Postnatal Care Experiences and Barriers to Care Utilization for Home- and Facility-Delivered Newborns in Uganda and Zambia

Key barriers to the provision and utilization of maternal health services in low-and lower-middle-income countries; a scoping review

BACKGROUND

The preservation and promotion of maternal health (MH) emerge as vital global health objectives. Despite the considerable emphasis on MH, there are still serious challenges to equitable access to MH services in many countries. This review aimed to determine key barriers to the provision and utilization of MH services in low- and lower-middle-income countries (LLMICs).

METHODS

In this scoping review, we comprehensively searched four online databases from January 2000 to September 2022. In this study, the approach proposed by Arksey and O'Malley was used to perform the review. Consequently, 117 studies were selected for final analysis. To determine eligibility, three criteria of scoping reviews (population, concept, and context) were assessed alongside the fulfillment of the STROBE and CASP checklist criteria. To synthesize and analyze the extracted data we used the qualitative content analysis method.

RESULTS

The main challenges in the utilization of MH services in LLMICs are explained under four main themes including, knowledge barriers, barriers related to beliefs, attitudes and preferences, access barriers, and barriers related to family structure and power. Furthermore, the main barriers to the provision of MH services in these countries have been categorized into three main themes including, resource, equipment, and capital constraints, human resource barriers, and process defects in the provision of services.

CONCLUSIONS

The evidence from this study suggests that many of the barriers to the provision and utilization of MH services in LLMICs are interrelated. Therefore, in the first step, it is necessary to prioritize these factors by determining their relative importance according to the specific conditions of each country. Consequently, comprehensive policies should be developed using system modeling approaches.

Utilization of Antenatal Care and Skilled Birth Delivery Services in Sub-Saharan Africa: A Systematic Scoping Review

Daily, the number of women who die around the world reaches an average of 800; these deaths are a result of obstetric complications in pregnancy and childbirth, and 99% of these deaths occur in low- and middle-income countries. This review probes the use of antenatal care (ANC) and skilled birth delivery (SBD) services in sub-Saharan Africa (SSA) and highlights research gaps using Arksey and O'Malley's methodological approach. The screening of abstracts and full text was carried out by two independent authors who ensured the eligibility of data extraction from the included articles. An exploration of the data was undertaken with descriptive analyses. In total, 350 potentially eligible articles were screened, and 137 studies were included for data extraction and analysis. From the 137 included studies, the majority were from Ethiopia (n = 40, 29.2%), followed by Nigeria (n = 30, 21.9%). Most of the studies were published between 2019 and 2023 (n = 84, 61%). Significant trends and challenges with ANC and SBD services emerged from the studies. It is revealed that there are wide gaps in the utilization of ANC and SBD services. Policy attention, intervention strategies to improve access, resources, rural-urban disparity, and women's literacy are recommended to improve the utilization of ANC and SBD services in SSA countries.

Assessing postnatal care for newborns in Sub-Saharan Africa: A multinational analysis

BACKGROUND

No doubt providing optimal postnatal care (PNC) prevents both maternal and neonatal deaths, in addition to the prevention of long-term complications. Sub-Saharan Africa (SSA) had the highest neonatal mortality rate, despite this adequate content of PNC for the newborn is not explored in SSA, therefore, it is important to identify the factors affecting adequate content of PNC for the newborn in the region. This may assist the program and policymakers to give an intervention based on the findings of the study.

METHODS

A secondary data analysis was performed using 21 SSA countries' Demographic and Health Surveys. A total weighted sample of 105,904 respondents were included in this study. A multilevel binary logistic regression model was fitted. The odds ratios along with the 95% confidence interval were generated to determine the individual and community-level factors of adequate PNC for the newborn. A p-value less than 0.05 was declared as statistical significance.

RESULTS

Adequate PNC for newborns in sub-Saharan Africa was 23.51% (95% CI: 23.26, 23.77). Mothers age ≥ 35(AOR  =  1.21,95% CI: 1.06,1.16), mothers' primary education (AOR  = 1.18, 95% CI: 1.13, 1.23), secondary education (AOR  = 1.58, 95% CI:1.51,1.66), higher education (AOR  = 1.61,95% CI:1.49,1.75), rich wealth status (AOR  = 1.05,95% CI = 1.01,1.10), ANC visits 1-7 (AOR  = 1.61,95% CI:1.51, 1.73), antenatal care (ANC) visit 8 and above (AOR  = 2.54,95% CI: 2.32, 2.77), health facility delivery (AOR  = 4.37, 95% CI:4.16,4.58), lived in east (AOR = 0.23,95% CI = (0.20,0.26), central(AOR = 0.21,95% CI = 0.19,0.24), west African sub-regions (AOR = 0.23,95% CI = 0.21, 0.27), Urban dwellers (AOR = 1.22,95% CI: 1.17,1.27), and low community poverty (AOR = 1.21 (95% CI = 1.11,1.31) were associated with adequate content of PNC for the newborn.

CONCLUSION

The finding of this study showed that the overall prevalence of adequate content of PNC for a newborn in SSA countries was low. The low prevalence of adequate content of postnatal care for newborns in SSA countries is a concerning issue that requires immediate attention. Age of the respondents, level of education, wealth status, ANC visits, place of delivery, residence, community-level poverty, and sub-region of SSA were the individual-level and the community-level variables significantly associated with adequate PNC for the newborn. Strategies should focus on increasing access to antenatal care services, particularly for vulnerable populations, such as younger mothers, those with lower education levels, and individuals residing in impoverished communities to improve PNC for the newborn.

Individual and community-level factors associated with women's utilization of postnatal care services in Uganda, 2016: a multilevel and spatial analysis

BACKGROUND

Over time, Uganda has experienced high levels of maternal mortality (435 deaths per 100,000 live births in 2006 to 336 deaths per 100,000 live births in 2016). The persistence of high levels of maternal mortality jeopardizes the achievement of Sustainable Development Goal (SDG) 3.1, which calls for reducing maternal mortality to 70 deaths per 100,000 live births by 2030. Conversely, the utilization of postnatal care (PNC) services in Uganda remained very low and has varied across regions. This study examined the individual and community-level factors influencing women's utilization of postnatal care services in Uganda.

METHODS

Secondary data from the 2016 Uganda Demographic and Health Survey (UDHS) were used in this study. The study population consisted of women aged 15 to 49 who reported giving birth in the five years preceding the 2016 UDHS survey. The factors associated with postnatal care services were identified using multilevel binary logistic regression and spatial analysis.

RESULTS

The result shows that the prevalence of postnatal care service utilization in Uganda was low (58.3%) compared to the World Health Organization (WHO) target of 100%. The univariate analysis shows that 13.7% of women were adolescents, 79% were of higher parity, and 70.4% had primary/no formal education, of which 76.6% resided in rural areas. On the other hand, the multilevel analysis results showed that women aged 20-29 years and 30-39 years were also found to be more likely to use PNC services (AOR = 1.2, 95% CI: 1.01-1.47). Women who received quality ANC (AOR = 2.1, 95% CI: 1.78-2.36) were more likely to use postnatal care services than their counterparts. At the community level, women who lived in media-saturated communities were more likely to use postnatal care services (AOR = 1.3, 95% CI: 1.01-1.65). The spatial analysis found that the Central, Eastern, and Northern regions were the areas of hotspots in the utilization of postnatal care services.

CONCLUSION

This study found that age, parity, level of education, place of residence, employment status, quality of the content of antenatal care, and community media saturation were the predictors of postnatal care service utilization. The spatial analysis showed that the spatial distributions of postnatal care service utilization were significantly varied across Uganda. The government must expand access to various forms of media throughout the country to increase PNC utilization.

Acceptance of the Advocacy Core Group approach in promoting integrated social and behaviour change for MNCH+N in Nigeria: a qualitative study

OBJECTIVE

This paper examines the acceptance of the Advocacy Core Group (ACG) programme, a social and behaviour change intervention addressing maternal, newborn, child health and nutrition (MNCH+N) in Bauchi and Sokoto states, with an additional focus on the perceived endorsement of health behaviours by social networks as a potential factor influencing acceptance.

DESIGN

This study used the qualitative social network analysis approach and used in-depth interviews to collect data from 36 participants across Bauchi and Sokoto states.

SETTING

This study was conducted in selected communities across Bauchi and Sokoto states.

PARTICIPANTS

A purposive sample of 36 participants comprised of men and women aged 15-49 years who have been exposed to the ACG programme.

RESULTS

Programme beneficiaries actively engaged in various ACG-related activities, including health messaging delivered through religious houses, social gatherings, home visits, community meetings and the media. As a result, they reported a perceived change in behaviour regarding exclusive breast feeding, antenatal care visits, family planning and malaria prevention. Our findings indicated consistent discussions on health behaviours between programme beneficiaries and their network partners (NPs), with a perceived endorsement of these behaviours by the NPs. However, a potential negative factor emerged, whereby NPs exhibited perceived disapproval of key behaviours, which poses a threat to behaviour adoption and, consequently, the success of the ACG model.

CONCLUSIONS

While findings suggest the successful implementation and acceptance of the model, it is important to address possible barriers and to further explore the socially determined acceptance of MNCH+N behaviours by NPs. Interventions such as the ACG model should mobilise the networks of programme participants, particularly those with decision-making power, to improve the uptake of health behaviours.

Facilitators and barriers of implementation of routine postnatal care guidelines for women: A systematic scoping review using critical interpretive synthesis

Background

Postnatal care (PNC) has the potential to prevent a substantial burden of maternal and newborn morbidity and mortality. This scoping review aimed to identify and synthesise themes related to facilitators and barriers of implementation of guidelines on routine PNC for women (postpartum care) in all settings.

Methods

This is a scoping review guided by the standard principles of Arksey & O'Malley's framework. We used the critical interpretive synthesis method to synthesise the whole body of evidence. We searched four databases (Medline, Embase, Global Health, CINAHL Plus) using a combination of search terms comprising four key concepts: postnatal care, routine care, guidelines and implementation. No restrictions on country or language of publication were applied. We excluded studies not presenting findings about PNC for women. We thematically charted the themes of studies included based on title and abstract screening. All studies included after full text screening were described and their results synthesised using the socio-ecological model framework. We did not conduct a risk of bias analysis or quality assessment of included studies.

Results

We identified a total of 8692 unique records and included 43 studies which identified facilitators and barriers to implementing routine guidelines in provision of PNC to women. Three quarters of studies pertained to PNC provision in high-income countries. Specific facilitators and barriers were identified and thematically presented based on whether they affect the provision of PNC or the intersection between provision of PNC and its use by women and families. We applied a critical global health lens to synthesise three constructs in the literature: finding a balance between standardisation and individualisation of PNC, the fragmented PNC provision landscape complicating the experiences of women with intersecting vulnerabilities, and the heavy reliance on the short postpartum period as an opportunity to educate and retain women and newborns in the health system.

Conclusions

This interpretive synthesis of evidence shows that the fragmented and narrow nature of PNC provision presents specific challenges to developing, adapting and implementing routine PNC guidelines. This results in a lack of linkages to social support and services, fails to address intersecting vulnerabilities and inequities among women, and negatively influences care seeking. There is a lack of evidence on how processes of individualising PNC provision can be applied in practice to support health workers in providing woman-centered PNC in various global settings.

Registration

https://www.protocols.io/private/C99DA688881F11EBB4690A58A9FEAC02.

Impact of beliefs on perception of newborn illness, caregiver behaviors, and care-seeking practices in Zambia's Southern province

Despite reductions in the number of under-five deaths since the release of the Sustainable Development Goals, the proportion of neonatal deaths among all under-five deaths has remained high. Neonatal health is linked to newborn care practices which are tied to distinct cultural perceptions of health and illness. We assessed how community beliefs in Zambia's Southern Province influence newborn care behaviors, perception of illness, and care-seeking practices, using qualitative data collected between February and April 2010. A total of 339 women participated in 36 focus group discussions (FGDs), with 9 FGDs conducted in each of the four study districts. In addition, 42 in-depth interviews (IDIs) were conducted with various key informants, with 11 IDIs conducted in Choma, 11 IDIs in Monze, 10 IDIs in Livingstone, and 10 IDIs in Mazabuka. The FGDs and IDIs indicate that beliefs among the Tonga people regarding postnatal illness prevention and management influence perceptions of newborn illness and care-seeking practices. Care seeking behaviors including when, why, and where parents seek newborn care are intimately tied to perception of disease among the Tonga people. These beliefs may stem from both indigenous and Western perspectives in Zambia's Southern Province. Findings are consistent with other analyses from Southern Province that highlighted the benefit of integrating local practices with Western biomedical care. Health systems models, led by policy makers and program designers, could aim to find synergies between community practices and formal health systems to support positive behavior change and satisfy multiple stakeholders.

Matters of Gender and Social Disparities Regarding Postnatal Care Use Among Nepalese Women: A Cross-Sectional Study in Morang District

Objective

The study compares the uses of postnatal care (PNC) and women's autonomy gradients across social caste and used intersectionality concepts to estimate odds ratio of women's autonomy and social caste on complete PNC.

Methods

A community-based cross-sectional study among 600 women aged 15-49 years who had at least one child younger than the age of 2 years in Morang District, Nepal, was conducted from April to July 2019. PNC, women's autonomy (decision-making power, freedom of movement, and control over finances) and social caste were collected by both methods. Multivariable logistic regressions were used to determine associations between women's autonomy, social caste, and complete PNC.

Results

Complete PNC totaled 13.5% of respondents. About one-fourth of respondents reported poor overall autonomy; however, non-Dalit demonstrated higher autonomy than Dalit. Non-Dalit exhibited greater odds of complete PNC by four times. Women exhibited high women's autonomy in decision-making power, control over finance, and freedom of movement and have greater odds of complete PNC than low autonomy by 17, 3, and 7 times, respectively.

Conclusion

The study raises awareness of intersectionality (gender and social caste), relating to maternal health in caste-based system countries. To improve maternal health outcomes, health care personnel should identify and systematically address barriers that women of lower-caste membership face and offer these women appropriate advice or resources to obtain care. A multilevel change program that involves different actors like husbands and community leaders is needed for improving women's autonomy and lessening stigmatized perceptions, attitudes, or practices toward non-Dalit caste-members.

The interaction between antenatal care and abnormal temperature during delivery and its relationship with postpartum care: a prospective study of 1,538 women in semi-rural Uganda

BACKGROUND

Postnatal care (PNC) is an important tool for reducing maternal and neonatal morbidity and mortality. However, what predicts receipt and maintenance in PNC, particularly events during pregnancy and the peripartum period, is not well understood. We hypothesized that fever or hypothermia during delivery would engender greater health consciousness among those attending antenatal care, leading to greater PNC engagement after hospital discharge and our objective was to evaluate this relationship.

METHODS

Women were prospectively enrolled immediately postpartum at Mbarara Regional Referral Hospital (MRRH). We collected postpartum vital signs and surveyed women by telephone about PNC receipt, fever, and infection at two and six weeks postpartum. Our outcome of interest was receipt of PNC post-discharge, defined as whether a participant visited a health facility and/or was hospitalized in the postpartum period. Our explanatory variables were whether a participant was ever febrile (> 38.0˚C) or hypothermic (< 36.0˚C) during delivery stay and whether a participant attended at least 4 antenatal care (ANC) visits. We used logistic regressions to estimate the association between ANC and fever/hypothermia with PNC, including an interaction term between ANC and fever/hypothermia to determine whether there was a modifying relationship between variables on PNC. Regression models were adjusted for age, marital status, parity, HIV serostatus, Mbarara residency, and whether the participant was referred to MRRH, RESULTS: Of the 1,541 women, 86 (5.6%) reported visiting a health facility and/or hospitalization and 186 (12.0%) had an abnormal temperature recorded during delivery stay. Of those who reported at least one visit, 59/86 (68.6%) delivered by cesarean, 37/86 (43.0%) reported post-discharge fever, and 44/86 (51.2%) reported post-discharge infection. Neither ANC attendance, abnormal temperature after delivery, nor their interaction term, were significantly associated with post-discharge PNC. The included covariates were not significantly associated with the outcome.

CONCLUSIONS

While the overall proportion of women reporting post-discharge PNC was low, those who reported visiting a health facility and/or hospitalization had high proportions of post-discharge fever, post-discharge infection, and cesarean delivery, which suggests that these visits may have been related to problem-focused care. No significant associations between ANC and PNC were observed in this cohort. Further research assessing ANC quality and PNC visit focus is needed to ensure ANC and PNC are optimized to reduce morbidity and mortality.

The role of Savings and Internal Lending Communities (SILCs) in improving community-level household wealth, financial preparedness for birth, and utilization of reproductive health services in rural Zambia: a secondary analysis

Background

Savings and Internal Lending Communities (SILCs) are a type of informal microfinance mechanism widely adapted in Zambia. The benefits of SILCs paired with other interventions have been studied in many countries. However, limited studies have examined SILCs in the context of maternal health. This study examined the association between having access to SILCs and: 1) household wealth, 2) financial preparedness for birth, and 3) utilization of various reproductive health services (RHSs).

Methods

Secondary analysis was conducted on baseline and endline household survey data collected as part of a Maternity Waiting Home (MWH) intervention trial in 20 rural communities across seven districts of Zambia. Data from 4711 women who gave birth in the previous year (baseline: 2381 endline: 2330) were analyzed. The data were stratified into three community groups (CGs): CG1) communities with neither MWH nor SILC, CG2) communities with only MWH, and CG3) communities with both MWH and SILC. To capture the community level changes with the exposure to SILCs, different women were randomly selected from each of the communities for baseline and endline data, rather than same women being surveyed two times. Interaction effect of CG and timepoint on the outcome variables – household wealth, saving for birth, antenatal care visits, postnatal care visits, MWH utilization, health facility based delivery, and skilled provider assisted delivery – were examined.

Results

Interaction effect of CGs and timepoint were significantly associated only with MWH utilization, health facility delivery, and skilled provider delivery. Compared to women from CG3, women from CG1 had lower odds of utilizing MWHs and delivering at health facility at endline. Additionally, women from CG1 and women from CG2 had lower odds of delivering with a skilled provider compared to women from CG3.

Conclusion

Access to SILCs was associated with increased MWH use and health facility delivery when MWHs were available. Furthermore, access to SILCs was associated with increased skilled provider delivery regardless of the availability of MWH. Future studies should explore the roles of SILCs in improving the continuity of reproductive health services.

Trial registration

NCT02620436.

"Why would I go if the infant was healthy?": Factors Influencing Postnatal Care Utilization in Chiapas, Mexico

Despite global efforts, postnatal care utilization remains low. There is almost no research on factors influencing postnatal care utilization in Latin America. Chiapas has one of the highest rates of maternal and neonatal mortality in Mexico. In 2014, we conducted 101 interviews with recently delivered women, male partners, traditional birth attendants (TBAs), and health staff, to assess factors influencing postnatal care utilization. Data underwent content analysis and thematic coding. Travel costs, postnatal seclusion practices, and a low perceived need for postnatal care were found to be disincentives to seek care. Providers ascribed low care adherence to cultural beliefs and low health literacy, while families indicated that their decision to seek facility care was mediated by the TBA's recognition of danger signs and perceived ability to manage complications. TBAs should be leveraged as gatekeepers, health literacy programs should emphasize the importance of primary care, and structural barriers to care should be reduced.

“Mothers will be lucky if utmost receive a single scheduled postnatal home visit”: An exploratory qualitative study, Northern Ethiopia

Background

Postnatal home visits (PNHVs) have been endorsed as strategy for delivery of postnatal care (PNC) to reduce newborn mortality and improve maternal outcomes. Despite the important role of the Health Extension Workers (HEWs) in improving the overall healthcare coverage, PNHV remains as a missed opportunity in rural Ethiopia. Thus, this study aimed to explore the barriers and facilitators of scheduled postnatal home visits in Northern Ethiopia.

Methods

We conducted an exploratory qualitative study on a total of 16 in-depth interviews with HEWs and mothers who gave birth one year prior to the study. In addition, focus group discussions were conducted with HEWs and key informant interviews were conducted with women development group leaders, supervisors, and healthcare authorities from April to June 2019 in two rural districts of Northern Ethiopia. Discussions and interviews were audio recorded and transcribed verbatim in the local language (Tigrigna) and translated into English. The translated scripts were thematically coded using Atlas ti scientific software. Field notes were also taken during the discussion and while conducting the interviews.

Results

Health system factors, community context, and individual level factors were considered as the barriers and facilitators of scheduled PNHVs. Leadership, governance, management, support and supervision, referral linkages, overwhelming workload, capacity building, logistics and supplies are the major sub-themes identified as health system factors. Physical characteristics like geographical location and topography, distance, and coverage of the catchment; and community support and participation like support from women’s development groups (WDGs), awareness of the community on the presence of the service and cultural and traditional beliefs were community contexts that affect PNHVs. Self-motivation to support and intrinsic job satisfaction were individual level factors that were considered as barriers and facilitators.

Conclusion

The finding of this study suggested that the major barriers of postnatal home visits were poor attention of healthcare authorities of the government bodies, lack of effective supervision, poor functional linkages, inadequate logistics and supplies, unrealistic catchment area coverage, poor community participation and support, and lack of motivation of HEWs. Henceforth, to achieve the scheduled PNHV in rural Ethiopia, there should be strong political commitment and healthcare authorities should provide attention to postnatal care both at facility and home with a strong controlling system.

Continuum of care for maternal health in Uganda: A national cross-sectional study

Introduction

A continuum of maternal care approach can reduce gaps and missed opportunities experienced by women and newborns. We determined the level of coverage and factors associated with the continuum of maternal care in Uganda.

Methods

We used weighted data from the Uganda Demographic and Health Survey (UDHS) 2016. We included 10,152 women aged 15 to 49 years, who had had a live birth within five years preceding the survey. Stratified two-stage cluster sampling design was used to select participants. Continuum of maternal care was considered when a woman had at least four antenatal care (ANC) visits, had delivered in a health facility and they had at least one postnatal check-up within six weeks. We conducted multivariable logistic regression analysis to determine factors associated with completion of the continuum of maternal care using SPSS version 25.

Results

The level of coverage of complete continuum of maternal care was 10.7% (1,091) (95% CI: 10.0–11.2). About 59.9% (6,080) (95% CI: 59.0–60.8) had four or more antenatal visits while 76.6% (7,780) (95% CI: 75.8–77.5) delivered in a health facility and 22.5% (2,280) (95% CI: 21.5–23.2) attended at least one postnatal care visit within six weeks. The following factors were associated with continuum of maternal care; initiating ANC in the first trimester (AOR 1.49, 95% CI: 1.23–1.79), having secondary level of education (AOR 1.60, 95% CI: 1.15–2.22) and tertiary level of education (AOR 2.08 95% CI: 1.38–3.13) compared to no formal education, being resident in Central Uganda (AOR 1.44, 95% CI:1.11–1.89), Northern Uganda (AOR 1.35, 95% CI: 1.06–1.71) and Western Uganda (AOR 0.61, 95% CI: 0.45–0.82) compared to Eastern Uganda, and exposure to newspapers and magazines.

Conclusion

The level of coverage of the complete continuum of maternal care was low and varied across regions. It was associated with easily modifiable factors such as early initiation of ANC, exposure to mass media and level of education. Interventions to improve utilisation of the continuum of maternal care should leverage mass media to promote services, especially among the least educated and the residents of Western Uganda.

Care-Seeking Behavior for Newborns in Rural Zambia

OBJECTIVES

Mothers in resource-limited areas face barriers in initiating care for ill newborns, leading to delays that may contribute to newborn mortality. This qualitative study conducted in rural Lufwanyama District in Zambia aimed to (1) explore mothers' healthcare-seeking related to newborn illness and (2) identify reasons for delaying care-seeking for ill newborns.

METHODS

We examined the perspectives of 60 mothers and 77 grandmothers of children under three years of age in 14 focus group discussions as part of the Lufwanyama Integrated Neonatal and Child Health Program study. We conducted a thematic analysis of verbatim transcripts using dedicated software.

RESULTS

Mothers and grandmothers were generally able to identify newborn danger signs and established a hierarchy of care-seeking based on the perceived severity of danger signs. However, inability to afford transportation, inaccessible health care facilities, high costs of medication prescribed at the health clinics, lack of respectful treatment and fear of newborns dying in the hospital prevented participants from seeking timely care. As traditional birth attendants (TBAs) and community health care workers (CHWs) have limited roles in newborns care beyond the immediate delivery setting, mothers often resorted to traditional healers for newborn care.

CONCLUSIONS

Based on cultural beliefs and influenced by traditions, mothers in Lufwanyama have developed hierarchical strategies to seek care for ill newborns. Barriers to treatment at health facilities often resulted in traditional care. Training both TBAs and CHWs in providing community-based newborn care and appropriate referrals could improve care-seeking and prevent newborn mortality in rural Zambia.

"Separated during the first hours"-Postnatal care for women and newborns during the COVID-19 pandemic: A mixed-methods cross-sectional study from a global online survey of maternal and newborn healthcare providers

Routine postnatal care (PNC) allows monitoring, early detection and management of complications, and counselling to ensure immediate and long-term wellbeing of mothers and newborns; yet effective coverage is sub-optimal globally. The COVID-19 pandemic disrupted availability and quality of maternal and newborn care despite established guidelines promoting continuity of essential services. We conducted a cross-sectional global online survey of 424 maternal and newborn healthcare providers from 61 countries, to explore PNC provision, availability, content and quality following the early phase of the COVID-19 pandemic. The questionnaire (11 languages), included four multiple-choice and four open-text questions on changes to PNC during the pandemic. Quantitative and qualitative responses received between July and December 2020 were analysed separately and integrated during reporting. Tightened rules for visiting postpartum women were reported in health facilities, ranging from shorter visiting hours to banning supportive companions and visitors. A quarter (26%) of respondents reported that mothers suspected/confirmed with COVID-19 were routinely separated from their newborns. Early initiation of breastfeeding was delayed due to waiting for maternal SARS-CoV-2 test results. Reduced provision of breastfeeding support was reported by 40% of respondents in high-income countries and 7% in low-income countries. Almost 60% reported that women were discharged earlier than usual and 27% perceived a reduction in attendance to outpatient PNC. Telemedicine and home visits were mostly reported in high-income countries to ensure safe care provision. Beyond the early phase of the COVID-19 pandemic, severe disruptions to content and quality of PNC continued to exist, whereas disruptions in availability and use were less commonly reported. Depriving women of support, reducing availability of PNC services, and mother-newborn separation could lead to negative long-term outcomes for women, newborns and families, and deny their rights to respectful care. Protecting these essential services is imperative to promoting quality woman-centred PNC during and beyond the pandemic.

Direct and opportunity costs related to utilizing maternity waiting homes in rural Zambia

•

Lack of financial resources is a critical barrier to utilising Maternity Waiting Homes (MWHs) in low-income countries (LICs).

•

Food and user fees are most frequent expenditures for women utilising MWHs in rural Zambia.

•

Being away from various household chores, the loss of income generating activities (IGAs), may also be a financial constraint in utilising MWHs.

Aim

To assess the direct and opportunity costs involved in utilising maternity waiting homes.

Method

A cross-sectional admission survey administered to women who used ten maternity waiting homes across two rural districts in Zambia. A total of 3,796 women participated in the survey. Descriptive analysis was conducted on three domains of the data: demographic characteristics of women, direct costs, and opportunity costs.

Findings

Waiting to deliver (86.3%), safe birth (70.8%), and distance (56.0%) were the most frequent reasons women reported for using a maternity waiting home. In terms of direct costs, roughly 65% of the women brought seven days or fewer days' worth of food to the maternity waiting homes, with salt, mealie meals, and vegetables being the most frequently brought items. Only 5.8% of the women spent money on transport. More than half of the women reported paying user fees that ranged from 1 to 5 or more kwacha (US$0.10- 0.52). In terms of opportunity costs, 52% of the women participated in some form of income generating activities (IGAs) when at home. Approximately 35% of the women reported they lost earned income (1 to 50 or more kwacha) by staying at a maternity waiting home.

Conclusion

A large proportion of women paid for food and user fees to access a maternity waiting home, while a low number of women paid for transport. Even though it is difficult to assign monetary value to women's household chores, being away from these responsibilities and the potential loss of earned income appear to remain a cost to accessing maternity waiting homes. More research is needed to understand how to overcome these financial constraints and assist women in utilising a maternity waiting home.

How women's experiences and perceptions of care influence uptake of postnatal care across sub-Saharan Africa: a qualitative systematic review

BACKGROUND

The burden of maternal and neonatal morbidity and mortality is a global health concern with the highest burden documented after childbirth in women and babies living in sub-Saharan Africa. To date, there is limited information on the quality of postnatal care and/or whether evidence-based interventions to improve postnatal care in a way that meets the specific health needs of each mother and her baby have been lacking. There is also limited data related to how quality of care (respectful or disrespectful) influences women's decision to access postnatal care.

OBJECTIVE

To systematically review available qualitative evidence for how quality of care (respectful or disrespectful) influences perceptions and experiences of, and decisions to, access postnatal care for women living in sub-Saharan Africa.

SEARCH STRATEGY

CINAHL plus, Cochrane library, Global Health, Medline, PubMed, Web of Science were searched from 2009-2019. Grey literature was searched on Google Scholar.

SELECTION CRITERIA

Qualitative literature in English describing women's perceptions and experiences of the quality of care they received after childbirth and how this influenced their perceptions of and decisions to access postnatal care.

DATA ANALYSIS

Thematic analysis was performed to extract subthemes and themes. Outcomes were themes from the qualitative data used to form a thematic synthesis.

RESULTS

Fifteen studies were included with data from 985 women interviewed face-to-face across eight countries. Descriptions of respectful care included healthcare providers being kind, supportive and attentive to women's needs. Women described preferring healthcare services where the healthcare providers communicated in a respectful and caring manner. Descriptions of disrespectful care included verbal and/or physical abuse and power imbalances between women and healthcare providers. Some women were denied postnatal care when attending a healthcare facility after giving birth at home. There is evidence to suggest that vulnerable women (adolescents; women with poor socioeconomic status; women who are HIV positive) are more likely to receive disrespectful care.

CONCLUSIONS

This systematic review describes how aspects of respectful and disrespectful maternity care influence women's perceptions and experiences of, and decisions to access postnatal care services. There is a need for a renewed focus to prioritise respectful maternity care and to sustainably provide good quality postnatal care to all women and their babies in a way that meets their expectations and health needs.

Late initiation and low utilization of postnatal care services among women in the rural setting in Northwest Tanzania: a community-based study using a mixed method approach

Background

Maternal and newborn mortality is high immediately after childbirth and up to 42 days postnatally despite the availability of interventions. Postnatal care is crucial in preventing mortality and improving the health of women and newborns. This prospective cohort study investigated the initiation and utilization of postnatal care at health facilities and explored users’ and providers’ perspectives on utilization of postnatal care services.

Methods

A sequential explanatory mixed method was used involving women who were followed from the 3rd trimester of pregnancy to 3–4 months postnatally in Northwest, Tanzania. From January to December 2018, a door-to-door survey was conducted 3–4 months postnatally among 1385 of these women. A convenience sample of women and community health workers participated in focus group discussions, and traditional birth attendants and nurses participated in key informant interviews to complement quantitative data. Data analyses were conducted using STATA version 13 and NVIVO version 12.

Study findings

Approximately, one half of participants attended postnatal care within 42 days after delivery. Postnatal care seeking within 48 h after delivery was reported by 14.6 % of the participants. Women who attended antenatal care at least four times, delivered at health facilities or experienced delivery-related complications were more likely to seek postnatal care. Limited knowledge on the postnatal care services and obstetric complications after childbirth, and not being scheduled for postnatal care by health providers negatively influenced services uptake. Overwhelming workload and shortages of supplies were reported to hinder the provision of postnatal care services.

Conclusions

Utilization of postnatal care services remains low in this setting as a result of a number of disparate and complex factors that influence women’s choices. Provision of effective postnatal care is hindered by lack of supplies, staffing, and inadequate infrastructure. To ensure accessibility and availability of quality services in this setting, both demand and supply sides factors need to be addressed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06695-8.

Disrespect and abuse as a predictor of postnatal care utilisation and maternal-newborn well-being: a mixed-methods systematic review

Introduction

Globally, a substantial number of women experience abusive and disrespectful care from health providers during childbirth. As evidence mounts on the nature and frequency of disrespect and abuse (D&A), little is known about the consequences of a negative experience of care on health and well-being of women and newborns. This review summarises available evidence on the associations of D&A of mother and newborns during childbirth and the immediate postnatal period (understood as the first 24 hours from birth) with maternal and neonatal postnatal care (PNC) utilisation, newborn feeding practices, newborn weight gain and maternal mental health.

Methods

We conducted a systematic review of all published qualitative, quantitative and mixed-methods studies on D&A and its postnatal consequences across all countries. Pubmed, Embase, Web of Science, LILACS and Scopus were searched using predetermined search terms. Quantitative and qualitative data were analysed and presented separately. Thematic analysis was used to synthesise the qualitative evidence.

Results

A total of 4 quantitative, 1 mixed-methods and 16 qualitative studies were included. Quantitative studies suggested associations between several domains of D&A and use of PNC as well as maternal mental health. Different definitions of exposure meant formal meta-analysis was not possible. Three main themes emerged from the qualitative findings associated with PNC utilisation: (1) women’s direct experiences; (2) women’s expectations and (3) women’s agency.

Conclusion

This review is the first to examine the postnatal effect of D&A of women and newborns during childbirth. We highlight gaps in research that could help improve health outcomes and protect women and newborns during childbirth. Understanding the health and access consequences of a negative birth experience can help progress the respectful care agenda.

Immediate postnatal care following childbirth in Ugandan health facilities: an analysis of Demographic and Health Surveys between 2001 and 2016

Introduction

Progress in reducing maternal and neonatal mortality, particularly in sub-Saharan Africa, is insufficient to achieve the Sustainable Developmental Goals by 2030. The first 24 hours following childbirth (immediate postnatal period), where the majority of morbidity and mortality occurs, is critical for mothers and babies. In Uganda,<50% of women reported receiving such care. This paper describes the coverage, changes over time and determinants of immediate postnatal care in Uganda after facility births between 2001 and 2016.

Methods

We analysed the 2006, 2011 and 2016 Ugandan Demographic and Health Surveys, including women 15–49 years with most recent live birth in a healthcare facility during the survey 5-year recall period. Immediate postnatal care coverage and changes over time were presented descriptively. Multivariable logistic regression was used to examine determinants of immediate postnatal care.

Results

Data from 12 872 mothers were analysed. Between 2006 and 2016, births in healthcare facilities increased from 44.6% (95% CI: 41.9% to 47.3%) to 75.2% (95% CI: 73.4% to 77.0%) and coverage of immediate maternal postnatal care from 35.7% (95% CI 33.4% to 38.1%) to 65.0% (95% CI: 63.2% to 66.7%). The majority of first checks occurred between 1 and 4 hours post partum; the median time reduced from 4 hours to 1 hour. The most important factor associated with receipt of immediate postnatal care was women having a caesarean section birth adjusted OR (aOR) 2.93 (95% CI: 2.28 to 3.75). Other significant factors included exposure to mass media aOR 1.38 (95% CI: 1.15 to 1.65), baby being weighed at birth aOR 1.84 (95% CI: 1.58 to 2.14) and receipt of antenatal care with 4+Antenatal visits aOR 2.34 (95% CI: 1.50 to 3.64).

Conclusion

In Uganda, a large gap in coverage remains and universal immediate postnatal care has not materialised through increasing facility-based births or longer length of stay. To ensure universal coverage of high-quality care during this critical time, we recommend that maternal and newborn services should be integrated and actively involve mothers and their partners.

Role of Savings and Internal Lending Communities (SILCs) in improving household wealth and financial preparedness for birth in rural Zambia

Savings and Internal Lending Communities (SILCs) are a type of informal microfinance mechanism adapted in many low- and middle-income countries (LMICs) to improve financial resources for poor and rural communities. Although SILCs are often paired with other health and non-health-related interventions, few studies have examined SILCs in the context of maternal health. This study examined the association between SILC participation, household wealth and financial preparedness for birth. The study also examined the association between sex and financial preparedness for birth. A secondary analysis was conducted on individual survey data collected from SILC participants in two rural districts of Zambia between October 2017 and February 2018. A convenience sample of 600 participants (Lundazi: n = 297; Mansa: n = 303) was analysed. Descriptive analyses were run to examine SILC participation and household wealth. Multiple binary logistic regression models were fit to assess the unadjusted and adjusted relationship between (1) SILC participation and household wealth, (2) SILC participation and financial preparedness for birth and (3) sex and financial preparedness for birth. The results show that SILC participation led to an average increase of 7.32 items of the 13 household wealth items. SILC participants who had their most recent childbirth after joining SILCs were more likely to be financially prepared for birth [adjusted odds ratio (AOR): 2.99; 95% confidence interval (95% CI): 1.70-5.26; P < 0.001] than participants who had their most recent childbirth before joining SILCs. Females were more likely to be financially prepared for birth than males if they had their most recent birth before joining an SILC (AOR: 1.79; 95% CI: 1.16-2.66; P < 0.01). SILC participation is shown to increase household wealth and financial preparedness for birth for both men and women. SILCs are a promising intervention that can help poor and rural populations by increasing financial resources and financially preparing parents for birth.

Home Birth in Rural Zambia: The Role of Intimate Partner Violence and Autonomous Decision-Making

INTRODUCTION

Skilled care is indicated as a measure to prevent the deaths of pregnant women across sub-Saharan Africa. Despite this, many women continue to give birth at home. There has been little attention as to how the experience of intimate partner violence (IPV) or autonomous decision-making about place of birth influences home births in rural Zambia. This study explores how markers of sociocultural gender inequities (prevalence of IPV and autonomous decision-making) correlate with home birth in rural Zambia.

METHODS

This secondary analysis uses quantitative data from a baseline household survey with women who had given birth within the past 13 months in rural Zambia. Control variables shown to be significant in the literature were included in the model, and binary logistic regression was used to assess the influence of IPV and autonomous decision-making on home birth.

RESULTS

This sample included 2381 women from rural Zambia, of whom 384 reported a home birth within the past 13 months. Women who were autonomously making the decision about where to give birth were more likely to have a home birth (adjusted odds ratio [AOR], 1.729; SE, 0.210; 95% CI, 1.362-2.194; P < .001). Self-report of experiencing physical IPV in the past 2 weeks was not significant in predicting home birth (AOR, 0.783; SE, 0.181; 95% CI, 0.496-1.234; P = .293). Women who self-identified as Tumbuka or other, were able to afford school fees, had completed secondary education or higher, were married, and had 4 or more antenatal care visits were significantly less likely to report a home birth.

DISCUSSION

This quantitative analysis did not corroborate findings from other research that implicates IPV as a predictor of home birth. Additionally, autonomous decision-making was not associated with a decrease in home births. Future work should incorporate qualitative or mixed methods strategies to comprehensively explore household- and facility-level interventions to promote facility birth.

Reactions to and explanations for the birth of a baby with albinism: a qualitative study in Busoga, Uganda

OBJECTIVES

Babies born with the genetic condition albinism lack pigment in their hair, skin and eyes due to compromised melanin production. This leads to poor vision and the risk of early death due to skin cancer. In Uganda, one of the least developed countries in the world, their lack of pigmentation makes them very different in appearance within their communities. Local explanations of albinism include links to witchcraft and the supernatural. We aimed to explore reactions to the birth of a baby with albinism in Uganda.

DESIGN

Secondary analysis of birth stories derived from qualitative interviews and focus group discussions in sharing circles.

SETTING

Interviews took place in the Busoga subregion (kingdom) in the eastern part of Uganda.

PARTICIPANTS

Seventy-three (73) participants took part in eight sharing circles (n=56) and 17 individual interviews. Participants included people with albinism, parents of people with albinism and a range of other interested parties, including local leaders and teachers.

RESULTS

Reactions were generally those of shock and rejection, although cases of acceptance were also recorded. The varied explanations given to account for this unexpected event included accounts involving witchcraft, ghosts, animal familiars and religion, as well as genetics. In a framework surmising that someone must possess a dark skin to be intrinsically valued in African societies a baby with albinism does not fulfil this requirement of 'personhood'. The mother was often blamed for having produced some 'thing' that is not a proper person.

CONCLUSIONS

We argue that a biomedical explanation, although unlikely to displace other understandings, helps to establish a baby with albinism as a real person with a genetic difference, and hence fosters greater acceptance.

Financial Preparedness for Birth Among Rural Zambian Women: Do Antenatal Care Contacts Make a Difference?

INTRODUCTION

Financial constraints are one of the biggest barriers for women of low-income countries to receive necessary reproductive health services. Educating women about the importance of saving money has been incorporated as a component of antenatal care (ANC) contacts, but little is known whether ANC contacts influence women's saving.

METHODS

A secondary analysis was conducted on data from a cross-sectional household survey study of 1109 women who recently gave birth in two rural districts of Zambia.

RESULTS

Receiving ANC contacts early and often and discussing saving money during ANC were associated with saving money for the mother's birth, but not with saving enough money for the most recent birth.

DISCUSSION

Continued effort is needed to encourage women to attend ANC contacts earlier and more frequently. Additionally, the importance of saving money for birth should be discussed during ANC contacts. Future studies need to explore why women's action in saving does not necessarily lead to saving enough for childbirth.

Adoption of outgroup norms provides evidence for social transmission in perinatal care practices among rural Namibian women

Background and objectives

How do new ideas spread in social groups? We apply the framework of cultural evolution theory to examine what drives change in perinatal care norms among Himba women in the Kunene region of Namibia. Access to formal medical care is on the rise in this region, and medical workers regularly visit communities to promote WHO-recommended perinatal care practices. This study investigates how various forms of social transmission affect women's uptake of medical recommendations concerning perinatal care.

Methodology

Based on interviews with one hundred Himba mothers, we used Bayesian multi-level logistical regression models to examine how perceptions of group preferences, prestige ascribed to outgroup conformers, interaction with the outgroup and access to resources affect norm adoption.

Results

Women who perceive medical recommendations as common in their group prefer, plan and practice these recommendations more often themselves. We observed a shift toward medical recommendations regarding birth location and contraception use that was in line with conformity bias predictions. Practices that serve as cultural identity markers persist in the population.

Conclusions and implications

Norm changes, and the cultural evolutionary processes that can lead to them, are not uniform, either in process or pace. Empirical studies like this one provide important examples of how these changes reflect local culture and circumstance and are critical for better understanding the models that currently predominate in cultural evolution work. These cases can also help bridge the gap between evolutionary anthropology and public health by demonstrating where promotion and prevention campaigns might be most effective.

Lay Summary

The recent promotion of WHO-recommended perinatal care practices in Namibia provides an opportunity to empirically study norm change using a cultural evolution framework. We found women adopt medical recommendations when they believe these are common in their social group. Local norms that were not discouraged persisted in the study group.

Confronting the culture of care: a call to end disrespect, discrimination, and detainment of women and newborns in health facilities everywhere

Quality and respect are increasingly recognized as critical aspects of the provision of health care, and poor quality may be an essential driver of low health care utilization, especially for maternal and neonatal care. Beyond differential access to care, unequal levels of quality exacerbate inequity, and those who need services most, including displaced, migrant, and conflict-affected populations, may be receiving poorer quality care, or may be deterred from seeking care at all.Examples from around the world show that mothers and their children are often judged and mistreated for presenting to facilities without clean or "modern" clothing, without soap or clean sheets to use in the hospital, or without gifts like sweets or candies for providers. Underfunded facilities may rely on income from those seeking care, but denying and shaming the poor further discriminates against vulnerable women and newborns, by placing additional financial burden on those already marginalized.The culture of care needs to shift to create welcoming environments for all care-seekers, regardless of socio-economic status. No one should fear mistreatment, denial of services, or detainment due to lack of gifts or payments. There is an urgent need to ensure that health care centers are safe, friendly, respectful, and hospitable spaces for women, their newborns, and their families.

"Midwives do not appreciate pregnant women who come to the maternity with torn and dirty clothing": institutional delivery and postnatal care in Torit County, South Sudan: a mixed method study

Background

South Sudan has one of the highest maternal mortality ratios in the world, at 789 deaths per 100,000 live births. The majority of these deaths are due to complications during labor and delivery. Institutional delivery under the care of skilled attendants is a proven, effective intervention to avert some deaths. The aim was to determine the prevalence and explore the factors that affect utilization of health facilities for routine delivery and postnatal care in Torit County, South Sudan.

Methods

A convergent parallel mixed method design combined a community survey among women who had delivered in the previous 12 months selected through a multistage sampling technique (n = 418) with an exploratory descriptive qualitative study. Interviews (n = 19) were conducted with policymakers, staff from non-governmental organizations and health workers. Focus group discussions (n = 12) were conducted among men and women within the communities. Bivariate and multivariate logistic regression were conducted to determine independent factors associated with institutional delivery. Thematic analysis was undertaken for the qualitative data.

Results

Of 418 participants who had delivered in the previous 12 months, 27.7% had institutional deliveries and 22.5% attended postnatal care at least once within 42 days following delivery. Four or more antenatal care visits increased institutional delivery 5 times (p < 0.001). The participants who had an institutional delivery were younger (mean age 23.3 years old) than those who had home deliveries (mean age 25.6 years). Any previous payments made for delivery in the health facility doubled the risk of home delivery (p = 0.021). Women were more likely to plan and prepare for home delivery than for institutional delivery and sought institutional delivery when complications arose. Perceived poor quality of care due to absence of health staff and lack of supplies was reported as a major barrier to institutional delivery. Women emphasized fear of discrimination based on social and economic status. Unofficial payments such as soap and sweets were reported as routine expectations and another major barrier to institutional delivery.

Conclusion

Interventions to stop unofficial payments and discrimination based on socio-economic status and to increase access to ANC, delivery services and PNC are needed.

Cultural beliefs and health-seeking practices: Rural Zambians' views on maternal-newborn care

•

Mothers caring for newborns have a maternal dualism between cultural and health system obligations.

•

Traditional newborn protective rituals were identified to help nurses provide health education.

•

Family and community expressed a strong need to protect the newborn using traditional belief systems.

Background

- Far too many newborns die or face serious morbidity in Zambia, as in many other sub-Saharan African countries. New knowledge is needed to enhance our understanding of newborn care and the cultural factors influencing the ways mothers seek newborn care. This study adds to the literature about rural Zambians’ cultural beliefs and practices related to newborn care and health-seeking practices that influence maternal-newborn health.

Objective

- The goal of this study was to describe the factors associated with newborn care in rural Zambia.

Design

- Sixty focus groups were conducted. Each group contained a minimum of 8 and maximum of 12 participants. Recruitment was conducted orally by word of mouth through the nurse in charge at the health facilities and village chiefs.

Setting

– Data were collected between June and August 2016 in 20 communities located in Zambia's rural Lundazi (Eastern province), Mansa, and Chembe (Luapula province) Districts.

Participants

- The study included community members (n = 208), health workers (n = 225), and mothers with infants younger than 1-year-old (n = 213).

Findings

- The following themes emerged. From mothers with infants, the dominant theme concerned traditional and protective newborn rituals. From community members, the dominant theme was a strong sense of family and community to protect the newborn, and from health workers, the major theme was an avoidance of shame. A fourth theme, essential newborn care, was common among all groups.

Key conclusions

– Together the themes pointed toward a maternal dualism for mothers in rural Zambia. Mothers with infants in rural Zambia likely experience a dualistic sense of responsibility to satisfy both cultural and health system expectations when caring for their newborns. Mothers are pulled to engage in traditional protective newborn care rituals while at the same time being pushed to attend ANC and deliver at the health facility. These findings can be used to understand how mothers care for their newborns to develop interventions aimed at improving maternal-child health outcomes.

Implications for practice

- There were findings about the culture-specific prevention of cough, care of the umbilical cord, and early introduction of traditional porridge that carry implications for nursing practice. There is an obvious need to reinforce the importance of partner testing for STIs during routine ANC even though there is a desire to preserve dignity.

Determinants of early postnatal care attendance: analysis of the 2016 Uganda demographic and health survey

Background

The first 2 days after childbirth present the highest risk of dying for a mother. Providing postnatal care within the first 2 days after childbirth can help avert maternal mortality because it allows early detection of problems that could result in adverse maternal health outcomes. Unfortunately, knowledge of the uptake of early postnatal care (EPNC), which is imperative for informing policies aimed at reducing maternal mortality, remains low in Uganda. Therefore, the purpose of this study is to investigate the determinants of early postnatal care attendance among Ugandan women.

Methods

This study was based on nationally representative data from the 2016 Uganda Demographic and Health Survey. The study sample comprised 5471 women (age 15–49) who delivered a child in the 2 years preceding the survey. We used logistic regression to identify factors associated with use of early postnatal care.

Results

Our findings showed that 50% of mothers used EPNC services for their most recent delivery in the 2 years preceding the survey. Women’s residence, education level, religion, wealth status, marital status, occupation, antenatal care attendance, place of delivery, birth order, perceived accessibility of health facilities, and access to mass media messages were associated with greater use of EPNC. The percentage of women receiving EPNC was much higher among women who delivered at a health facility, either a public facility (63%) or private facility (65%), versus only 9% among women who delivered at home. Multivariate analysis showed that delivery at a health facility was the most important determinant of early postnatal care attendance.

Conclusions

To increase mothers’ use of EPNC services and improve maternal survival in Uganda, programs could promote and strengthen health facility delivery and ensure that EPNC services are provided to all women before discharge. Even so, the fact that only about two-thirds of women who delivered at a health facility received early postpartum care shows substantial room for improvement. Interventions should target women who deliver at home, women who attend fewer than four antenatal care visits, and women with a primary education.

Utilization of Postnatal Healthcare Services Delivered through Home Visitation and Health Facilities for Mothers and Newborns: An Integrative Review from Developing Countries

Despite evidence about the value of high quality postnatal services for the survival, health and wellbeing of the mother and neonate, sub-optimal use of the available services delivered through public sector remains a persistent challenge in India and most low-middle income countries. An extensive search till Dec 31, 2017 in databases including PubMed, Scopus and Science Direct was conducted and selected studies were organized, categorized and summarized for integrated review. Of the 3463 studies screened, 47 relevant studies were identified through integrated systematic process. The 'nexus' framework consisting of four domains namely: social-cultural, educational, organizational and economic-physical were used to determine the promoters and inhibitors of postnatal care-utilization. The important inhibitory factors at household and community context were myths-cultural practices, gaps in the awareness of mother and families regarding danger signs and postnatal complications and hesitancy to contact health workers due to trust deficit. There were lack of clarity about job responsibilities, poor quality of training, skills building and supervision of front line workers. Quality of home visits, and irregular incentives to health workers were other factors. The facilitating factors were mother's autonomy, young mothers, access to media and repeated and timely contact with the health worker, antenatal care (ANC) attendance and institutional deliveries, conditional cash transfer and availability of health insurance. Several factors like social mobilization, skill building and training cut across the domains of the nexus framework. The review suggested a multi-dimensional focus on implementing integrated continuum of care models covering prenatal-postnatal and infancy period.

Magnitude and determinants for place of postnatal care utilization among mothers who delivered at home in Ethiopia: a multinomial analysis from the 2016 Ethiopian demographic health survey

Introduction

Above half of mothers in Ethiopia give birth at home. Home based care within the first week after birth as a complementary strategy to facility-based postnatal care service is critical to increase the survival of both mothers and newborns. However, evidence on utilization of postnatal care and location of service among mothers who delivered at home in Ethiopia is insufficiently documented. Therefore, this study assessed the magnitude and determinants for place of postnatal care service utilization among mothers who delivered at home in Ethiopia.

Methods

We used the 2016 Ethiopian Demographic and Health Survey, and extracted data from 4491 mothers who delivered at home during 5 years preceding the survey. A multinomial logistic regression model was applied to examine the determinants of both facility and home -based postnatal care service utilization. Likelihood ratio test was used to see the model fitness and p-value of < 0.05 was used to determine statistical significance at 95% confidence interval.

Results

From the total 4491 mothers who delivered at home, only 130(2.9%) and 236(5.3%) of them utilized postnatal service at home and at a health facility respectively. Being from an urban region (AOR = 0.378, 95%CI: 0.193–0.740), ever using the calendar method to delay pregnancy (AOR = 0.528, 95%CI: 0.337–0.826), receiving four and above antenatal care visits (AOR = 0.245, 95%CI: 0.145–0.413) and having a bank account (AOR = 0.479, 95%CI: 0.243–0.943) were the factors associated with utilizing home- based postnatal care. Similarly being a follower of the orthodox religion (AOR = 1.698, 95%CI: 1.137–2.536), being in the rich wealth index (AOR = 0.608, 95%CI: 0.424–0.873), ever using the calendar method to delay pregnancy (AOR = 0.694, 95%CI: 0.499–0.966), wantedness of the pregnancy (AOR = 0.264, 95%CI: 0.352–0.953), receiving four and above antenatal care visits (AOR = 0.264, 95%CI: 0.184–0.380) and listening to radio at least once a week (AOR = 0.652, 95%CI: 0.432–0.984) were the determinants of facility-based postnatal care utilization.

Conclusion

The coverage of postnatal care service utilization among mothers who delivered at home was very low. Living in urban region, following the Orthodox religion, having higher wealth index, having a bank account, ever using calendar method to delay pregnancy, wantedness of the pregnancy, receiving four and above antenatal care visit and listening to radio at least weakly were associated with postnatal care service utilization. Therefore, targeted measures to improve socio-economic status, strengthen the continuum of care, and increase health literacy communication are critically important to increase postnatal care service utilization among women who deliver at home in Ethiopia.

The quality of maternal-fetal and newborn care services in Jordan: a qualitative focus group study

Background

The antenatal, intrapartum, and postnatal periods are considered high-risk periods for the health of mothers and their newborns. Although the current utilization rate of some maternal and child care services in Jordan is encouraging, detailed information about the quality of these services is limited. Therefore, this study aimed to explore the quality of maternal-fetal and newborn antenatal care (ANC), delivery, and postnatal care (PNC) services in Jordan.

Methods

We conducted 12 focus group discussions (FGDs) with pregnant and postpartum women who attended maternal-child care services in three major hospitals in Jordan. All FGDs were recorded and transcribed verbatim. An inductive thematic analysis approach was used to identify themes and subthemes.

Results

The content analysis of the FGDs revealed a consensus among the discussants regarding the importance of ANC and PNC services for the health of mothers and their newborns. However, the participating women viewed ANC to be much more important than PNC. With regards to the choice between public and private antenatal care services, some of the discussants were disposed towards the private sector. Reasons for this included longer consultation time, a higher quality of services, better interpersonal and communication skills of healthcare providers, better treatment, more advanced equipment and devices, availability of female obstetricians, and more flexible appointment times. These women only perceived public hospital services to be necessary in cases of pregnancy-related complications and labor, as the costs of private sector services in such cases are too high. The findings also revealed that mothers usually only seek PNC services to check up on their newborn’s health and not their own.

Conclusion

Visiting private ANC clinics throughout pregnancy while giving birth in public facilities leads to the discontinuity and fragmentation in maternal-fetal and child healthcare services. To address this fragmentation, healthcare systems are proposed to establish interprofessional teamwork that requires different healthcare providers with complementary skills and practices in both public and private settings to work co-operatively and collectively. Investment in new technologies and interventions which enhance coordination and collaboration between public and private healthcare settings is necessary for the provision of non-traditional maternal healthcare.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4232-9) contains supplementary material, which is available to authorized users.

What matters to women and healthcare providers in relation to interventions for the prevention of postpartum haemorrhage: A qualitative systematic review

Background

Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and morbidity. Reducing deaths from PPH is a global challenge. The voices of women and healthcare providers have been missing from the debate around best practices for PPH prevention. The aim of this review was to identify, appraise and synthesize available evidence about the views and experiences of women and healthcare providers on interventions to prevent PPH.

Methods

We searched eight electronic databases and reference lists of eligible studies published between 1996 and 2018, reporting qualitative data on views and experiences of PPH in general, and of any specific preventative intervention(s). Authors’ findings were extracted and synthesised using meta-ethnographic techniques. Confidence in the quality, coherence, relevance and adequacy of data underpinning the resulting themes was assessed using GRADE-CERQual. A line of argument synthesis was developed.

Results

Thirty-five studies from 29 countries met our inclusion criteria. Our results indicate that women and healthcare providers recognise the dangers of severe blood loss in the perinatal and postpartum period, but don’t always share the same beliefs about the causes and consequences of PPH. Skilled birth attendants and traditional birth attendants (TBA’s) want to prevent PPH but may lack the required resources and training. Women generally appreciate PPH prevention strategies, especially where their individual needs, beliefs and values are taken into account. Women and healthcare providers also recognize the value of using uterotonics (medications that contract the uterus) to prevent PPH but highlight safety concerns and potential misuse of the drugs as acceptability and implementation issues.

Conclusions

Based on stakeholder views and experiences, PPH prevention strategies are more likely to be successful where all stakeholders agree on the causes and consequences of severe postpartum blood loss, especially in the context of sufficient resources and effective implementation by competent, suitably trained providers.

Clinical cascades as a novel way to assess physical readiness of facilities for the care of small and sick neonates in Kenya and Uganda

BACKGROUND

Globally, there were 2.7 million neonatal deaths in 2015. Significant mortality reduction could be achieved by improving care in low- and middle-income countries (LMIC), where the majority of deaths occur. Determining the physical readiness of facilities to identify and manage complications is an essential component of strategies to reduce neonatal mortality.

METHODS

We developed clinical cascades for 6 common neonatal conditions then utilized these to assess 23 health facilities in Kenya and Uganda at 2 time-points in 2016 and 2017. We calculated changes in resource availability over time by facility using McNemar's test. We estimated mean readiness and loss of readiness for the 6 conditions and 3 stages of care (identification, treatment, monitoring-modifying treatment). We estimated overall mean readiness and readiness loss across all conditions and stages. Finally, we compared readiness of facilities with a newborn special care unit (NSCU) to those without using the two-sample test of proportions.

RESULTS

The cascade model estimated mean readiness of 26.3-26.6% across the 3 stages for all conditions. Mean readiness ranged from 11.6% (respiratory distress-apnea) to 47.8% (essential newborn care) across both time-points. The model estimated overall mean readiness loss of 30.4-31.9%. There was mild to moderate variability in the timing of readiness loss, with the majority occurring in the identification stage. Overall mean readiness was higher among facilities with a NSCU (36.8%) compared to those without (20.0%).

CONCLUSION

The cascade model provides a novel approach to quantitatively assess physical readiness for neonatal care. Among 23 facilities in Kenya and Uganda, we identified a consistent pattern of 30-32% readiness loss across cascades and stages. This aggregate measure could be used to monitor and compare readiness at the facility-, health system-, or national-level. Estimates of readiness and loss of readiness may help guide strategies to improve care, prioritize resources, and promote neonatal survival in LMICs.

Implementation of a community-based intervention in the most rural and remote districts of Zambia: a process evaluation of safe motherhood action groups

BACKGROUND

A community-based intervention known as Safe Motherhood Action Groups (SMAGs) was implemented to increase coverage of maternal and neonatal health (MNH) services among the poorest and most remote populations in Zambia. While the outcome evaluation demonstrated statistically significant improvement in the MNH indicators, targets for key indicators were not achieved, and reasons for this shortfall were not known. This study was aimed at understanding why the targeted key indicators for MNH services were not achieved.

METHODS

A process evaluation, in accordance with the Medical Research Council (MRC) framework, was conducted in two selected rural districts of Zambia using qualitative approaches. Focus group discussions were conducted with SMAGs, volunteer community health workers, and mothers and in-depth interviews with healthcare providers. Content analysis was done.

RESULTS

We found that SMAGs implemented much of the intervention as was intended, particularly in the area of women's education and referral to health facilities for skilled MNH services. The SMAGs went beyond their prescribed roles to assist women with household chores and personal problems and used their own resources to enhance the success of the intervention. Deficiencies in the intervention were reported and included poor ongoing support, inadequate supplies and lack of effective transportation such as bicycles needed for the SMAGs to facilitate their work. Factors external to the intervention, such as inadequacy of health services and skilled healthcare providers in facilities where SMAGs referred mothers and poor geographical access, may have led SMAGs to engage in the unintended role of conducting deliveries, thus compromising the outcome of the intervention.

CONCLUSION

We found evidence suggesting that although SMAGs continue to play pivotal roles in contribution towards accelerated coverage of MNH services among hard-to-reach populations, they are unable to meet some of the critical sets of MNH service-targeted indicators. The complexities of the implementation mechanisms coupled with the presence of setting specific socio-cultural and geographical contextual factors could partially explain this failure. This suggests a need for innovating existing implementation strategies so as to help SMAGs and any other community health system champions to effectively respond to MNH needs of most-at-risk women and promote universal health coverage targeting hard-to-reach groups.

Defining disrespect and abuse of newborns: a review of the evidence and an expanded typology of respectful maternity care

Amid increased attention to quality of obstetric care and respectful maternity care globally, insufficient focus has been given to quality of care and respectful care for newborns in the postnatal period. Especially in low and middle income countries, where low utilisation of obstetric and neonatal services is of concern, it is plausible that poor quality of care or mistreatment of newborns or stillborn infants will influence future care seeking, both for the health care needs of the growing infant and for subsequent pregnancies. Preliminary evidence indicates that mistreatment of newborns exists, both in the immediate and later postnatal periods. Definitions have been developed for instances of mistreatment of women during labour and delivery, but how newborns fit into the categorisations and critical questions around how to conceptualise dignified care for newborns have not been well addressed.

The WHO recently published “Standards for improving quality of maternal and newborn care in health facilities”, which provides a series of clinical and experiential standards that health facilities should strive to provide for all patients. Presented here are a number of the experiential measures, as well as health system requirements, which could be further developed to encompass the explicit needs of newborns and stillborn infants, and their families. Specific WHO Standards that require more attention for newborns are those related to effective communication, informed consent and emotional support (including for bereaved families).

Using seven categories previously developed for respectful maternity care generally, a literature review was conducted on mistreatment of newborns. The review revealed examples of mistreatment of newborns in six of the seven categories. Common occurrences were failure to meet a professional standard of care, stigma and discrimination, and health system constraints. Many instances of mistreatment of newborns related to neglect and non-consented care rather than outright physical or verbal abuse. Two additional categories were also identified for newborns related to legal accountability and bereavement care.

More research is needed into the prevalence of disrespect, abuse, and stigmatisation of newborns and further discussions are needed about how to provide quality care for all patients, including the smallest and most vulnerable.