Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis

Awareness and healthcare seeking behavior of neonatal danger signs, and predictor variables among mothers/caregivers in four developing regional state of Ethiopia

INTRODUCTION

Mothers/caregivers should be aware of a newborn's danger signs and promptly seek medical attention. Hence, this study assessed mothers'/caregivers' awareness, healthcare seeking behaviors for neonatal danger signs and their determinants in the developing regional state of Ethiopia.

METHODS

A community-based cross-sectional study was employed among mothers/caregivers of neonates in the developing regional state of Ethiopia. The sample was determined in collaboration with the Central Statistics Agency of Ethiopia. Stratified multi-stage cluster sampling was used to recruit the sample. Data were collected through an interviewer administered structured questionnaire using a tablet computer. Descriptive statistics and binary logistic regression were applied to identify determinants of awareness and treatment-seeking behavior for neonatal danger signs.

RESULTS

The result of the study showed that nearly one-third (32.7%) of the respondents had a good level of awareness of neonatal danger signs, and 69.0% of the respondents had good healthcare-seeking practice about neonatal danger signs. Regional state (Benishangul-Gumuz) [AOR = 1.61; 95% CI (1.09, 2.39)], Muslim's [AOR = 1.75; 95% CI (1.20, 2.55)] and permission to travel to a health facility [AOR = 0.48; 95% CI (0.37, 0.63)] were determinants of mothers'/caregivers' awareness about neonatal danger signs. Antenatal care (ANC) attendance and institutional delivery were shown to have a positive association with neonatal healthcare seeking (AOR = 2.14 and AOR = 2.37, respectively).

CONCLUSION

In Ethiopia's developing regional states, mothers/caregivers were remarkably unaware of neonatal danger signs. Region, religion, mothers'/caregivers' age, and need for permission to travel to a health facility were predictor variables for neonatal danger sign awareness. Better healthcare seeking practices, which are determined by ANC attendance and institutional delivery, are observed in these regions. Federal and regional governments should give these regions due attention. Moreover, regional health bureaus and health professionals should tackle the problem by focusing on the identified factors.

Effectiveness of Capacity-Building and Quality Improvement Interventions to Improve Day-of-Birth Care in Kinshasa, Democratic Republic of the Congo

In sub-Saharan African settings like the Democratic Republic of the Congo, high-quality care during childbirth and the immediate postpartum period is lacking in public facilities, necessitating multipronged interventions to improve care. We used a pre-post design to examine the effectiveness of a low-dose, high-frequency capacity-building and quality improvement (QI) intervention to improve care for women and newborns around the day of birth in 16 health facilities in Kinshasa, Democratic Republic of the Congo. Effectiveness was assessed based on changes in provider skills, key health indicators, and beneficiary satisfaction. To assess changes in the competency of the 188 providers participating in the intervention, we conducted objective structured clinical examinations on care for mothers and newborns on the day of birth, immediate postpartum family planning (PPFP) counseling and method provision, and postabortion care before and after implementation of training and at 6 and 12 months after training. Interrupted time series (ITS) analysis techniques were used to analyze routine health service data for changes in select maternal, newborn, and postpartum outcomes before and after the intervention. To assess changes in clients' perceptions of care, 2 rounds of telephone surveys were administered. Before the intervention, less than 2% of participating providers demonstrated competency in skills. Immediately after training, more than 80% demonstrated competency, and 70% retained competency after 12 months. ITS analyses show the risk of early neonatal death declined significantly by 9% (95% confidence interval [CI]=4%, 13%, P<.001), and likelihood of immediate PPFP uptake increased significantly by 72% (95% CI=53%, 92%, P<.001). Client satisfaction improved by 58% over the life of the project. These findings build on previous studies documenting the effectiveness of clinical capacity-building and QI approaches. If implemented at scale, this approach has the potential to substantively contribute to improving maternal and perinatal health in similar settings.

Acceptability, values, and preferences of older people for chronic low back pain management; a qualitative evidence synthesis

BACKGROUND

Chronic primary low back pain (CPLBP) and other musculoskeletal conditions represent a sizable attribution to the global burden of disability, with rates greatest in older age. There are multiple and varied interventions for CPLBP, delivered by a wide range of health and care workers. However, it is not known if these are acceptable to or align with the values and preferences of care recipients. The objective of this synthesis was to understand the key factors influencing the acceptability of, and values and preferences for, interventions/care for CPLBP from the perspective of people over 60 and their caregivers.

METHODS

We searched MEDLINE, CINAHL and OpenAlex, for eligible studies from inception until April 2022. We included studies that used qualitative methods for data collection and analysis; explored the perceptions and experiences of older people and their caregivers about interventions to treat CPLBP; from any setting globally. We conducted a best fit framework synthesis using a framework developed specifically for this review. We assessed our certainty in the findings using GRADE-CERQual.

RESULTS

All 22 included studies represented older people's experiences and had representation across a range of geographies and economic contexts. No studies were identified on caregivers. Older people living with CPLBP express values and preferences for their care that relate to therapeutic encounters and the importance of therapeutic alliance, irrespective of the type of treatment, choice of intervention, and intervention delivery modalities. Older people with CPLBP value therapeutic encounters that validate, legitimise, and respect their pain experience, consider their context holistically, prioritise their needs and preferences, adopt a person-centred and tailored approach to care, and are supported by interprofessional communication. Older people valued care that provided benefit to them, included interventions beyond analgesic medicines alone and was financially and geographically accessible.

CONCLUSIONS

These findings provide critical context to the implementation of clinical guidelines into practice, particularly related to how care providers interact with older people and how components of care are delivered, their location and their cost. Further research is needed focusing on low- and middle-income settings, vulnerable populations, and caregivers.

Perceptions and attitudes of midwives on respectful maternity care during childbirth: a qualitative study in three district hospitals of Kigali City of Rwanda

Introduction

Respectful Maternity Care (RMC) is "a universal human right for every childbearing woman". In Rwanda, few studies conducted on RMC assessed how women perceive care provided during childbirth, yet little is known about providers' perspectives. We investigated the perceptions and attitudes of midwives towards the provision of RMC to complement women's viewpoints.

Methods

this qualitative study used individual in-depth interviews in Kinyarwanda language. A purposive sampling method was used to reach out to twenty-eight midwives from three district hospitals in Kigali City. Transcribed interviews were translated into English and thematic content analysis was performed using Atlas Ti, version 7. The University of Rwanda College of Medicine and Health Sciences Institutional Review Board (Ref: 363/CHMS/IRB/2019) ethically approved this study before data collection.

Results

the majority of participants revealed that they have knowledge on RMC and perceive that they provide maternal health care based on women´s rights. Positive attitudes towards providing RMC were reported by midwives, however, a considerable number of participants reported the existence of abusive practices. The majority of midwives reported facing many challenges affecting their ability to provide respectful maternal care.

Conclusion

midwives understand the seven rights of women and have a positive attitude towards providing RMC. However, abusive practices still exist while providing RMC with considerable challenges, including overload and lack of labour monitoring materials. The adjustment of the ratio of midwives to clients and the availability of essential materials in labour monitoring is recommended to improve the quality of healthcare received by women during childbirth.

Towards a positive postnatal experience in Sub-Saharan African countries: the receipt of adequate services during the immediate postpartum period: a multilevel analysis

Background

Existing studies in the Sub-Saharan African (SSA) region have focused mainly on the frequency of postnatal visits, with little emphasis on the adequacy of care provided during visits. Hence, this study aimed to investigate the magnitude of receiving an adequate number of World Health Organization-recommended contents of care during the immediate postpartum visit, and its predictors in SSA countries.

Methods

The appended women file of the most recent (2016-2021) standardized Demographic and Health Survey report of eighteen Sub-Saharan African countries with a weighted sample of 56,673 women was used for the study. The influence of each predictor on the uptake of adequate postnatal care has been examined using multilevel mixed-effects logistic regression. Significant predictors were reported using the adjusted odds ratio (aOR) with their respective 95% confidence intervals (95% CI).

Results

The pooled prevalence of adequate postnatal care service uptake was found to be 42.94% (95% CI: 34.14, 49.13). Living in the southern sub-region (aOR = 3.08 95% CI: 2.50, 3.80), institutional delivery (aOR = 3.15; 95% CI: 2.90, 3.43), early initiation of ANC (aOR = 1.74; 95% CI: 1.45, 2.09), quality of antenatal care (aOR = 1.59; 95% CI: 1.42, 1.78), Caesarean delivery (aOR = 1.59; 95% CI: 1.42, 1.78), autonomy in decision-making (aOR = 1.30; 95% CI: 1.11, 1.39), high acceptance toward wife beating attitude (aOR = 0.83; 95% CI: 0.73, 0.94), and reading newspapers (aOR = 1.37; 95% CI: 1.21, 1.56) were identified as predictors of receiving adequate postnatal services during the immediate postpartum period.

Conclusion

The findings revealed low coverage of adequate postnatal care service uptake in the region. The Federal Ministry of Health and healthcare managers in each country should coordinate their efforts to develop interventions that promote women's empowerment to enhance their autonomy in decision-making and to reduce attitudes towards wife beating. Healthcare providers ought to strive to provide skilled delivery services and early initiation of antenatal care.

Redefining Maternal Wellness: The Role of Antenatal Exercises in Musculoskeletal Issues Among Primigravida Mothers

During pregnancy, there are notable alterations in biomechanics, hormones, and vascular functioning, which frequently result in a range of musculoskeletal ailments, including back pain, leg cramps, and pelvic girdle discomfort. The significance of pregnancy-related musculoskeletal problems on women's daily functioning and general well-being is highlighted by their widespread occurrence worldwide, necessitating heightened focus and implementation of effective therapeutic approaches. The main aims of this study were to assess the effectiveness of prenatal exercises in musculoskeletal discomfort and investigate the association between post-intervention levels of discomfort and certain demographic factors. A quantitative technique was used in this study, utilizing a pre-experimental design conducted for three months. A total of 60 primigravida mothers were selected as participants through purposive sampling. The study was conducted in a Maternity Tertiary Care Center located in Tamil Nadu. The intervention encompassed the provision of antenatal exercises, specifically focusing on abdominal tightness, pelvic tilting, and foot and ankle movements. The researcher demonstrated the exercises for 20 minutes, and afterward, mothers were asked to perform the activities themselves. The process was monitored and observed for two weeks. The findings were statistically significant, suggesting a noteworthy decrease in musculoskeletal disorders following the implementation of the intervention. The statistical analysis revealed a significant degree of significance (P = 0.001), confirming the efficacy of the exercises. Before the implementation of the intervention, a significant proportion of mothers, namely, 45 (75%) reported experiencing moderate back pain. However, following the intervention, this percentage notably fell to 33.34% (20). The incidence of moderate pelvic pain decreased from 80% (48) to 30% (18), and a comparable pattern was observed in the reduction of leg cramps. Additionally, the research identified significant associations between the improvements and a range of demographic and obstetric factors, including the level of education, occupation, family structure, age at marriage, and weight of the mother. The results highlight the significance of incorporating antenatal exercises as a regular component of prenatal care to minimize musculoskeletal discomfort, hence promoting the overall health and well-being of expectant mothers.

Midwives' experiences of the consequences of navigating barriers to maternity care

Midwives in Low- and middle-income countries, experience myriad barriers that have consequences for them and for maternity care. This article provides insight into the consequences of the barriers that Ghanaian midwives face in their workplaces. Glaserian Grounded Theory methodology using semi-structured interviews and non-participant observations was applied in this study. The study participants comprised of 29 midwives and a pharmacist, a social worker, a health services manager, and a National Insurance Scheme manager in Ghana. Data collection and analysis occurred concurrently while building on already analyzed data. In this study it was identified that barriers to Ghanaian midwives' ability to provide maternity care can have physiological, psychological, and socioeconomic consequences for midwives. It also negatively impacted maternity care. Implementing new ameliorating measures to mitigate the barriers that Ghanaian midwives encounter, and the consequences that those barriers have on them would improve midwife retention and care quality.

Effect of mentorship and a mHealth application in updating provider skills and knowledge in maternal and newborn care in two informal settlements of Nairobi

BACKGROUND

Children and women in urban informal settlements have fewer choices to access quality maternal and newborn health care. Many facilities serving these communities are under-resourced and staffed by fewer providers with limited access to skills updates. We sought to increase provider capacity by equipping them with skills to provide general and emergency obstetric and newborn care in 24 facilities serving two informal settlements in Nairobi. We present evidence of the combined effect of mentorship using facility-based mentors who demonstrate skills, support skills drills training, and provide practical feedback to mentees and a self-guided online learning platform with easily accessible EmONC information on providers' smart phones.

METHODS

We used mixed methods research with before and after cross-sectional provider surveys conducted at baseline and end line. During end line, 18 in-depth interviews were conducted with mentors and mentees who were exposed, and providers not exposed to the intervention to explore effectiveness and experience of the intervention on quality maternal health services.

RESULTS

Results illustrated marked improvement from ability to identify antepartum hemorrhage (APH), postpartum hemorrhage (PPH), manage retained placenta, ability to identify and manage obstructed labour, Pre-Eclampsia and Eclampsia (PE/E), puerperal sepsis, and actions taken to manage conditions when they present. Overall, out of 95 elements examined there were statistically significant improvements of both individual scores and overall scores from 29/95 at baseline (30.5%) to 44.3/95 (46.6%) during end line representing a 16- percentage point increase (p > 0.001). These improvements were evident in public health facilities representing a 17.3% point increase (from 30.9% at baseline to 48.2% at end line, p > 0.001). Similarly, providers working in private facilities exhibited a 15.8% point increase in knowledge from 29.7% at baseline to 45.5% at end line (p = 0.0001).

CONCLUSION

This study adds to the literature on building capacity of providers delivering Maternal and Newborn Health (MNH) services to women in informal settlements. The complex challenges of delivering MNH services in informal urban settings where communities have limited access require a comprehensive approach including ensuring access to supplies and basic equipment. Nevertheless, the combined effects of the self-guided online platform and mentorship reinforces EmONC knowledge and skills. This combined approach is more likely to improve provider competency, and skills as well as improving maternal and newborn health outcomes.

A meta-ethnography of how children and young people with chronic non-cancer pain and their families experience and understand their condition, pain services, and treatments

BACKGROUND

Chronic non-cancer pain in childhood is widespread, affecting 20% to 35% of children and young people worldwide. For a sizeable number of children, chronic non-cancer pain has considerable negative impacts on their lives and quality of life, and leads to increased use of healthcare services and medication. In many countries, there are few services for managing children's chronic non-cancer pain, with many services being inadequate. Fourteen Cochrane Reviews assessing the effects of pharmacological, psychological, psychosocial, dietary or physical activity interventions for managing children's chronic non-cancer pain identified a lack of high-quality evidence to inform pain management. To design and deliver services and interventions that meet the needs of patients and their families, we need to understand how children with chronic non-cancer pain and their families experience pain, their views of services and treatments for chronic pain, and which outcomes are important to them.

OBJECTIVES

1. To synthesise qualitative studies that examine the experiences and perceptions of children with chronic non-cancer pain and their families regarding chronic non-cancer pain, treatments and services to inform the design and delivery of health and social care services, interventions and future research. 2. To explore whether our review findings help to explain the results of Cochrane Reviews of intervention effects of treatments for children's chronic non-cancer pain. 3. To determine if programme theories and outcomes of interventions match children and their families' views of desired treatments and outcomes. 4. To use our findings to inform the selection and design of patient-reported outcome measures for use in chronic non-cancer pain studies and interventions and care provision to children and their families. The review questions are: 1. How do children with chronic non-cancer pain and their families conceptualise chronic pain? 2. How do children with chronic non-cancer pain and their families live with chronic pain? 3. What do children with chronic non-cancer pain and their families think of how health and social care services respond to and manage their child's chronic pain? 4. What do children with chronic non-cancer pain and their families conceptualise as 'good' chronic pain management and what do they want to achieve from chronic pain management interventions and services?

SEARCH METHODS

Review strategy: we comprehensively searched 12 bibliographic databases including MEDLINE, CINAHL, PsycInfo and grey literature sources, and conducted supplementary searches in 2020. We updated the database searches in September 2022.

SELECTION CRITERIA

To identify published and unpublished qualitative research with children aged 3 months to 18 years with chronic non-cancer pain and their families focusing on their perceptions, experiences and views of chronic pain, services and treatments. The final inclusion criteria were agreed with a patient and public involvement group of children and young people with chronic non-cancer pain and their families.

DATA COLLECTION AND ANALYSIS

We conducted a qualitative evidence synthesis using meta-ethnography, a seven-phase, systematic, interpretive, inductive methodology that takes into account the contexts and meanings of the original studies. We assessed the richness of eligible studies and purposively sampled rich studies ensuring they addressed the review questions. Cochrane Qualitative Methods Implementation Group guidance guided sampling. We assessed the methodological limitations of studies using the Critical Appraisal Skills Programme tool. We extracted data on study aims, focus, characteristics and conceptual findings from study reports using NVivo software. We compared these study data to determine how the studies related to one another and grouped studies by pain conditions for synthesis. We used meta-ethnography to synthesise each group of studies separately before synthesising them all together. Analysis and interpretation of studies involved children with chronic non-cancer pain and their families and has resulted in theory to inform service design and delivery. Sampling, organising studies for synthesis, and analysis and interpretation involved our patient and public involvement group who contributed throughout the conduct of the review. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each review finding. We used a matrix approach to integrate our findings with existing Cochrane Reviews on treatment effectiveness for children's chronic non-cancer pain.

MAIN RESULTS

We synthesised 43 studies sampled from 170 eligible studies reported in 182 publications. Included studies involved 633 participants. GRADE-CERQual assessments of findings were mostly high (n = 21, 58%) or moderate (n = 12, 33%) confidence with three (8%) low or very low confidence. Poorly managed, moderate or severe chronic non-cancer pain had profound adverse impacts on family dynamics and relationships; family members' emotions, well-being, autonomy and sense of self-identity; parenting strategies; friendships and socialising; children's education and future employment prospects; and parental employment. Most children and parents understood chronic non-cancer pain as having an underlying biological cause and wanted curative treatment. However, families had difficulties seeking and obtaining support from health services to manage their child's pain and its impacts. Children and parents felt that healthcare professionals did not always listen to their experiences and expertise, or believe the child's pain. Some families repeatedly visited health services seeking a diagnosis and cure. Over time, some children and families gave up hope of effective treatment. Outcomes measured within trials and Cochrane Reviews of intervention effects did not include some outcomes of importance to children and families, including impacts of pain on the whole family and absence of pain. Cochrane Reviews have mainly neglected a holistic biopsychosocial approach, which specifies the interrelatedness of biological, psychological and social aspects of illness, when selecting outcome measures and considering how chronic pain management interventions work.

AUTHORS' CONCLUSIONS

We had high or moderate confidence in the evidence contributing to most review findings. Further research, especially into families' experiences of treatments and services, could strengthen the evidence for low or very low confidence findings. Future research should also explore families' experiences in low- to middle-income contexts; of pain treatments including opioid use in children, which remains controversial; and of social care services. We need development and testing of family-centred interventions and services acceptable to families. Future trials of children's chronic non-cancer pain interventions should include family-centred outcomes.

Introduction and roll-out of self-learning App for midwifery during the COVID-19 pandemic and its sustainability in Cambodia

Similar to other countries, coronavirus disease (COVID-19) pandemic significantly impacted not only the ability of midwives to deliver high quality maternal care, but also their ability to access professional development opportunities, including in-service training in Cambodia. In response, we developed a Cambodian version of Safe Delivery App (SDA), aligned to Cambodia's clinical guidelines. The SDA is a free digital job aid and learning platform for skilled birth attendants developed by Maternity Foundation that works offline and is used in more than 40 countries after adapting to the country context. In the year and a half since its launch in June 2021, SDA has become established in Cambodia, with more than 3,000 people, accounting for nearly half the number of midwives in Cambodia, downloading and using it on their devices, and 285 people having completed its self-learning modules. The review of the introduction process revealed that publicity on the professional association's social networking sites, in-person in-depth hands-on training, and troubleshooting in a managed social networking group were useful in promoting the use of the application, and that the Continuing Professional Development Program accreditation has been a strong motivator for completing the self-study program. On the other hand, the COVID-19 pandemic has led to increased use of digital tools, but it is important to prevent the expansion of the digital divide when implementing new digital tools, including SDA.

Exploring the factors contributing to increase in facility child births in Bangladesh between 2004 and 2017-2018

Background

Although Bangladesh has gained rapid improvement in births at health facilities, yet far behind to achieve the SDG target. Assessing the contribution of factors in increased use of delivery at facilities are important to demonstrate.

Objective

To explore the determinants and their contribution in explaining increased use of facility child births in Bangladesh.

Participants

Reproductive-aged women (15-49 years) of Bangladesh.

Methods and materials

We used the latest five rounds (2004, 2007, 2011, 2014, 2017-2018) of Bangladesh Demographic and Health Surveys (BDHSs). The regression based classical decomposition approach has been used to explore the determinants and their contribution in explaining the increased use of facility child birth.

Results

A sample of 26,686 reproductive-aged women were included in the analysis, 32.90% (8780) from the urban and 67.10% (17,906) from the rural area. We observed a 2.4-fold increase in delivery at facilities from 2004 to 2017-2018, in rural areas it is more than three times higher than the urban areas. The change in mean delivery at facilities is about 1.8 whereas, the predicted change is 1.4. In our full sample model antenatal care visits contribute the largest predicted change of 22.3%, wealth and education contributes 17.3% and 15.3% respectively. For the rural area health indicator (prenatal doctor visit) is the largest drivers contributing 42.7% of the predicted change, hereafter education, demography and wealth. However, in urban area education and health contributed equally 32.0% of the change followed by demography (26.3%) and wealth (9.7%). Demographic variables (maternal BMI, birth order, age at marriage) contributing more than two-thirds (41.2%) of the predicted change in the model without the health variables. All models showed more than 60.0% predictive power.

Conclusion

Health sector interventions should focus both coverage and quality of maternal health care services to sustain steady improvements in child birth facilities.

Midwives' perceptions towards the ministry of health guidelines for the provision of immediate postpartum care in rural health facilities in Uganda

BACKGROUND

Guidelines for clinical practice have been part of the Ministry of health's efforts to improve the quality of care for over two decades. Their benefits have been documented in Uganda. However, having practice guidelines may not always result in their use in care provision. We explored the midwives' perceptions towards the ministry of health guidelines for providing immediate postpartum care.

METHODS

An exploratory descriptive qualitative study was conducted in three districts in Uganda from September 2020 to January 2021. In-depth interviews with 50 midwives from 35 health centers and 2 hospitals in Mpigi, Butambala, and Gomba districts were done. Thematic analysis of data was done.

RESULTS

Three themes emerged; awareness and use of the guidelines, perceived drivers, and perceived barriers to the provision of immediate postpartum care. The subthemes for theme I included; awareness of the guidelines, variations in the postpartum care practices, variations in preparedness to manage women with complications, and varied access to continuing midwifery education. Fear of complications and litigation were the perceived drivers of guideline use. On the other hand, lack of knowledge, busy maternity units, organization of the care, and the midwives' perceptions about their clients were the barriers to guideline use. Midwives felt that new guidelines and policies regarding immediate postpartum care should be disseminated widely.

CONCLUSION

The midwives felt that the guidelines were good for the prevention of postpartum complications but their knowledge of the guidelines for the provision of immediate postpartum care was suboptimal. They desired on-job training and mentorship to help them bridge the knowledge gaps. Variations in patient assessment, monitoring, and pre-discharge care were acknowledged and said to be due to a poor reading culture and health facility factors like patient-midwife ratios, unit setup, and prioritization of labor.

Evaluation of Dakshata, a scale-up WHO SCC and mentoring-based program, for improving quality of intrapartum care in public sector in Rajasthan, India: repeated mixed-methods surveys

BACKGROUND

The Dakshata program in India aims to improve resources, providers' competence, and accountability in labour wards of public sector secondary care hospitals. Dakshata is based on the WHO Safe Childbirth Checklist coupled with continuous mentoring. In Rajasthan state, an external technical partner trained, mentored and periodically assessed performance; identified local problems, supported solutions and assisted the state in monitoring implementation. We evaluated effectiveness and factors contributing to success and sustainability.

METHODS

Using three repeated mixed-methods surveys over an 18-month period, we assessed 24 hospitals that were at different stages of program implementation at evaluation initiation: Group 1, training had started and Group 2, one round of mentoring was complete. Data on recommended evidence-based practices in labour and postnatal wards and in-facility outcomes were collected by directly observing obstetric assessments and childbirth, extracting information from case sheets and registers, and interviewing postnatal women. A theory-driven qualitative assessment covered key domains of efficiency, effectiveness, institutionalization, accountability, sustainability, and scalability. It included in-depth interviews with administrators, mentors, obstetric staff, and officers/mentors from the external partner.

RESULTS

Overall, average adherence to evidence-based practices improved: Group 1, 55 to 72%; and Group 2, 69 to 79%, (for both p < 0.001) from baseline to endline. Significant improvement was noted in several practices in the two groups during admission, childbirth, and within 1 hour of birth but less in postpartum pre-discharge care. We noted a dip in several evidence-based practices in 2nd assessment, but they improved later. The stillbirth rate was reduced: Group 1: 1.5/1000 to 0.2; and Group 2: 2.5 to 1.1 (p < 0.001). In-depth interviews revealed that mentoring with periodic assessments was highly acceptable, efficient means of capacity building, and ensured continuity in skills upgradation. Nurses felt empowered, however, the involvement of doctors was low. The state health administration was highly committed and involved in program management; hospital administration supported the program. The competence, consistency, and support from the technical partner were highly appreciated by the service providers.

CONCLUSION

The Dakshata program was successful in improving resources and competencies around childbirth. The states with low capacities will require intensive external support for a head start.

Limiting adverse birth outcomes in resource-limited settings (LABOR): protocol of a prospective intrapartum cohort study

Background: Each year, nearly 300,000 women and 5 million fetuses or neonates die during childbirth or shortly thereafter, a burden concentrated disproportionately in low- and middle-income countries. Identifying women and their fetuses at risk for intrapartum-related morbidity and death could facilitate early intervention. Methods: The Limiting Adverse Birth Outcomes in Resource-Limited Settings (LABOR) Study is a multi-country, prospective, observational cohort designed to exhaustively document the course and outcomes of labor, delivery, and the immediate postpartum period in settings where adverse outcomes are frequent. The study is conducted at four hospitals across three countries in Ghana, India, and Zambia. We will enroll approximately 12,000 women at presentation to the hospital for delivery and follow them and their fetuses/newborns throughout their labor and delivery course, postpartum hospitalization, and up to 42 days thereafter. The co-primary outcomes are composites of maternal (death, hemorrhage, hypertensive disorders, infection) and fetal/neonatal adverse events (death, encephalopathy, sepsis) that may be attributed to the intrapartum period. The study collects extensive physiologic data through the use of physiologic sensors and employs medical scribes to document examination findings, diagnoses, medications, and other interventions in real time. Discussion: The goal of this research is to produce a large, sharable dataset that can be used to build statistical algorithms to prospectively stratify parturients according to their risk of adverse outcomes. We anticipate this research will inform the development of new tools to reduce peripartum morbidity and mortality in low-resource settings.

Limiting adverse birth outcomes in resource-limited settings (LABOR): protocol of a prospective intrapartum cohort study

Background: Each year, nearly 300,000 women and 5 million fetuses or neonates die during childbirth or shortly thereafter, a burden concentrated disproportionately in low- and middle-income countries. Identifying women and their fetuses at risk for intrapartum-related morbidity and death could facilitate early intervention. Methods: The Limiting Adverse Birth Outcomes in Resource-Limited Settings (LABOR) Study is a multi-country, prospective, observational cohort designed to exhaustively document the course and outcomes of labor, delivery, and the immediate postpartum period in settings where adverse outcomes are frequent. The study is conducted at four hospitals across three countries in Ghana, India, and Zambia. We will enroll approximately 12,000 women at presentation to the hospital for delivery and follow them and their fetuses/newborns throughout their labor and delivery course, postpartum hospitalization, and up to 42 days thereafter. The co-primary outcomes are composites of maternal (death, hemorrhage, hypertensive disorders, infection) and fetal/neonatal adverse events (death, encephalopathy, sepsis) that may be attributed to the intrapartum period. The study collects extensive physiologic data through the use of physiologic sensors and employs medical scribes to document examination findings, diagnoses, medications, and other interventions in real time. Discussion: The goal of this research is to produce a large, sharable dataset that can be used to build statistical algorithms to prospectively stratify parturients according to their risk of adverse outcomes. We anticipate this research will inform the development of new tools to reduce peripartum morbidity and mortality in low-resource settings.

Knowledge and skills of pre-eclampsia management among healthcare providers working in antenatal clinics in Zanzibar

BACKGROUND

Pre-eclampsia and eclampsia are the leading causes of perinatal morbidity and mortality worldwide. Early detection and treatment of preeclampsia is lifesaving; however, evidence suggests that the majority of women in low and middle income-countries are not routinely screened for high blood pressure during antenatal care, that those with severe and mild pre-eclampsia are not monitored for blood pressure and proteinuria as needed, and the magnesium sulphate is not administered as needed. The purpose of this study was therefore to assess knowledge and skills in pre-eclampsia and eclampsia management and their associated factors among healthcare providers working in antenatal clinics in Zanzibar.

METHODS

This was a cross-sectional analytical study conducted in all levels of healthcare facilities in Zanzibar. The study involved 176 healthcare providers (nurses and doctors) who were randomly selected. A self-administered questionnaire was used to collect data and descriptive and inferential statistics were used in the analysis whereby logistic regression models were employed. The Chi-square coefficient, odds ratio, and 95% confidence intervals were reported, and the level of significance was set at p < 0.05.

RESULTS

The mean age of healthcare providers was 35.94 (SD ± 7.83) years. The proportion of healthcare providers with adequate knowledge was 49.0%, and 47% had adequate skills. Knowledge level was predicted by working in higher healthcare facility levels (AOR: 3.28, 95% CI: 1.29-8.29), and having attended on-the-job training on pre-eclampsia (AOR: 7.8, 95% CI: 2.74 - 22.75). Skills were predicted by having attended on-job training (AOR: 8.6, 95% CI: 2.45 - 30.16), having working experience of five years or above in antenatal care units (AOR: 27.89, 95% CI: 5.28 - 148.89) and being a medical doctor or assistant medical doctor (AOR: 18.9, 95% CI: 2.1-166).

CONCLUSION

Approximately half of Zanzibar's ANC healthcare workers demonstrated inadequate knowledge and skills in preeclampsia care, indicating a critical need for targeted interventions to reduce maternal morbidity and mortality. Knowledge is predicted by attending on-the-job training and working in higher healthcare facility level, while skills is predicted by attending on job training, more years of working experience in antenatal care units and being a medical doctor or assistant medical doctor The study recommends the healthcare facility institutions to provide on-the-job training to for the healthcare providers working in lower healthcare facility levels.

Availability and functionality of neonatal care units in healthcare facilities in Mtwara region, Tanzania: The quest for quality of in-patient care for small and sick newborns

BACKGROUND

Evidence shows that delivery of prompt and appropriate in-patient newborn care (IPNC) through health facility (HF)-based neonatal care and stabilization units (NCU/NSUs) reduce preventable newborn mortalities (NMs). This study investigated the HFs for availability and performance of NCU/NSUs in providing quality IPNC, and explored factors influencing the observed performance outcomes in Mtwara region, Tanzania.

METHODS

A cross-sectional study was conducted using a follow-up explanatory mixed-methods approach. HF-based records and characteristics allowing for delivery of quality IPNC were reviewed first to establish the overall HF performance. The review findings were clarified by healthcare staff and managers through in-depth interviews (IDIs) and focus group discussions (FGDs).

RESULTS

About 70.6% (12/17) of surveyed HFs had at least one NCU/NSU room dedicated for delivery of IPNC but none had a fully established NCUs/NSU, and 74.7% (3,600/4,819) of needy newborns were admitted/transferred in for management. Essential medicines such as tetracycline eye ointment were unavailable in 75% (3/4) of the district hospitals (DHs). A disparity existed between the availability and functioning of equipment including infant radiant warmers (92% vs 73%). Governance, support from implementing patterns (IPs), and access to healthcare commodities were identified from qualitative inquiries as factors influencing the establishment and running of NCUs/NSUs at the HFs in Mtwara region, Tanzania.

CONCLUSION

Despite the positive progress, the establishment and performance of NCUs/NSUs in providing quality IPNC in HFs in Mtwara region is lagging behind the Tanzania neonatal care guideline requirements, particularly after the IPs of newborn health interventions completed their terms in 2016. This study suggests additional improvement plans for Mtwara region and other comparable settings to optimize the provision of quality IPNC and lower avoidable NMs.

Perceptions, Motivations, and Empowerment Strategies of Midwives in Rural and Remote Areas of Northern Morocco

The shortage of midwives is a problem in rural and remote areas. This is mainly the consequence of job insecurity and difficult living conditions. The present study aimed to identify and analyse the perceptions and motivations of midwives in rural and remote areas of northern Morocco on the quality of their working life and the motivational factors and empowerment strategies they use to maintain and develop their work. It is a qualitative study that follows Van Manen's hermeneutic phenomenology approach. Three focus groups and in-depth interviews were conducted with 15 midwives from rural and remote areas. The results indicate that midwives in rural and remote areas have a negative perception of the quality of the work and their personal life because of the scarcity of basic resources, unfavourable working conditions, and the personal sacrifices they have to make to support themselves. However, some factors favour their efforts. Therefore, there is a need to promote intersectoral policies that focus on improving material and human resources, as well as the working and personal conditions of midwives and the factors that support and empower them.

"A person who does not have money does not enter": a qualitative study on refugee women's experiences of respectful maternity care

Background

Women’s childbirth experiences in health facilities is at the core of quality of care. Their perceptions of poor-quality care, including disrespectful care at health facilities during childbirth, is recognized as a significant barrier to seeking care for subsequent births. Research that explores women’s perspectives of the dimensions of disrespect and mistreatment during childbirth in Arab countries is scarce, and there is none pertaining to refugee groups who carry the burden of multiple vulnerabilities and who suffer from discontinued care, especially in fragile health systems. This paper aims at presenting Palestinian, Iraqi and Syrian refugee women’s experiences, understanding and interpretation of disrespect and mistreatment during childbirth in hospitals in Lebanon.

Methods

This study employed phenomenology, a qualitative research design to generate data through in-depth interviews. Women who were 3 to 6 months postpartum were recruited through the non-governmental organizations (NGOs) that are actively engaged in providing welfare and healthcare services to different populations of refugee women in Lebanon. In total, 24 women were interviewed. All interviews were audio recorded, transcribed verbatim and subjected to thematic analysis.

Results

Of the 24 women who participated in this study, 9 were Palestinian, 12 were Syrian and 3 were Iraqi. The participants spoke of restricted choices to hospitals, care providers and to types of birth, while revealing adverse experiences during childbirth in healthcare facilities, including verbal and physical abuse, disrespectful verbal and non-verbal communication by healthcare providers. They also reported sub-standard care, denial of birth companions and breaches to their privacy. Our findings exemplify how the coverage of the cost of facility-based births by UN agencies and NGOs increase refugee women’s vulnerability to disrespect and mistreatment during childbirth.

Conclusion

This study shows how disrespect and mistreatment are intertwined in a complex system which is devised to ensure access to facility-based birth for displaced populations. Implications for programs and policies point to the need for strengthening capacity and for providing resources for the adaptation of global guidelines into context-specific strategies for the provision of quality maternity care during humanitarian crises and beyond.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05083-2.

Discharge preparation and readiness after birth: a scoping review of global policies, guidelines and literature

BACKGROUND

Despite the existence of global recommendations, postnatal care provided following childbirth is variable and often fails to address a woman's concerns about herself and the parents' concerns about their baby. Discharge from a facility after birth is a key moment to ensure the woman, parents and newborn receive support for the transition to care in the home. We mapped the current policies, guidance and literature on discharge preparation and readiness to identify key concepts and evidence and inform recommendations to be considered in a World Health Organization (WHO) guidance on postnatal care.

METHODS

We were guided by the Johanna Briggs Institute approach, and developed inclusion criteria based on existing defintions of discharge preparation and readiness, and criteria for discharge readiness compiled by international professional organisaitons. To identify guidelines and policies we searched websites and archives of guideline organisations, and contacted individuals and professional societies working on postnatal care. We searched 14 electronic databases to locate published research and other literature on discharge preparation and readiness. For documents that met the inclusion criteria we extracted key characteristics, summarised discharge readiness criteria and components and discharge preparation steps, and characterised interventions to improve discharge preparation.

RESULTS

The review provides a systematic map of criteria for discharge that are in use and the common steps healthcare providers take in preparing women and newborns for the transition home. The mapping also identified interventions used to strengthen discharge preparation, theories and models that conceptualise discharge preparation, scales for measuring discharge readiness and qualitative studies on the perspectives of women, men and healthcare providers on postnatal discharge.

CONCLUSIONS

The findings highlight contrasts between the research literature and policy documents. They indicate potential gaps in current discharge policies, and point to the need for more comprehensive discharge assessment and education to better identify and meet the needs of women, parents/caregivers and families prior to discharge and identify those who may require additional support.

PROTOCOL REGISTRATION DETAILS

The protocol for the review was registered with protocols.io on 23 November 2020: https://doi.org/10.17504/protocols.io.bpzymp7w.

Estimating maternity ward birth attendant time use in India: a microcosting study

OBJECTIVES

Despite global concern over the quality of maternal care, little is known about the time requirements to complete the essential birth practices. Using three microcosting data collection methods within the BetterBirth trial, we aimed to assess time use and the specific time requirements to incorporate the WHO Safe Childbirth Checklist into clinical practice.

SETTING

We collected detailed survey data on birth attendant time use within the BetterBirth trial in Uttar Pradesh, India. The BetterBirth trial tested whether the peer-coaching-based implementation of the WHO Checklist was effective in improving the quality of facility-based childbirth care.

PARTICIPANTS

We collected measurements of time to completion for 18 essential birth practices from July 2016 through October 2016 across 10 facilities in five districts (1559 total timed observations). An anonymous survey asked about the impact of the WHO Checklist on birth attendants at every intervention facility (15 facilities, 83 respondents) in the Lucknow hub. Additionally, data collectors visited facilities to conduct a census of patients and birth attendants across 20 facilities in seven districts between June 2016 and November 2016 (six hundred and ten 2-hour facility observations).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure of this study is the per cent of staff time required to complete the essential birth practices included in the WHO Checklist.

RESULTS

When birth attendants were timed, we found practices were completed rapidly (18 s to 2 min). As the patient load increased, time dedicated to clinical care increased but remained low relative to administrative and downtime. On average, WHO Checklist clinical care accounted for less than 7% of birth attendant time use per hour.

CONCLUSIONS

We did not find that a coaching-based implementation of the WHO Checklist was a burden on birth attendant's time use. However, questions remain regarding the performance quality of practices and how to accurately capture and interpret idle and break time.

TRIAL REGISTRATION NUMBER

NCT02148952.

Development of a clinical prediction model for perinatal deaths in low resource settings

BACKGROUND

Most pregnancy-related deaths in low and middle income countries occur around the time of birth and are avoidable with timely care. This study aimed to develop a prognostic model to identify women at risk of intrapartum-related perinatal deaths in low-resourced settings, by (1) external validation of an existing prediction model, and subsequently (2) development of a novel model.

METHODS

A prospective cohort study was conducted among pregnant women who presented consecutively for delivery at the maternity unit of Zanzibar's tertiary hospital, Mnazi Mmoja Hospital, the Republic of Tanzania between October 2017 and May 2018. Candidate predictors of perinatal deaths included maternal and foetal characteristics obtained from routine history and physical examination at the time of admission to the labour ward. The outcomes were intrapartum stillbirths and neonatal death before hospital discharge. An existing stillbirth prediction model with six predictors from Nigeria was applied to the Zanzibar cohort to assess its discrimination and calibration performance. Subsequently, a new prediction model was developed using multivariable logistic regression. Model performance was evaluated through internal validation and corrected for overfitting using bootstrapping methods.

FINDINGS

5747 mother-baby pairs were analysed. The existing model showed poor discrimination performance (c-statistic 0·57). The new model included 15 clinical predictors and showed promising discriminative and calibration performance after internal validation (optimism adjusted c-statistic of 0·78, optimism adjusted calibration slope =0·94).

INTERPRETATION

The new model consisted of predictors easily obtained through history-taking and physical examination at the time of admission to the labour ward. It had good performance in predicting risk of perinatal death in women admitted in labour wards. Therefore, it has the potential to assist skilled birth attendance to triage women for appropriate management during labour. Before routine implementation, external validation and usefulness should be determined in future studies.

FUNDING

The study received funding from Laerdal Foundation, Otto Kranendonk Fund and UMC Global Health Fellowship. TD acknowledges financial support from the Netherlands Organisation for Health Research and Development (grant 91617050).

Evaluating the effects of maternal positions in childbirth: An overview of Cochrane Systematic Reviews

INTRODUCTION

The purpose of this study is to conduct an overview of Cochrane systematic reviews (SRs) evaluating the effects of maternal positions in childbirth in order to compile existing evidence for relevant research questions that have been addressed by more than one review, to provide a succinct summary of the up-to-date evidence and to identify areas for future research.

METHODS

An electronic search was conducted in the Cochrane database. Two primary outcomes were the duration of labor and birth, and operative birth. The quality of included reviews was assessed using the AMSTAR criteria, and the quality of the evidence was rated using the GRADE criteria.

RESULTS

We included 3 Cochrane SRs. There was a significant mean difference (MD) found in the duration of the first stage by 1 hour and 22 minutes (MD= -1.21; 95% CI: -2.35 – -0.07, I²=94%) and reduction in caesarean section rates (RR=0.71; 95% CI: 0.54–0.94, I²=0%) in the upright birth position group compared with the horizontal. Also, there was a statistically significant difference in the duration (minutes) of the second stage of labor (MD= -6.16; 95% CI: -9.74 – -2.59, I²=91%) and a reduction in assisted vaginal birth rates (RR=0.75, 95% CI: 0.66–0.86, I²=29%) in the upright group compared with the horizontal without epidural analgesia. The quality of evidence within the reviews was very low to moderate.

CONCLUSIONS

There is currently a limited body of evidence to clearly assess the benefits and risks of assuming upright positions during childbirth. The overview highlights the need for high-quality research studies, involving better definition and comprehensive assessment of the effects of squatting during childbirth.

Community mobilization to strengthen support for appropriate and timely use of antenatal and postnatal care: A review of reviews

Background

Antenatal care (ANC) and postnatal care (PNC) are critical opportunities for women, babies and parents/families to receive quality care and support from health services. Community-based interventions may improve the accessibility, availability, and acceptance of this vital care. For example, community mobilization strategies have been used to involve and collaborate with women, families and communities to improve maternal and newborn health.

Objective

To synthesize existing reviews of evidence on community mobilization strategies that strengthen support for appropriate and timely use of ANC and PNC.

Methods

Six databases (MEDLINE, Embase, CINAHL, PsychINFO, Cochrane Library, PROSPERO) were searched for published reviews that describe community mobilization related strategies for ANC and/or PNC. Reviews were eligible for inclusion if they described any initiatives or strategies targeting the promotion of ANC and/or PNC uptake that included an element of community mobilization in a low- or middle-income country (LMIC), published after 2000. Included reviews were critically appraised according to the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Evidence Syntheses. This review of reviews was conducted following JBI guidelines for undertaking and reporting umbrella reviews.

Results

In total 23 papers, representing 22 reviews were included. While all 22 reviews contained some description of community mobilization and ANC/PNC, 13 presented more in-depth details on the community mobilization processes and relevant outcomes. Seventeen reviews focused on ANC, four considered both ANC and PNC, and only one focused on PNC. Overall, 16 reviews reported at least one positive association between community mobilization activities and ANC/PNC uptake, while five reviews presented primary studies with no statistically significant change in ANC uptake and one included a primary study with a decrease in use of antenatal facilities. The community mobilization activities described by the reviews ranged from informative, passive communication to more active, participatory approaches that included engaging individuals or consulting local leaders and community members to develop priorities and action plans.

Conclusions

While there is considerable momentum around incorporating community mobilization activities in maternal and newborn health programs, such as improving community support for the uptake of ANC and PNC, there is limited evidence on the processes used. Furthermore, the spectrum of terminology and variation in definitions should be harmonized to guide the implementation and evaluation efforts.

First responder, clinician, and non‐clinical support staff knowledge, attitudes, and behaviours towards people presenting for emergency care following self‐harm: a mixed evidence synthesis

This is a protocol for a Cochrane Review (qualitative). The objectives are as follows:

The objectives of this review are threefold, as follows.

Firstly, to assess the content of knowledge, attitudes, and behaviours of first responders, clinicians, and non‐clinical support staff towards service users with SH presentations. 

Secondly, to understand how service user and staff characteristics (e.g. age, gender, sociodemographic background), type of SH presentation (e.g. method, repetition), and contextual factors (e.g. hospital environment, presence of bystanders) affect the knowledge, attitudes, and behaviours of first responders, clinicians, and non‐clinical support staff in providing acute care.

Thirdly, to assess whether clinicians' knowledge, attitudes, and behaviours have evolved over time.

Universal coverage of the first antenatal care visit but poor continuity of care across the maternal and newborn health continuum among Nepalese women: analysis of levels and correlates

Background

Routine maternity care visits (MCVs) such as antenatal care (ANC), institutional delivery, and postnatal care (PNC) visits are crucial to utilisation of maternal and newborn health (MNH) interventions during pregnancy-postnatal period. In Nepal, however, not all women complete these routine MCVs. Therefore, this study examined the levels and correlates of (dis)continuity of MCVs across the antenatal-postnatal period.

Methods

We conducted further analysis of the 2016 Nepal Demographic and Health Survey. A total of 1,978 women aged 15–49 years, who had live birth two years preceding the survey, were included in the analysis. The outcome variable was (dis)continuity of routine MCVs (at least four ANC visits, institutional delivery, and PNC visit) across the pathway of antennal through to postnatal period. Independent variables included several social determinants of health under structural, intermediary, and health system domains. Multinomial logistic regression was conducted to identify the correlates of routine MCVs. Relative risk ratios (RR) were reported with 95% confidence intervals at a significance level of p<0.05.

Results

Approximately 41% of women completed all routine MCVs with a high proportion of discontinuation around childbirth. Women of disadvantaged ethnicities, from low wealth status, who were illiterate had higher RR of discontinuation of MCVs (compared to completion of all MCVs). Similarly, women who speak Bhojpuri, from remote provinces (Karnali and Sudurpaschim), who had a high birth order (≥4), who were involved in the agricultural sector, and who had unwanted last birth had a higher RR of discontinuation of MCVs. Women discontinued routine MCVs if they had poor awareness of health mother-groups and perceived the problem of not having female providers.

Conclusions

Routine monitoring using composite coverage indicators is required to track the levels of (dis)continuity of routine MCVs at the maternity care continuum. Strategies such as raising awareness on the importance of maternity care, care provision from female health workers could potentially improve the completion of MCVs. In addition, policy and programmes for continuity of maternity care are needed to focus on women with socioeconomic and ethnic disadvantages and from remote provinces.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00791-4.

Action leveraging evidence to reduce perinatal mortality and morbidity (ALERT): study protocol for a stepped-wedge cluster-randomised trial in Benin, Malawi, Tanzania and Uganda

Background

Insufficient reductions in maternal and neonatal deaths and stillbirths in the past decade are a deterrence to achieving the Sustainable Development Goal 3. The majority of deaths occur during the intrapartum and immediate postnatal period. Overcoming the knowledge-do-gap to ensure implementation of known evidence-based interventions during this period has the potential to avert at least 2.5 million deaths in mothers and their offspring annually. This paper describes a study protocol for implementing and evaluating a multi-faceted health care system intervention to strengthen the implementation of evidence-based interventions and responsive care during this crucial period.

Methods

This is a cluster randomised stepped-wedge trial with a nested realist process evaluation across 16 hospitals in Benin, Malawi, Tanzania and Uganda. The ALERT intervention will include four main components: i) end-user participation through narratives of women, families and midwifery providers to ensure co-design of the intervention; ii) competency-based training; iii) quality improvement supported by data from a clinical perinatal e-registry and iv) empowerment and leadership mentoring of maternity unit leaders complemented by district based bi-annual coordination and accountability meetings. The trial’s primary outcome is in-facility perinatal (stillbirths and early neonatal) mortality, in which we expect a 25% reduction. A perinatal e-registry will be implemented to monitor the trial. Our nested realist process evaluation will help to understand what works, for whom, and under which conditions. We will apply a gender lens to explore constraints to the provision of evidence-based care by health workers providing maternity services. An economic evaluation will assess the scalability and cost-effectiveness of ALERT intervention.

Discussion

There is evidence that each of the ALERT intervention components improves health providers’ practices and has modest to moderate effects. We aim to test if the innovative packaging, including addressing specific health systems constraints in these settings, will have a synergistic effect and produce more considerable perinatal mortality reductions.

Trial registration

Pan African Clinical Trial Registry (www.pactr.org): PACTR202006793783148. Registered on 17th June 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07155-z.

Global stakeholder perspectives of home birth: a systematic scoping review

Home birth is experienced by people very differently worldwide. These experiences likely differ by the type of stakeholder involved (women, their support persons, birth attendants, policy-makers), the experience itself (low-risk birth, transfer to hospital, previous deliveries), and by the health system within which home birth occurs (e.g., high-resource versus low- and middle-resource countries). Research evidence of stakeholders' perspectives of home birth could usefully inform personal and policy decisions about choosing and providing home birth, but the current literature is fragmented and its breadth is not fully understood.We conducted a systematic scoping review to understand how the research literature on stakeholders' perspectives of home birth is characterized in terms of populations, settings and identified issues, and what potential gaps exist in the research evidence. A range of electronic, web-based and key informant sources of evidence were searched. Located references were assessed, data extracted, and descriptively analyzed using robust methods.Our analysis included 460 full reports. Findings from 210 reports of studies in high-resource countries suggested that research with fathers and same-sex partners, midwives, and vulnerable populations and perspectives of freebirth and transfer to hospital could be synthesized. Gaps in primary research exist with respect to family members, policy makers, and those living in rural and remote locations. A further 250 reports of studies in low- and middle-resource countries suggested evidence for syntheses related to fathers and other family members, policy makers, and other health care providers and examination of issues related to emergency transfer to hospital, rural and remote home birth, and those who birth out of hospital, often at home, despite receiving antenatal care intended to increase healthcare-seeking behavior. Gaps in primary research suggest an examination is needed of perspectives in countries with higher maternal mortality and among first-time mothers and young mothers.Our scoping review identified a considerable body of research evidence on stakeholder perspectives of home birth. These could inform the complex factors influencing personal decisions and health system planning around home birth in both high- and low- and middle-resource countries. Future primary research is warranted on specific stakeholders worldwide and with vulnerable populations in areas of high maternal mortality.

Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: a qualitative evidence synthesis

BACKGROUND

Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents' views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination.

OBJECTIVES

- Explore parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. - Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. - Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020.

SELECTION CRITERIA

We included studies that: utilised qualitative methods for data collection and analysis; focused on parents' or caregivers' views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided.

DATA COLLECTION AND ANALYSIS

We used a pre-specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income-level settings. We extracted contextual and methodological data from each sampled study. We used a meta-ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review.

MAIN RESULTS

We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South-East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high-, middle-, and low-income settings. Many complex factors were found to influence parents' vaccination views and practices, which we divided into four themes. Firstly, parents' vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents' vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, 'neoliberal logic', suggests that many parents, particularly from high-income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness.

AUTHORS' CONCLUSIONS

Our review has revealed that parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users.

Obstetric neonatal emergency simulation workshops in remote and regional South India: a qualitative evaluation

Background

Healthcare facilities in remote locations with poor access to a referral centre have a high likelihood of health workers needing to manage emergencies with limited support. Obstetric and neonatal clinical training opportunities to manage childbirth emergencies are scant in these locations, especially in low- and middle-income countries.

Objectives

This study aimed to explore the factors, which influenced healthcare worker experience of attending birth emergencies in remote and regional areas of South India, and the perceived impact of attending the Obstetric and Neonatal Emergency Simulation (ONE-Sim) workshop on these factors.

Design

Qualitative descriptive study using pre- and post-workshop qualitative surveys.

Settings

Primary healthcare facilities in remote/regional settings in three states of South India.

Participants

A total of 125 healthcare workers attended the workshops, with 85 participants completing the pre- and post-workshop surveys included in this study. Participants consisted of medical and nursing staff and other health professionals involved in care at childbirth.

Methods

ONE-Sim workshops (with a learner-centred approach) were conducted across three different locations for interprofessional teams caring for birthing women and their newborns, using simulation equipment and immersive scenarios. Thematic analysis was employed to the free-text responses obtained from the surveys consisting of open-ended questions.

Results

Participants identified their relationship with the patient, the support provided by other health professionals, identifying their gaps in knowledge and experience, and the scarcity of resources as factors that influenced their experience of birth emergencies. Following the workshops, participant learning centred on improving team and personal performance and approaching future emergencies with greater confidence.

Conclusions

Challenges experienced by healthcare workers across sites in remote and regional South India were generally around patient experience, senior health professional support and resources. The technical and interpersonal skills introduced through the ONE-Sim workshop may help to address some of these factors in practice.

Perinatal outcomes among births to women with infection during pregnancy

OBJECTIVE

This study is part of the Global Maternal Sepsis Study (GLOSS). It aimed to estimate neonatal near-miss (NNM) and perinatal death frequency and maternal risk factors among births to women with infection during pregnancy in low-income and middle-income countries (LMIC).

DESIGN

We conducted a 1-week inception hospital-based cohort study.

SETTING

The study was carried out in 408 hospitals in 43 LMIC of all the WHO regions in 2017.

PATIENTS

We included women with suspected or confirmed infection during pregnancy with at least 28 weeks of gestational age up to day-7 after birth. All babies born to those women were followed from birth until the seventh day after childbirth. Perinatal outcomes were considered at the end of the follow-up.

MAIN OUTCOME MEASURES

Perinatal outcomes were (i) babies alive without severe complication, (ii) NNM and (iii) perinatal death (stillbirth and early neonatal death).

RESULTS

1219 births were analysed. Among them, 25.9% (n=316) and 10.1% (n=123) were NNM and perinatal deaths, respectively. After adjustment, maternal pre-existing medical condition (adjusted odds ratios (aOR)=1.5; 95% CI 1.1 to 2.0) and maternal infection suspected or diagnosed during labour (aOR=1.9; 95% CI 1.2 to 3.2) were the independent risk factors of NNM. Maternal pre-existing medical condition (aOR=1.7; 95% CI 1.0 to 2.8), infection-related severe maternal outcome (aOR=3.8; 95% CI 2.0 to 7.1), mother's infection suspected or diagnosed within 24 hours after childbirth (aOR=2.2; 95% CI 1.0 to 4.7) and vaginal birth (aOR=1.8; 95% CI 1.1 to 2.9) were independently associated with increased odds of perinatal death.

CONCLUSIONS

Overall, one-third of births were adverse perinatal outcomes. Pre-existing maternal medical conditions and severe infection-related maternal outcomes were the main risk factors of adverse perinatal outcomes.

Developing and implementing a model of equitable distribution of mentorship in districts with spatial inequities and maldistribution of human resources for maternal and newborn care in Rwanda

Background

The shortage of health care providers (HCPs) and inequity in their distribution along with the lack of sufficient and equal professional development opportunities in low-income countries contribute to the high mortality and morbidity of women and newborns. Strengthening skills and building the capacity of all HCPs involved in Maternal and Newborn Health (MNH) is essential to ensuring that mothers and newborns receive the required care in the period around birth. The Training, Support, and Access Model (TSAM) project identified onsite mentorship at primary care Health Centers (HCs) as an approach that could help reduce mortality and morbidity through capacity building of HCPs in Rwanda. This paper presents the results and lessons learnt through the design and implementation of a mentorship model and highlights some implications for future research.

Methods

The design phase started with an assessment of the status of training in HCs to inform the selection of Hospital-Based Mentors (HBMs). These HBMs took different courses to become mentors. A clear process was established for engaging all stakeholders and to ensure ownership of the model. Then the HBMs conducted monthly visits to all 68 TSAM assigned HCs for 18 months and were extended later in 43 HCs of South. Upon completion of 6 visits, mentees were requested to assist their peers who are not participating in the mentoring programme through a process of peer mentoring to ensure sustainability after the project ends.

Results

The onsite mentorship in HCs by the HBMs led to equal training of HCPs across all HCs regardless of the location of the HC. Research on this mentorship showed that the training improved the knowledge and self-efficacy of HCPs in managing postpartum haemorrhage (PPH) and newborn resuscitation. The lessons learned include that well trained midwives can conduct successful mentorships at lower levels in the healthcare system. The key challenge was the inconsistency of mentees due to a shortage of HCPs at the HC level.

Conclusions

The initiation of onsite mentorship in HCs by HBMs with the support of the district health leaders resulted in consistent and equal mentoring at all HCs including those located in remote areas.

Healthcare workers' perceptions and experiences of communicating with people over 50 years of age about vaccination: a qualitative evidence synthesis

BACKGROUND

Infectious diseases are a major cause of illness and death among older adults. Vaccines can prevent infectious diseases, including against seasonal influenza, pneumococcal diseases, herpes zoster and COVID-19. However, the uptake of vaccination among older adults varies across settings and groups. Communication with healthcare workers can play an important role in older people's decisions to vaccinate. To support an informed decision about vaccination, healthcare workers should be able to identify the older person's knowledge gaps, needs and concerns. They should also be able to share and discuss information about the person's disease risk and disease severity; the vaccine's effectiveness and safety; and practical information about how the person can access vaccines. Therefore, healthcare workers need good communication skills and to actively keep up-to-date with the latest evidence. An understanding of their perceptions and experiences of this communication can help us train and support healthcare workers and design good communication strategies.

OBJECTIVES

To explore healthcare workers' perceptions and experiences of communicating with older adults about vaccination.

SEARCH METHODS

We searched MEDLINE, CINAHL and Scopus on 21 March 2020. We also searched Epistemonikos for related reviews, searched grey literature sources, and carried out reference checking and citation searching to identify additional studies. We searched for studies in any language.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored the perceptions and experiences of healthcare workers and other health system staff towards communication with adults over the age of 50 years or their informal caregivers about vaccination.

DATA COLLECTION AND ANALYSIS

We extracted data using a data extraction form designed for this review. We assessed methodological limitations using a list of predefined criteria. We extracted and assessed data regarding study authors' motivations for carrying out their study. We used a thematic synthesis approach to analyse and synthesise the evidence. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We examined each review finding to identify factors that may influence intervention implementation and we developed implications for practice.

MAIN RESULTS

We included 11 studies in our review. Most studies explored healthcare workers' views and experiences about vaccination of older adults more broadly but also mentioned communication issues specifically. All studies were from high-income countries. The studies focused on doctors, nurses, pharmacists and others working in hospitals, clinics, pharmacies and nursing homes. These healthcare workers discussed different types of vaccines, including influenza, pneumococcal and herpes zoster vaccines. The review was carried out before COVID-19 vaccines were available. We downgraded our confidence in several of the findings from high confidence to moderate, low or very low confidence. One reason for this was that some findings were based on only small amounts of data. Another reason was that the findings were based on studies from only a few countries, making us unsure about the relevance of these findings to other settings. Healthcare workers reported that older adults asked about vaccination to different extents, ranging from not asking about vaccines at all, to great demand for information (high confidence finding). When the topic of vaccination was discussed, healthcare workers described a lack of information, and presence of misinformation, fears and concerns about vaccines among older adults (moderate confidence). The ways in which healthcare workers discussed vaccines with older adults appeared to be linked to what they saw as the aim of vaccination communication. Healthcare workers differed among themselves in their perceptions of this aim and about their own roles and the roles of older adults in vaccine decisions. Some healthcare workers thought it was important to provide information but emphasised the right and responsibility of older adults to decide for themselves. Others used information to persuade and convince older adults to vaccinate in order to increase 'compliance' and 'improve' vaccination rates, and in some cases to gain financial benefits. Other healthcare workers tailored their approach to what they believed the older adult needed or wanted (moderate confidence). Healthcare workers believed that older adults' decisions could be influenced by several factors, including the nature of the healthcare worker-patient relationship, the healthcare worker's status, and the extent to which healthcare workers led by example (low confidence). Our review also identified factors that are likely to influence how communication between healthcare workers and older adults take place. These included issues tied to healthcare workers' views and experiences regarding the diseases in question and the vaccines; as well as their views and experiences of the organisational and practical implementation of vaccine services.

AUTHORS' CONCLUSIONS

There is little research focusing specifically on healthcare workers' perceptions and experiences of communication with older adults about vaccination. The studies we identified suggest that healthcare workers differed among themselves in their perceptions about the aim of this communication and about the role of older adults in vaccine decisions. Based on these findings and the other findings in our review, we have developed a set of questions or prompts that may help health system planners or programme managers when planning or implementing strategies for vaccination communication between healthcare workers and older adults.

Factors that influence the provision of postnatal care by health workers: a qualitative evidence synthesis

This is a protocol for a Cochrane Review (qualitative). The objectives are as follows:

To explore the views, experiences, and behaviours of health workers in order to understand the factors that influence their provision of postnatal care. 

Facility-level determinants of quality routine intrapartum care in Afghanistan

BACKGROUND

Although there have been notable improvements in availability and utilization of maternal health care in Afghanistan over the last few decades, risk of maternal mortality remains very high. Previous studies have highlighted gaps in quality of emergency obstetric and newborn care practices, however, little is known about the quality of routine intrapartum care at health facilities in Afghanistan.

METHODS

We analyzed a subset of data from the 2016 Afghanistan Maternal and Newborn Health Quality of Care Assessment that comprised of observations of labor, delivery and immediate post-partum care, as well as health facility assessments and provider interviews across all accessible public health facilities with an average of five or more births per day in the preceding year (N = 77). Using the Quality of the Process of Intrapartum and Immediate Postpartum Care index, we calculated a quality of care score for each observation. We conducted descriptive and bivariate analyses and built a multivariate linear regression model to identify facility-level factors associated with quality of care scores.

RESULTS

Across 665 childbirth observations, low quality of care was observed such that no health facility type received an average quality score over 56%. The multivariate regression model indicated that availability of routine labor and delivery supplies, training in respectful maternity care, perceived gender equality for training opportunities, recent supervision, and observation during supervision have positive, statistically significant associations with quality of care.

CONCLUSIONS

Quality of routine intrapartum care at health facilities in Afghanistan is concerningly low. Our analysis suggests that multi-faceted interventions are needed to address direct and indirect contributors to quality of care including clinical care practices, attention to client experiences during labor and childbirth, and attention to staff welfare and opportunities, including gender equality within the health workforce.

The effect of continuous midwifery services on the delivery mode, labor progress, and nursing satisfaction of primiparas during natural deliveries

OBJECTIVE

To analyze the effect of continuous midwifery services on the delivery mode, labor progress, and primiparas' nursing satisfaction levels during natural deliveries.

METHODS

340 primiparas admitted to our hospital from January 2017 to June 2020 were recruited as the study cohort and randomized into a continuous midwifery group and a traditional midwifery group, with 170 patients in each group. They underwent traditional midwifery nursing services and continuous midwifery services, respectively. The two groups' delivery modes, labor progress, analgesic methods, perinatal Self-Rating Anxiety Scale (SAS) scores, postpartum hemorrhage amounts, Apgar scores, and nursing satisfaction levels were compared.

RESULTS

The natural delivery rate in the continuous midwifery group was higher than it was in the traditional midwifery group (P<0.05). The maternal non-drug analgesia rate in the continuous midwifery group was higher than it was in the traditional midwifery group (P<0.05). The duration of the first stage in the continuous midwifery group was shorter than it was in the traditional midwifery group (P<0.05). The comparisons made during the second and third stages in the two groups showed no statistical differences (P>0.05). The SAS scores in the continuous midwifery group were significantly better than the SAS scores in the traditional midwifery group at the time of waiting for delivery and at one day after delivery (P<0.01). The postpartum hemorrhage amounts in the continuous midwifery group were lower than they were in the traditional midwifery group (P<0.01). The neonatal Apgar scores and maternal nursing satisfaction levels in the continuous midwifery group were better than they were in the traditional midwifery group (P<0.01).

CONCLUSION

Continuous delivery services for primiparas during natural delivery can significantly increase the natural delivery rate, reduce the use of analgesics, shorten the delivery times, alleviate the delivery-related anxiety levels in the primiparas, reduce postpartum hemorrhages, effectively improve the delivery outcomes, improve the quality of the newborns, and improve the primiparas' nursing satisfaction levels, so it is worthy of clinical promotion and application.

Improving the experience of facility-based delivery for vulnerable women through obstetric care navigation: a qualitative evaluation

Background

Global disparities in maternal mortality could be reduced by universal facility delivery. Yet, deficiencies in the quality of care prevent some mothers from seeking facility-based obstetric care. Obstetric care navigators (OCNs) are a new form of lay health workers that combine elements of continuous labor support and care navigation to promote obstetric referrals. Here we report qualitative results from the pilot OCN project implemented in Indigenous villages in the Guatemalan central highlands.

Methods

We conducted semi-structured interviews with 17 mothers who received OCN accompaniment and 13 staff—namely physicians, nurses, and social workers—of the main public hospital in the pilot’s catchment area (Chimaltenango). Interviews queried OCN’s impact on patient and hospital staff experience and understanding of intended OCN roles. Audiorecorded interviews were transcribed, coded, and underwent content analysis.

Results

Maternal fear of surgical intervention, disrespectful and abusive treatment, and linguistic barriers were principal deterrents of care seeking. Physicians and nurses reported cultural barriers, opposition from family, and inadequate hospital resources as challenges to providing care to Indigenous mothers. Patient and hospital staff identified four valuable services offered by OCNs: emotional support, patient advocacy, facilitation of patient-provider communication, and care coordination. While patients and most physicians felt that OCNs had an overwhelmingly positive impact, nurses felt their effort would be better directed toward traditional nursing tasks.

Conclusions

Many barriers to maternity care exist for Indigenous mothers in Guatemala. OCNs can improve mothers’ experiences in public hospitals and reduce limitations faced by providers. However, broader buy-in from hospital staff—especially nurses—appears critical to program success. Future research should focus on measuring the impact of obstetric care navigation on key clinical outcomes (cesarean delivery) and mothers’ future care seeking behavior.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03842-1.

How can human resources for health interventions contribute to sexual, reproductive, maternal, and newborn healthcare quality across the continuum in low- and lower-middle-income countries? A systematic review

BACKGROUND

Well-trained, competent, and motivated human resources for health (HRH) are crucial to delivering quality service provision across the sexual, reproductive, maternal, and newborn health (SRMNH) care continuum to achieve the 2030 Sustainable Development Goals (SDGs) maternal and neonatal health targets. This review aimed to identify HRH interventions to support lay and/or skilled personnel to improve SRMNH care quality along the continuum in low- and lower-middle-income countries (LLMICs).

METHODS

A structured search of CINAHL, Cochrane Library/trials, EMBASE, PubMed, SCOPUS, Web of Science, and HRH Global Resource Centre databases was undertaken, guided by the PRISMA framework. The inclusion criteria sought to identify papers with a focus on 1. HRH management, leadership, partnership, finance, education, and/or policy interventions; 2. HRH interventions' impact on two or more quality SRMNH care packages across the continuum from preconception to pregnancy, intrapartum and postnatal care; 3. Skilled and/or lay personnel; and 4. Reported primary research in English from LLMICs. A deductive qualitative content analysis was employed using the World Health Organization-HRH action framework.

RESULTS

Out of identified 2157 studies, 24 intervention studies were included in the review. Studies where ≥ 4 HRH interventions had been combined to target various healthcare system components, were more effective than those implementing ≤ 3 HRH interventions. In primary care, HRH interventions involving skilled and lay personnel were more productive than those involving either skilled or lay personnel alone. Results-based financing (RBF) and its policy improved the quality of targeted maternity services but had no impact on client satisfaction. Local budgeting, administration, and policy to deliver financial incentives to health workers and improve operational activities were more efficacious than donor-driven initiatives. Community-based recruitment, training, deployment, empowerment, supportive supervision, access to m-Health technology, and modest financial and non-financial incentives for community health workers (CHWs) improved the quality of care continuum. Skills-based, regular, short, focused, onsite, and clinical simulation, and/or mobile phone-assisted in-service training of skilled personnel were more productive than knowledge-based, irregular, and donor-funded training. Facility-based maternal and perinatal death reviews, coupled with training and certification of skilled personnel, positively affected SRMNH care quality across the continuum. Preconception care, an essential component of the SRMNH care continuum, lacks studies and services in LLMICs.

CONCLUSIONS

We recommend maternal and perinatal death audits in all health facilities; respectful, woman-centered care as a critical criterion of RBF initiatives; local administration of health worker allowances and incentives; and integration of CHWs into the healthcare system. There is an urgent need to include preconception care in the SRMNH care continuum and studies in LLMICs.

Neonatal mortality and associated factors in Ethiopia: a cross-sectional population-based study

Background

The neonatal period is the most critical time of human life for diseases. Neonatal morbidity and mortality are significant contributors to under-five morbidity and mortality in a low-income country like Ethiopia. Women are one of the key actors for the improvement of maternal, neonatal, and child healthcare utilization. However, there's no evidence on the association of women’s decision-making autonomy with neonate death at a national level in Ethiopia. Therefore, this study aimed to assess the neonatal mortality and associated factors in Ethiopia.

Methods

A total of 5128 neonates born 5 years before the survey from the Ethiopian Demographic and Health Survey 2016 were reviewed. A multivariable logistic regression model was employed to assess the effect of women's autonomy and identify the determinate predictors of neonate death risk.

Results

The rate of neonatal mortality in Ethiopia was 20.7 per 1000 live births). Women's hadn't autonomy in health care increase neonatal death by 2.72 times compared with those that had autonomy. Hadn't postnatal care was caused grown neonatal death by 5.48 times (AOR 5.48, 95% CI 1.29, 23.26). Delivering at a health institution had 0.61 times lowered neonatal death risk compared with delivering at of health institution without a health facility (AOR 0.61, 95% CI 0.38,0.97). Breastfeeding immediately within 1 h after birth had 0.17 times reduce neonatal death risk compared with not initiation of breastfeeding (AOR 0.17, 95% CI 0.12, 0.26). Women's gave birth single had 0.09 times reduced neonatal death risk than those that gave birth multiple (AOR 0.09, 95% CI 0.05, 0.18). Unknowingly, male neonates had a 1.84 times higher risk of death than females (AOR 1.84, 95% CI 1.20, 2.81).

Conclusions

Neonatal mortality rate was significantly related to women's hadn't decided power on health care, hadn't postnatal care, delivered out of health institution, breastfed not immediately, and gave birth multiple. It is important to encourage mothers autonomy, use postnatal care service, and deliver in health institutions.

Risks of Adverse Neonatal Outcomes in Early Adolescent Pregnancy Using Group Prenatal Care as a Strategy for Public Health Policies: A Retrospective Cohort Study in Brazil

Background: Adolescent pregnancy is a public health concern and many studies have evaluated neonatal outcomes, but few have compared younger adolescents with older using adequate prenatal care. Objective: To compare the risks of adverse neonatal outcomes in younger pregnant adolescents who are properly followed through group prenatal care (GPC) delivered by specialized public services. Methods: This retrospective cohort study followed pregnant adolescents (aged 10-17 years) who received GPC from specialized public services in Brazil from 2009 to 2014. Data were obtained from medical records and through interviews with a multidisciplinary team that treated the patients. The neonatal outcomes (low birth weight, prematurity, Apgar scores with 1 and 5 min, and neonatal death) of newborns of adolescents aged 10-13 years were compared to those of adolescents aged 14-15 years and 16-17 years. Incidence was calculated with 95% confidence intervals (CIs) and compared over time using a chi-squared test to observe trends. Poisson Multivariate logistic regression was used to adjust for confounding variables. The results are presented as adjusted relative risks or adjusted mean differences. Results: Of the 1,112 adolescents who were monitored, 758 were included in this study. The overall incidence of adverse neonatal outcomes (low birth weight and prematurity) was measured as 10.2% (95% CI: 9.7-11.5). Apgar scores collected at 1 and 5 min were found to be normal, and no instance of fetal death occurred. The incidence of low birth weight was 16.1% for the 10-13 age group, 8.7% for the 14-15 age group and 12.1% for the 16-17 age group. The incidence of preterm was measured at 12, 8.5, and 12.6% for adolescents who were 10-13, 14-15, and 16-17 years of age, respectively. Neither low birth weight nor prematurity levels significantly differed among the groups (p > 0.05). The infants born to mothers aged 10-13 years presented significantly (p < 0.05) lower Apgar scores than other age groups, but the scores were within the normal range. Conclusions: Our findings showed lower incidence of neonatal adverse outcomes and no risk difference of neonatal outcomes in younger pregnancy adolescents. It potentially suggests that GPC model to care pregnant adolescents is more important than the age of pregnant adolescent, however further research is needed.

Assessment of midwifery care providers intrapartum care competencies, in four sub-Saharan countries: a mixed-method study protocol

BACKGROUND

We aim to assess competencies (knowledge, skills and attitudes) of midwifery care providers as well as their experiences and perceptions of in-service training in the four study countries; Benin, Malawi, Tanzania and Uganda as part of the Action Leveraging Evidence to Reduce perinatal mortality and morbidity in sub-Saharan Africa project (ALERT). While today more women in low- and middle-income countries give birth in health care facilities, reductions in maternal and neonatal mortality have been less than expected. This paradox may be explained by the standard and quality of intrapartum care provision which depends on several factors such as health workforce capacity and the readiness of the health system as well as access to care.

METHODS

Using an explanatory sequential mixed method design we will employ three methods (i) a survey will be conducted using self-administered questionnaires assessing knowledge, (ii) skills drills assessing basic intrapartum skills and attitudes, using an observation checklist and (iii) Focus Group Discussions (FGDs) to explore midwifery care providers' experiences and perceptions of in-service training. All midwifery care providers in the study facilities are eligible to participate in the study. For the skills drills a stratified sample of midwifery care providers will be selected in each hospital according to the number of providers and, professional titles and purposive sampling will be used for the FGDs. Descriptive summary statistics from the survey and skills drills will be presented by country. Conventional content analysis will be employed for data analysis of the FGDs.

DISCUSSION

We envision comparative insight across hospitals and countries. The findings will be used to inform a targeted quality in-service training and quality improvement intervention related to provision of basic intrapartum care as part of the ALERT project.

TRIAL REGISTRATION

PACTR202006793783148-June 17th, 2020.

An exploration of patient-provider dynamics and childbirth experiences in rural and urban Peru: a qualitative study

Background

Between 2006 and 2013, Peru implemented national programs which drastically decreased rates of maternal and neonatal mortality. However, since 2013, maternal and neonatal mortality in Peru have increased. Additionally, discrimination, abuse, and violence against women persists globally and impacts birthing experiences and mental health. This qualitative study sought to better understand the attitudes and beliefs regarding childbirth among women and providers in Southern Peru. This study also explores how these beliefs influence utilization of skilled care, patient-provider dynamics, and childbirth experiences and identifies factors that impact providers’ provision of care.

Methods

Thirty semi-structured interviews were conducted with 15 participants from rural Colca Canyon and 15 participants from urban Arequipa between April and May 2018. In each region, 10 women who had experienced recent births and five providers were interviewed. Provider participants predominantly identified as female and were mostly midwives. All interviews were conducted, transcribed, and coded in Spanish. A framework analysis was followed, and data were charted into two separate thematic frameworks using contextual and evaluative categories of conceptualization of childbirth.

Results

All recent births discussed were facility-based births. Four domains emerged: women’s current birth experiences, provision of childbirth care, beliefs about childbirth among women and providers, and future health-seeking behavior. Findings suggest that women’s feelings of helplessness and frustration were exacerbated by their unmet desire for respectful maternity care and patient advocacy or companionship. Providers attributed strain to perceived patient characteristics and insufficient support, including resources and staff.

Conclusions

Our findings suggest current childbirth experiences placed strain on the patient-provider dynamic and influenced women’s attitudes and beliefs about future experiences. Currently, the technical quality of safe childbirth is the main driver of skilled birth attendance and facility-based births for women regardless of negative experiences. However, lack of respectful maternity care has been shown to have major long-term implications for women and subsequently, their children. This is one of the first studies to describe the nuances of patient-provider relationships and women’s childbirth experiences in rural and urban Peru.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03586-y.

Care-experienced cHildren and young people's Interventions to improve Mental health and wEll-being outcomes: Systematic review (CHIMES) protocol

INTRODUCTION

The mental health and well-being of children and young people who have been in care (ie, care-experienced) are a priority. There are a range of interventions aimed at addressing these outcomes, but the international evidence-base remains ambiguous. There is a paucity of methodologically robust systematic reviews of intervention effectiveness, with few considering the contextual conditions under which evaluations were conducted. This is important in understanding the potential transferability of the evidence-base across contexts. The present systematic review will adopt a complex systems perspective to synthesise evidence reporting evaluations of mental health and well-being interventions for care-experienced children and young people. It will address impact, equity, cost-effectiveness, context, implementation and acceptability. Stakeholder consultation will prioritise a programme theory, and associated intervention, that may progress to further development and evaluation in the UK.

METHODS AND ANALYSIS

We will search 16 bibliographic databases from 1990 to June 2020. Supplementary searching will include citation tracking, author recommendation, and identification of evidence clusters relevant to included evaluations. The eligible population is children and young people (aged ≤25 years) with experience of being in care. Outcomes are (1) mental, behavioural or neurodevelopmental disorders; (2) subjective well-being; (3) self-harm; suicidal ideation; suicide. Study quality will be appraised with methodologically appropriate tools. We will construct a taxonomy of programme theories and intervention types. Thematic synthesis will be used for qualitative data reporting context, implementation and acceptability. If appropriate, meta-analysis will be conducted with outcome and economic data. Convergent synthesis will be used to integrate syntheses of qualitative and quantitative data.

ETHICS AND DISSEMINATION

We have a comprehensive strategy for engagement with care-experienced children and young people, carers and social care professionals. Dissemination will include academic and non-academic publications and conference presentations. Ethical approval from Cardiff University's School of Social Sciences REC will be obtained if necessary.

PROSPERO REGISTRATION NUMBER

CRD42020177478.

Intrapartum Fetal Heart Monitoring Practices in Selected Facilities in Aspirational Districts of Jharkhand, Odisha and Uttarakhand

Background

The risk of mortality for the mother and the newborn is aggravated during birth in low- and middle-income countries due to preventable causes, which can be addressed with increased quality of care practices. One such practice is intrapartum fetal heart rate (FHR) monitoring, which is crucial for the early detection of fetal ischemia, but is inadequately monitored in low- and middle-income countries. In India, there is currently a lack of sufficient data on FHR monitoring.

Methods

An assessment using facility records, interviews and observation was conducted in seven facilities providing tertiary, secondary or primary level care in aspirational districts of three states. The study sought to investigate the frequency of monitoring, devices used for monitoring and challenges in usage.

Results

FHR was not monitored as per standard protocol. Case sheets revealed 70% of labor was monitored at least once. Only 33% of observed cases were monitored every half hour during active labor, and none were monitored every 5 min during the second stage of labor. More time was observed for monitoring with a Doppler compared with a stethoscope, as providers reported fluctuation in readings. Reportedly, low audibility and a perceived need of expertise were associated with using a stethoscope. High case load and the time required for monitoring were reported as challenges in adhering to standard monitoring protocols.

Conclusion

The introduction of a standardized device and a short refresher training on the World Health Organization and skilled birth attendant protocols for FHR monitoring will improve usage and compliance.

Use of a participatory quality assessment and improvement tool for maternal and neonatal hospital care. Part 2: Review of the results of quality cycles and of factors influencing change

BACKGROUND

Information about the use of the findings of quality assessments in maternal and neonatal (MN) care is lacking and the development of tools capable to effectively address quality gaps is a key priority. Furthermore, little is known about factors that act as barriers or facilitators to change at facility level. Based on the extensive experience made with the WHO Quality Assessment and Improvement MN (QA/QI MN) tool, an overview is provided of the improvements in quality of care (QoC) which were obtained over time and of the factors influencing change.

METHODS

All documented reports on the implementation of the WHO QA/QI MN tool were searched and screened for inclusion. Reports were considered if bringing evidence from both the baseline assessment and the reassessment. Changes were considered in four domains: maternal care, neonatal care, infrastructure and policies, with reference made to WHO maternal and neonatal care standards. The observed improvements were categorized according to intensity and extent across the sample of health facilities. Factors influencing change were categorized into internal and external and further classified as barriers or facilitators.

RESULTS

Changes were documented after an average period of 1.2 years from first assessment in 27 facilities belonging to 9 different countries in Central and Eastern Europe (3), Central Asia (3), sub-Saharan Africa (2) and Latin America (1). Improvements were observed in all areas of care but were greater and more frequently observed in areas related to appropriate case management and respectful care for both mothers and newborns. Although widespread across most facilities and countries, the observed improvements were not covering all the quality gaps observed at the baseline assessment nor were always sufficient to achieve standard care. Factors facilitating change as well as barriers were mainly related to the capacity of the managers and head of units to involve and motivate their staff members.

CONCLUSIONS

The use of WHO QA/QI MN tool proved effective in promoting significant changes in quality of care. The review of observed improvements and of factors influencing change at facility level shows that participatory assessment tools that promote a constructive dialogue with hospital managers and staff and support them in acquiring capacity in this role are crucial to implement effective quality cycles.

The effect of the community midwifery model on maternal and newborn health service utilization and outcomes in Busia County of Kenya: a quasi-experimental study

BACKGROUND

Poor women in hard-to-reach areas are least likely to receive healthcare and thus carry the burden of maternal and perinatal mortality from complications of childbirth. This study evaluated the effect of an enhanced community midwifery model on skilled attendance during pregnancy/childbirth as well as on maternal and perinatal outcomes against the backdrop of protracted healthcare workers' strikes in rural Kenya.

METHODS

The study used a quasi-experimental (one-group pretest-posttest) design. The study spanned three time periods: December 2016-February 2017 when doctors were on strike (P1), March-May 2017 when no healthcare providers were on strike (P2), and June-October 2017 when nurses/midwives were on strike (P3), which was also the period when the project enhanced the capacity of community midwives (CMs) to provide services at the community level. Analysis entailed comparison of frequencies/means of maternal and newborn health service utilization data across the three periods.

RESULTS

The monthly average number of clients obtaining services from CMs across the three time periods was: first antenatal care (ANC) (P1-1.8, P2-2.3, P3-9.9), fourth ANC (P1-1.4, P2-1.0, P3-7.1), skilled birth (P1-1.5, P2-1.7, P3-13.1) and the differences in means were statistically significant (p < 0.05). Over the period, the monthly average number of clients obtaining services from health facilities was: first ANC (P1-55.7, P2-70.8, P3-4.0), fourth ANC (P1-29.6, P2-38.1, P3-1.2) and skilled birth (P1-63.1, P2-87.4, P3-5.6), p < 0.05. There were no statistically significant differences in the average number of clients obtaining services from CMs or health facilities between P1 and P2 (p > 0.05). There was, however, a statistically significant increase in the average number of clients obtaining services from CMs in P3 accompanied by a statistically significant decline in the average number of clients obtaining services from health facilities (p < 0.05). First ANC increased by 68%, fourth ANC by 75%, skilled births by 68%, and postnatal care by 33% in P3 (p < 0.0001). There was a non-significant decline in macerated stillbirths and neonatal deaths in P3.

CONCLUSIONS

The findings underscore the importance of integrating community-level health service providers (CMs and health volunteers) into the primary health care system to complement service delivery according to their level of expertise, especially in low-resource settings.

Maternal Health Infrastructure and Interpersonal Quality of Care During Childbirth: An Examination of Facility Delivery in Malawi

OBJECTIVES

The maternal health field has recently focused on the importance of interpersonal quality of care and continues to cite structural deficits as a contributor to poor interpersonal treatment. This hypothesis is supported by qualitative evidence. This study quantitatively tested the effect of maternal health structural inputs on interpersonal quality of care during childbirth.

METHODS

Analyses were conducted using data from the 2013 to 2014 Malawi Service Provision Assessment, which documented the availability and quality of health facility services and included the observation of laboring and delivering women. Maternal health structural inputs were measured using 26 facility infrastructure variables. The outcome, interpersonal quality of care, was measured as a sum score of 12 items collected during the observations. Crude and adjusted associations between maternal health structural inputs on interpersonal quality of care were assessed using linear regression with cluster robust standard errors.

RESULTS

345 Observations of delivering women in 174 health facilities were included in the analysis. 19.1% of women delivered in a facility with high maternal health structural inputs, and the mean interpersonal quality of care score was 8.9/12. Maternal health structural inputs had a small, non-meaningful association with interpersonal quality of care during childbirth (adjusted β - 0.19, 95% CI - 0.85, 0.47).

CONCLUSIONS FOR PRACTICE

These findings do not verify the quality of care frameworks or qualitative evidence that support the relationship between structure and interpersonal quality of care. While structural inputs are important for health system performance, the results suggest that they might not be necessary for a respectful childbirth experience.