to promote their own health with or without the support of health workers could help promote the uptake and adherence to supplementation. This systematic review assessed the evidence around self-management of IFA or folic acid supplementation accessed over-the-counter during pre-pregnancy, pregnancy and postnatal periods.Methods Peer-reviewed studies were included if they compared self-management of IFA or folic acid supplementation with health worker-initiated supplement use on maternal and/or fetal and newborn health outcomes, end-users’ or health workers’ values and preferences, or cost and/or cost-effectiveness. We searched PubMed, CINAHL, LILACS and EMBASE for articles published through November 2020, hand-searched clinical trial registries, reviewed databases and contacted experts in the field. Abstract screening and full-text review were conducted independently by two reviewers.Results Overall, 2344 results were identified, and 28 studies were identified for full-text review. All studies were excluded, as they were not primary research, lacked the outcomes of interest, lacked specificity in supplement type, and/or lacked a comparison group.Conclusion No evidence was identified that distinguishes self-management of folic acid supplements pre-pregnancy and of IFA supplements during pregnancy and postnatal, highlighting a gap in our current understanding of self-care related to dietary supplementation in pregnancy. The findings of this review identify an area for further research to support the current movement towards self-care interventions as an added choice to help individuals more fully attain their reproductive health and rights.Systematic review registration number PROSPERO CRD42020205548

Objectives To describe the long-term socioeconomic and reproductive health outcomes of women in Uganda by adolescent birth history.Design Cross-sectional study.Setting Uganda.Participants Women aged 40–49 years at the 2016 Uganda Demographic and Health Survey.Outcome measures We compared socioeconomic and reproductive outcomes among those with first birth

BackgroundThe World Health Organization (WHO) recommends one ultrasound scan before 24 weeks gestation as part of routine antenatal care (WHO 2016). We explored influences on provision and uptake through views and experiences of pregnant women, partners, and health workers.MethodsWe undertook a systematic review (PROSPERO CRD42021230926). We derived summaries of findings and overarching themes using metasynthesis methods. We searched MEDLINE, CINAHL, PsycINFO, SocIndex, LILACS, and AIM (Nov 25th 2020) for qualitative studies reporting views and experiences of routine ultrasound provision to 24 weeks gestation, with no language or date restriction. After quality assessment, data were logged and analysed in Excel. We assessed confidence in the findings using Grade-CERQual.FindingsFrom 7076 hits, we included 80 papers (1994-2020, 23 countries, 16 LICs/MICs, over 1500 participants). We identified 17 review findings, (moderate or high confidence: 14/17), and four themes: sociocultural influences and expectations; the power of visual technology; joy and devastation: consequences of ultrasound findings; the significance of relationship in the ultrasound encounter. Providing or receiving ultrasound was positive for most, reportedly increasing parental-fetal engagement. However, abnormal findings were often shocking. Some reported changing future reproductive decisions after equivocal results, even when the eventual diagnosis was positive. Attitudes and behaviours of sonographers influenced service user experience. Ultrasound providers expressed concern about making mistakes, recognising their need for education, training, and adequate time with women. Ultrasound sex determination influenced female feticide in some contexts, in others, termination was not socially acceptable. Overuse was noted to reduce clinical antenatal skills as well as the use and uptake of other forms of antenatal care. These factors influenced utility and equity of ultrasound in some settings.ConclusionThough antenatal ultrasound was largely seen as positive, long-term adverse psychological and reproductive consequences were reported for some. Gender inequity may be reinforced by female feticide following ultrasound in some contexts. Provider attitudes and behaviours, time to engage fully with service users, social norms, access to follow up, and the potential for overuse all need to be considered.

Summary: Background: Amid efforts to improve the quality of care for women and neonates during childbirth, there is growing interest in the experience of care, including respectful care practices. However, there is little research on the prevalence of practices that might constitute mistreatment of neonates. This study aims to describe the care received by neonates up to 2 h after birth in a sample of three countries in west Africa. Methods: Data from this multicountry, facility-based, observational study were collected on 15 neonatal care practices across nine facilities in Ghana, Guinea, and Nigeria, as part of WHO's wider multicountry study on how women are treated during childbirth. Women were eligible if they were admitted to the participating health facilities for childbirth, in early established labour or active labour, aged 15 years or older, and provided written informed consent on behalf of themselves and their neonate. All labour observations were continuous, one-to-one observations of women and neonates by independent data collectors. Descriptive statistics and multivariate logistic regressions were used to examine associations between these neonatal care practices, maternal and neonate characteristics, and maternal mistreatment. Early neonate deaths, stillbirths, and higher order multiple births were excluded from analysis. Findings: Data collection took place from Sept 19, 2016, to Feb 26, 2017, in Nigeria; from Aug 1, 2017, to Jan 18, 2018, in Ghana; and from July 1 to Oct 30, 2017, in Guinea. We included data for 362 women–neonate dyads (356 [98%] with available data for neonatal care practices) in Nigeria, 760 (749 [99%]) in Ghana, and 558 (522 [94%]) in Guinea. Delayed cord clamping was done for most neonates (1493 [91·8%] of 1627); other practices, such as skin-to-skin contact, were less commonly done (1048 [64·4%]). During the first 2 h after birth, separation of the mother and neonate occurred in 844 (51·9%) of 1627 cases; and was more common for mothers who were single (adjusted odds ratio [AOR; adjusting for country, maternal age, education, marital status, neonate weight at birth, and neonate sex] 1·8, 95% CI 1·3–2·6) than those who were married or cohabiting. Lack of maternal education was associated with increased likelihood of neonates not receiving recommended breastfeeding practices. Neonates with a low birthweight (

Consensus is lacking on the most appropriate indicators to document progress in safe abortion at programmatic and country level. We conducted a scoping review to provide an extensive summary of abortion indicators used over 10 years (2008–2018) to inform the debate on how progress in the provision and access to abortion care can be best captured. Documents were identified in PubMed and Popline and supplemented by materials identified on major non-governmental organisation websites. We screened 1999 abstracts and seven additional relevant documents. Ultimately, we extracted information on 792 indicators from 142 documents. Using a conceptual framework developed inductively, we grouped indicators into seven domains (social and policy context, abortion access and availability, abortion prevalence and incidence, abortion care, abortion outcomes, abortion impact and characteristics of women) and 40 subdomains. Indicators of access and availability and of the provision of abortion care were the most common. Indicators of outcomes were fewer and focused on physical health, with few measures of psychological well-being and no measures of quality of life or functioning. Similarly, there were few indicators attempting to measure the context, including beliefs and social attitudes at the population level. Most indicators used special studies either in facilities or at population level. The list of indicators (in online supplemental appendix) is an extensive resource for the design of monitoring and evaluation plans of abortion programmes. The large number indicators, many specific to one source only and with similar concepts measured in a multitude of ways, suggest the need for standardisation.

Introduction Complications due to unsafe abortions are an important cause of morbidity and mortality in many sub-Saharan African countries. We aimed to characterise abortion-related complication severity, describe their management, and to report women’s experience of abortion care in Africa.Methods A cross-sectional study was implemented in 210 health facilities across 11 sub-Saharan African countries. Data were collected on women’s characteristics, clinical information and women’s experience of abortion care (using the audio computer-assisted self-interviewing (ACASI) system). Severity of abortion complications were organised in five hierarchical mutually exclusive categories based on indicators present at assessment. Descriptive bivariate analysis was performed for women’s characteristics, management of complications and reported experiences of abortion care by severity. Generalised linear estimation models were used to assess the association between women’s characteristics and severity of complications.Results There were 13 657 women who had an abortion-related complication: 323 (2.4%) women were classified with severe maternal outcomes, 957 (7.0%) had potentially life-threatening complications, 7953 (58.2%) had moderate complications and 4424 (32.4%) women had mild complications. Women who were single, multiparous, presenting ≥13 weeks of gestational age and where expulsion of products of conception occurred prior to arrival to facility were more likely to experience severe complications. For management, the commonly used mechanical methods of uterine evacuation were manual vacuum aspiration (76.9%), followed by dilation and curettage (D&C) (20.1%). Most frequently used uterotonics were oxytocin (50∙9%) and misoprostol (22.7%). Via ACASI, 602 (19.5%) women reported having an induced abortion. Of those, misoprostol was the most commonly reported method (54.3%).Conclusion There is a critical need to increase access to and quality of evidence-based safe abortion, postabortion care and to improve understanding around women’s experiences of abortion care.

Background Access to high-quality, person-centred care during pregnancy and childbirth is a global priority. Positive experience of care is key in particular, because it is both a fundamental right and can influence health outcomes and future healthcare utilisation. Despite its importance for accountability and action, systematic guidance on measuring experience of care is limited.Methods We conducted a scoping review of published literature to identify measures/instruments for experience of facility-based pregnancy and childbirth (abortion, antenatal, intrapartum, postnatal and newborn) care. We systematically searched five bibliographic databases from 1 January 2007 through 1 February 2019. Using a predefined evidence template, we extracted data on study design, data collection method, study population and care type as reported in primary quantitative articles. We report results narratively.Results We retrieved 16 528 unique citations, including 171 eligible articles representing, 157 unique instruments and 144 unique parent instruments across 56 countries. Half of the articles (90/171) did not use a validated instrument. While 82% (n=141) of articles reported on labour and childbirth care, only one reported on early pregnancy/abortion care. The most commonly reported sub-domains of user experience were communication (84%, 132/157) and respect and dignity (71%, 111/157). The primary purpose of most papers was measurement (70%, 119/171), largely through cross-sectional surveys.Conclusion There are alarming gaps in measurement of user experience for abortion, antenatal, postnatal and newborn care, including lack of validated instruments to measure the effects of interventions and policies on user experience.Protocol registration details This review was registered and published on PROSPERO (CRD42017070867). PROSPERO is an international database of prospectively registered systematic reviews in health and social care.

Summary: Background: Unintended pregnancy and abortion estimates document trends in sexual and reproductive health and autonomy. These estimates inform and motivate investment in global health programmes and policies. Variability in the availability and reliability of data poses challenges for measuring and monitoring trends in unintended pregnancy and abortion. We developed a new statistical model that jointly estimated unintended pregnancy and abortion that aimed to better inform efforts towards global equity in sexual and reproductive health and rights. Methods: We developed a model that simultaneously estimated incidence of unintended pregnancy and abortion within a Bayesian framework. Data on pregnancy intentions and abortion were compiled from country-based surveys, official statistics, and published studies found through a literature search, and we obtained data on livebirths from the World Population Prospects. We analysed results by World Bank income groups, Sustainable Development Goal regional groupings, and the legal status of abortion. Findings: In 2015–19, there were 121·0 million unintended pregnancies annually (80% uncertainty interval [UI] 112·8–131·5), corresponding to a global rate of 64 unintended pregnancies (UI 60–70) per 1000 women aged 15–49 years. 61% (58–63) of unintended pregnancies ended in abortion (totalling 73·3 million abortions annually [66·7–82·0]), corresponding to a global abortion rate of 39 abortions (36–44) per 1000 women aged 15–49 years. Using World Bank income groups, we found an inverse relationship between unintended pregnancy and income, whereas abortion rates varied non-monotonically across groups. In countries where abortion was restricted, the proportion of unintended pregnancies ending in abortion had increased compared with the proportion for 1990–94, and the unintended pregnancy rates were higher than in countries where abortion was broadly legal. Interpretation: Between 1990–94 and 2015–19, the global unintended pregnancy rate has declined, whereas the proportion of unintended pregnancies ending in abortion has increased. As a result, the global average abortion rate in 2015–19 was roughly equal to the estimates for 1990–94. Our findings suggest that people in high-income countries have better access to sexual and reproductive health care than those in low-income countries. Our findings indicate that individuals seek abortion even in settings where it is restricted. These findings emphasise the importance of ensuring access to the full spectrum of sexual and reproductive health services, including contraception and abortion care, and for additional investment towards equity in health-care services. Funding: UK Aid from the UK Government, Dutch Ministry of Foreign Affairs, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), and The Bill & Melinda Gates Foundation.