Women's autonomy and husbands' involvement in maternal health care in Nepal

Impact of social determinants of health on progression from potentially life-threatening complications to near miss events and death during pregnancy and post partum in a middle-income setting: an observational study

OBJECTIVE

To assess the potential associations between social determinants of health (SDH) and severe maternal outcomes (SMO), to better understand the social structural framework and the contributory, non-clinical mechanisms associated with SMO.

STUDY DESIGN

Prospective observational study.

STUDY SETTING

Tertiary referral centre in south-eastern region of India.

PARTICIPANTS

One thousand and thirty-three women with potentially life-threatening complications (PLTC) were identified using WHO criteria.

RISK FACTORS ASSESSED

Social Determinants of Health (SDH).

PRIMARY OUTCOMES

Severe maternal outcomes, which include maternal near-miss and maternal death.

STATISTICAL ANALYSIS

Logistic regression to assess the association between SDH and clinical factors on SMO, expressed as adjusted ORs (aOR) with a 95% CI.

RESULTS

Of the 37 590 live births, 1833 (4.9%) sustained PLTC, and 380 (20.7%) developed SMO. Risk of SMO was higher with increasing maternal age (adjusted OR (aOR) 1.04 (95% CI 1.01 to 1.07)), multiparity (aOR 1.44 (1.10 to 1.90)), medical comorbidities (aOR 1.50 (1.11 to 2.02)), obstetric haemorrhage (aOR 4.63 (3.10 to 6.91)), infection (aOR 2.93 (1.83 to 4.70)), delays in seeking care (aOR 3.30 (2.08 to 5.23)), and admissions following a referral (aOR 2.95 (2.21 to 3.93)). SMO was lower in patients from socially backward community (aOR 0.45 (0.33 to 0.61)), those staying more than 10 km from hospital (aOR 0.56 (0.36 to 0.78)), those attending at least four antenatal visits (aOR=0.53 (0.36 to 0.78)) and those referred from resource-limited facilities (aOR=0.62 (0.46 to 0.84)).

CONCLUSION

This study demonstrates the independent contribution of SDH to SMO among those sustaining PLTC in a middle-income setting, highlighting the need to formulate preventive strategies beyond clinical considerations.

Interrelatedness of women's health-behaviour cognitions: A dyadic study of female family members on carrying heavy loads during pregnancy in Nepal

OBJECTIVES

Decisions about reproductive health are often influenced by women's female family members, particularly in low-resource contexts. However, previous research has focused primarily on individual behavioural determinants. We investigated the interrelatedness of female family members' reproductive health behaviour with a dyadic version of an extended health action process approach. We investigated this for carrying heavy loads during pregnancy and postpartum, a risk factor for reproductive health in many low-income countries such as Nepal.

DESIGN

This cross-sectional study included dyads of daughters-in-law and mothers-in-law in rural Nepal (N = 476, nested in 238 dyads).

METHODS

Dyads of daughters- and mothers-in-law were surveyed about avoiding carrying heavy loads during pregnancy and postpartum. The effects of a woman's cognitions and her female dyadic partner's cognitions on their intention and behaviour about avoiding carrying loads were estimated using linear mixed models.

RESULTS

The results showed that a mother-in-law's cognitions were related to her daughter-in-law's intentions and vice versa. The mother-in-law's cognitions were also related to the daughter-in-law's behaviour. The mother-in-law's self-efficacy and injunctive norms related to the daughter-in-law's intention and behaviour over and above the daughter-in-law's own self-efficacy and injunctive norms.

CONCLUSION

Female Nepali family members' cognitions about carrying heavy loads during pregnancy and postpartum are interrelated. Including female family members in interventions to help women manage their reproductive health in low-resource populations seems promising. These novel findings add to the growing body of research indicating the importance of including a dyadic perspective when understanding and changing health behaviour.

Predictors of maternal health services uptake in West African region: a multilevel multinomial regression analysis of demographic health survey reports

BACKGROUND

Pursuant to studies, receiving the three key maternal health services (Antenatal Care, Skilled Delivery Service, and Postnatal Care) in a continuum could prevent 71% of global maternal deaths. Despite the Western African region being known for its high maternal death and poor access to maternal health services, there is a dearth of studies that delve into the spectrum of maternal health services uptake. Hence, this study aimed to assess the level and predictors of partial and adequate utilization of health services in a single analytical model using the most recent Demographic and Health Survey (DHS) data (2013-2021).

METHODS

This study was based on the appended women's (IR) file of twelve West African countries. STATA software version 16 was used to analyze a weighted sample of 89,504 women aged 15-49 years. A composite index of maternal health service utilization has been created by combining three key health services and categorizing them into 'no', 'partial', or 'adequate' use. A multilevel multivariable multinomial logistic regression analysis was carried out to examine the effects of each predictor on the level of service utilization. The degree of association was reported using the adjusted relative risk ratio (aRRR) with a corresponding 95% confidence interval, and statistical significance was declared at p < 0.05.

RESULTS

66.4% (95% CI: 64.9, 67.7) and 23.8% (95% CI: 23.3, 24.2) of women used maternal health services partially and adequately, respectively. Togo has the highest proportion of women getting adequate health care in the region, at 56.7%, while Nigeria has the lowest proportion, at 11%. Maternal education, residence, wealth index, parity, media exposure (to radio and television), enrolment in health insurance schemes, attitude towards wife beating, and autonomy in decision-making were identified as significant predictors of partial and adequate maternal health service uptake.

CONCLUSION

The uptake of adequate maternal health services in the region was found to be low. Stakeholders should plan for and implement interventions that increase women's autonomy. Program planners and healthcare providers should give due emphasis to those women with no formal education and from low-income families. The government and the private sectors need to collaborate to improve media access and increase public enrolment in health insurance schemes.

Cultural barriers to male partners' involvement in antenatal care in Limpopo province

Background

Participation of male partners in antenatal care (ANC) is a complicated process that involves social and behavioural transformation. It necessitates that males take a more active part in reproductive health. Men's participation in prenatal care has been linked to beneficial health outcomes such as enhanced maternal health outcomes across the world. However, culture has been identified as a barrier to male partners' participation in prenatal care.

Aim

The aim of the study was to explore and describe the cultural barriers to male partner involvement in ANC.

Setting

The study focussed on selected clinics and hospitals under Vhembe District, Limpopo province.

Methods

Qualitative, exploratory, descriptive, and contextual research design was used in this study. Qualitative data were collected through individual semi-structured interviews and Focus Group Discussions (FGDs). A thematic analysis approach was used to analyse the collected data from semi-structured interviews and FGDs.

Results

The findings revealed three themes: cultural beliefs and practices that affect male partners' involvement in ANC; gender-related barriers that affect male partners' involvement in ANC; and socioeconomic barriers to male partners' involvement in ANC.

Conclusion

The study's findings revealed that certain cultural beliefs and practices are a stumbling block to male partners' involvement in antenatal healthcare.

Contribution

Culturally based developed strategy might help in improving the knowledge and practices of male partners in ANC.

Factors associated with men's participation in postpartum family planning: a study of Kiswa Health Centre III, Kampala, Uganda

Low uptake of family planning among women is predominantly attributed to low participation of men in postpartum family planning. In order to improve maternal health, strengthening male participation in family planning is an important public health initiative. This study aimed to assess factors associated with participation of men in postpartum care at Kiswa Health Centre III, Nakawa division, Kampala. An analytical cross-sectional study design involving collection of quantitative data was used. Systematic random sampling was used to select study participants. Data was collected using semi-structured questionnaires. Data entry and cleaning was performed using EpiData version 12 and analysed using Stata version 14. 80.0% of respondents participated in postpartum family planning. Approval of family planning use, knowledge on family planning and information source were significantly associated with male involvement in postpartum family planning. Respondents who approved family planning use at home were 15.5 times more likely to get involved in family planning services as compared to those who didn't approve family planning. Conclusively, there was a generally high level of male involvement in postpartum family planning in comparison with the national levels. Approval of family planning at home increased the likelihood of men's participation in family planning.IMPACT STATEMENTWhat is already known on this subject? Evidence has it that short birth intervals of less than 15 months have been found to be associated with adverse pregnancy outcomes including induced abortions, miscarriages, preterm births, neonatal and child mortalities, still births and maternal depletion syndrome. In Africa, generally, low family uptake among women is also attributed to low men participation in postpartum family planning.What do the results of this study add? Approval of family planning use, knowledge on family planning and information source were associated with male involvement in postpartum family planning. Respondents who approved family planning use at home were 15.5 times more likely to get involved in postpartum family planning services as compared to those who didn't approve family planning.What are the implications of these findings for clinical practice and/or further research? In this study, the involvement of men was relatively high, but more studies are needed in other locations to compare with this finding. Otherwise, consolidation of such high involvement is highly needed, as this can be a starting point for further improvement.

An examination of the factors associated with male partner attendance in antenatal care in India

BACKGROUND

A growing body of literature indicates that including male partners in antenatal care can be instrumental to improving women's health service utilization and maternal and child health outcomes. Despite this, very few studies have documented overall trends in male partner attendance and what factors influence this involvement within the Indian context. In this study, we used nationally representative data to examine levels of male partner attendance in antenatal care and the factors associated with male partner attendance.

METHODS

Data were used from the National Family Health Survey (NFHS-4) conducted in 2015-16. Weighted (probability weights) descriptive statistics were conducted to summarize the level of male partner attendance in antenatal care in India, and multivariable logistic regression models were constructed to estimate the factors associated with male partner attendance in antenatal care.

RESULTS

In 2015, of the women who had attended at least one antenatal care contact during their pregnancy, about 85% reported that their male partners had accompanied them to antenatal care contacts, with variations across regions. Level of education, household wealth, knowledge of pregnancy-related issues, men's age at marriage, region, and women's level of autonomy emerged as significant predictors of male partner attendance in antenatal care.

CONCLUSIONS

The results of this study highlight the multiple influences that shape male partners' attendance in antenatal care. The findings underscore the need for a multi-faceted approach to programs and interventions aimed at encouraging male partner involvement; recognizing men both as individuals, as well as being situated within the family/household and community.

Handbooks and health interpreters: How men are assets for their pregnant partners in Senegal

INTRODUCTION

Global health researchers often approach fatherhood initiatives from a deficit-based perspective, assuming men need sensitization, education, or correction. Senegalese men, which some global health and development organizations have determined to be uninvolved, are part of a team of prenatal and postpartum support called the "entourage" and have a very specific role to play as ad hoc health interpreters.

METHODS

The findings of this article come from 12 months of ethnographic research in Dakar, Senegal in 2018. In addition to participant-observation in three maternity wards across the city, semi-structured interviews were conducted with 32 pregnant women, 27 expectant fathers, and numerous family members, midwives, physicians, and governmental and nongovernmental organization employees. Data were coded and evaluated using thematic analysis.

RESULTS

In Senegal, the Handbook of Mother and Child Health is distributed in state-funded maternity wards. The Handbook outlines what pregnant women should know about pregnancy and how to appropriately engage with clinical services. Male partners of pregnant women commonly read the book for and to their pregnant partners. Men are placed in the unique position of intermediary between pregnant women and the State and as such, they learn a lot about pregnancy and childbirth, as well as prenatal and postpartum care.

CONCLUSIONS

Our ethnographic insights challenge global health rhetoric that frames men as uninvolved in women and children's health and this study demonstrates that future interventions should take an asset-based approach to men's involvement. Senegalese men are uniquely positioned by gendered expectations to act as health interpreters for their pregnant partners. We conclude with specific, actionable recommendations for the Senegalese case.

Clarifying the unmet clinical need during medical device innovation in women's health - A narrative review

Medical technologies are pervasive across women's health, spanning across obstetric and gynecological care. FemTech, the sector responsible for developing these technologies, is growing at 15.6% per annum. However, there are concerns of disconnects between new product development (NPD) and the care afforded to women in consequence of implementing these innovations. The most crucial stage of NPD involves understanding the clinical need. Without a clear need and clinical use case, innovators risk developing solutions which do not address the issues women and caregivers experience. Thus, the product will miss the market and experience limited uptake. Tools for performing clinical needs assessments and defining the use case are being developed. This review provides an analysis of their strengths and weaknesses to inform FemTech innovators of the available resources. We further discuss concepts for creating a unified approach to assessing unmet needs such that technologies have a higher chance of improving women's healthcare.

From global recommendations to (in)action: A scoping review of the coverage of companion of choice for women during labour and birth

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

Unlocking the potential for engaging men to improve reproductive, maternal, and neonatal health in Karnali Province, Nepal

Background

Adolescent girls and young women (AGYW) often experience early childbearing and have poor utilization of reproductive, maternal, and neonatal health (RMNH) services in Nepal. Involving men in such services has been increasingly recognized globally to improve gender-equitable reproductive health behaviour in husbands. This qualitative study assessed the implementation of Healthy Transitions’ male engagement interventions in Karnali Province, Nepal which were implemented to improve gender-equitable attitudes, and supportive RMNH care-seeking behaviors among the husbands of young women.

Methods

We conducted a summative qualitative study that included in-depth interviews with 12 AGYW as primary beneficiaries and their husbands (N = 12) and in-laws (N = 8). In addition, key informant interviews were conducted with health workers (N = 8), local government representatives (N = 4), members of Health Facility Operation and Management Committee (N = 8) and project implementers (N = 12). Due to COVID-19-related travel restrictions and lockdowns, all interviews were conducted via phone calls and online consultation. Data were analyzed using multistage coding and thematic content analysis.

Results

AGYW, their husbands, in-laws and health workers were receptive to the Healthy transitions’ male engagement initiatives. They perceived that the project contributed a momentum to facilitate men’s gender-responsive behaviour. Many participants reported that male engagement interventions, including home visits, community dialogues, and social events improved husbands’ support for their wives during menstruation, pregnancy, and childbirth. The activities also facilitated spousal communication and improved the couple’s decision-making for family planning use. Women reported that improved support from their husbands increased their self-confidence.

Conclusions

This study sheds light on the role of male engagement strategies to improve RMNH in a context where inequitable gender norms and roles are highly prevalent. Our findings highlight the potential to improve RMNH by addressing barriers to male engagement.

Predictors of the utilisation of continuum of maternal health care services in India

Background

Utilisation of continuum of maternal health care services is crucial for a healthy pregnancy and childbirth and plays an important role in attaining Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs) related to maternal and child health. This paper aims to assess the percentage of dropouts across various stages of utilization of continuum of maternal health services (CMHS) in India and also investigates the factors hindering the utilization of these services.

Methods

We used recent data from National Family Health Survey(NFHS) encompassing a total sample of 1,70,937 pregnant women for the period 2015–16. The percentage of women dropping out while seeking maternal health care is measured using descriptive statistics. While, the factors impeding the utilization of maternal health services is estimated using a Multinomial Logistic Regression Model, where dependent variable (CMHS) is defined as complete care, incomplete care and no care.

Results

Only17% of pregnant women availed the utilisation of complete care and 83% either did not seek any care or dropped after seeking one or two services. For instance, it is found that 79% of women who registered for antenatal care services (ANC) did not avail the same adequately. An empirical investigation of determinants of inadequate utilization of CMHS revealed that factors like individual characteristics, for instance- access to media (RRR: 2.06) and mother’s education play (RRR: 3.61) a vital role in the uptake of CMHS. It is also found that the interaction between wealth index and place of residence plays a pivotal role in seeking complete care. Lastly, the results revealed that male participation (RRR: 2.69) and contacting multi-purpose worker (MPW) (RRR: 2.33) are also at play.

Conclusion

The study suggests that the major determinants of utilisation of CMHS are access to media, mother’s education, affordability barriers and male participation. Hence, policy recommendations should be oriented towards strengthening these dimensions and the utilisation of adequate ANC has to be considered as the need of the hour.

Husbands' Plan to Participate in Birth Preparedness and Complication Readiness in Haramaya Health and Demographic Surveillance System Site, Eastern Ethiopia: A Community-Based Cross-Sectional Study

Background

Partner involvement in maternal health services utilization remains a major public challenge in the developing world. Strategies of involving men in maternal health services are a critical and proven intervention for reducing maternal and neonatal mortality by ensuring safe delivery and reducing complications during childbirth. Moreover, the husbands' involvement during pregnancy helps their spouses to make timely decisions and avoid maternal delays, especially first and second delays. Although birth and complication readiness have been studied in developing countries such as Ethiopia, almost all previous researchers were focused primarily on women participants. Therefore, we aimed to investigate factors associated with husband involvement in birth preparedness and complication readiness plan in Haramaya Health and Demographic Surveillance site, Eastern Ethiopia.

Methods

A community-based cross-sectional study was conducted from March 1 to 30, 2020 among men whose wives were pregnant in Haramaya Health and Demographic Surveillance (HDSS) site in Eastern Ethiopia. The calculated sample size was 653, however while contacting 653 husbands only 630 had given the full interview, hence 630 respondents were remained in the analysis. Participants were approached through a systematic sampling technique. Data were collected using a pre-tested structured questionnaire through a face-to-face interview, and entered into Epidata version 3.1 and analyzed using SPSS version 22 (IBM SPSS Statistics, 2013). The prevalence was reported using proportion with 95% Confidence Interval (CI) and summary measures. Predictors were assessed using a multivariable logistic regression analysis model and reported using an adjusted odds ratio (AOR) with 95%CI. Statistical significance was declared at p < 0.05.

Results

Overall, the prevalence of the husband's plan to participate in birth preparedness and complication readiness was 59.6% (95%CI:56-64%). In the final model of multivariable analysis, predictors like husband's knowledge of birth preparedness and complication readiness [AOR = 4.18, 95%CI:2.05, 8.51], having a discussion with spouse on the place of delivery [AOR = 6.84, 95% CI: 4.17, 11.22], husband's knowledge of danger signs during labor and delivery [AOR = 3.19, 95 % CI: 1.52, 6.71], and making a postpartum plan[AOR = 2.30, 95 % CI: 1.38, 3.85] were factors statistically associated with husband's plan to participate in birth preparedness.

Conclusions

This study pointed out that two in every five husbands failed to plan birth preparedness and complication readiness. As a result, all stakeholders should emphasize male partners' education in terms of birth preparedness and complication readiness, as well as knowledge of danger signs during labor and delivery. They should also encourage male partners to discuss a place of delivery and have a postpartum plan in place to reduce potential complications related to labor and delivery.

Influence of women's decision-making autonomy on antenatal care utilisation and institutional delivery services in Nigeria: evidence from the Nigeria Demographic and Health Survey 2018

BACKGROUND

In the context of global health priority, understanding the role of power dynamics among women as an important intervention required towards achieving optimum maternal and child health outcomes is crucial. This study examined the influence of women's decision-making autonomy on antenatal care utilisation and institutional delivery services in Nigeria.

METHODS

The data for the study were derived from the 2018 Nigeria Demographic and Health Survey and comprised a weighted sample of 20,100 births in the last five years that preceded the survey among married/cohabiting childbearing women. Descriptive and analytical analyses were carried out, including frequency tables and multivariate using the binary logistic regression model.

RESULTS

The study revealed that despite a large number of women initiating antenatal care visits before 12 weeks of pregnancy (75.9%), far fewer numbers had at least eight antenatal care visits (24.2%) and delivered in a health facility (58.2%). It was established that the likelihood of having at least eight antenatal care visits was significantly increased among women who enjoyed decision-making autonomy on their healthcare (aOR: 1.24, CI: 1.02-1.51) and how their earnings are spent (aOR: 2.02, CI: 1.64-2.48). Surprisingly, women's decision-making autonomy on how their earnings are spent significantly reduced the odds of initiating antenatal care visits early (aOR: 0.75, CI: 0.63-0.89). Some socio-economic and demographic factors were observed to have a positive influence on quality antenatal care utilisation and delivery in a health facility.

CONCLUSION

In conclusion, women's decision-making autonomy on their healthcare and how their earnings are spent was significantly found to be protective factors to having eight antenatal care visits during pregnancy. Conversely, women's autonomy on how their earnings are spent significantly hindered their initiation of early antenatal care visits. There is a need for more pragmatic efforts through enlightenment and empowerment programmes of women to achieve universal access to quality maternal healthcare services in Nigeria.

Comparing the timeliness and adequacy of antenatal care uptake between women who married as child brides and adult brides in 20 sub-Saharan African countries

CONTEXT

Considering the persistent poor maternal and child health outcomes in sub-Saharan Africa (SSA), this study undertook a comparative analysis of the timing and adequacy of antenatal care uptake between women (aged 20-24 years) who married before age 18 and those who married at age 18 or above.

METHOD

Data came from Demographic and Health Surveys of 20 SSA countries. We performed binary logistic regression analysis on pooled data of women aged 20-24 (n = 33,630).

RESULTS

Overall, the percentage of child brides in selected countries was 57.1%, with the lowest prevalence found in Rwanda (19.1%) and the highest rate in Chad (80.9%). Central and West African countries had the highest prevalence of child marriage compared to other sub-regions. Bivariate results indicate that a lower proportion of child brides (50.0%) had 4+ ANC visits compared to the adult brides (60.9%) and a lower percentage of them (34.0%) initiated ANC visits early compared to the adult brides (37.5%). After controlling for country of residence and selected socio-economic and demographic characteristics, multivariable results established significantly lower odds of having an adequate/prescribed number of ANC visits among women who married before age 15 (OR: 0.63, CI: 0.57-0.67, p<0.001), and women who married at ages 15-17 (OR: 0.81, CI: 0.75-0.84, p<0.001) compared to those who married at age 18+. Similar results were established between age at first marriage and timing of first ANC visit. Other interesting results emerged that young women who married earlier than age 18 and those who married at age 18+ differ significantly by several socio-economic and demographic characteristics.

CONCLUSION

Efforts to improve maternal and child health outcomes in SSA must give attention to address the underutilization and late start of antenatal care uptake among child brides.

Women decision-making autonomy on maternal health service and associated factors in low- and middle-income countries: Systematic review and meta-analysis

OBJECTIVE

This study was done to determine the overall estimate of decision-making autonomy on maternal health services and associated factors in low- and middle-income countries.

METHOD

PubMed, Science Direct, Google Scholar, Scopus, and the Ethiopian University online library were searched. Data were extracted using Microsoft Excel and analyzed using STATA statistical software (version 14). Publication bias was checked by forest plot, Begg's rank test, and Egger's regression test. To look for heterogeneity, I² was computed, and an overall estimated analysis was carried out. Subgroup analysis was done by country, year, and publication. Joanna Briggs Institute quality assessment tool was used to check the quality of each study. We carried out a leave-one-out sensitivity analysis.

RESULTS

Out of 1305 articles retrieved, 19 studies (with 104,871 study participants) met eligibility criteria and were included in this study. The pooled prevalence of women's decision-making autonomy on maternal health services in low- and middle-income countries was 55.15% (95% confidence interval: 44.11-66.19; I² = 98.6%, P < 0.001). Based on subgroup analysis, decision-making autonomy in maternal health services was the highest in Ethiopia at 61.36% (95% confidence interval: 50.58-72.15) and the lowest in Nigeria at 36.16% (95% confidence interval: 12.99-43.39). It was 32.16% (95% confidence interval: 32.72-39.60) and 60.18% (95% confidence interval: 47.92-72.44) before and after 2016, respectively. It was also 54.64% (95% confidence interval: 42.51-66.78) in published studies and 57.91% (95% confidence interval: 54.80-61.02) in unpublished studies. Age (adjusted odds ratio = 2.67; 95% confidence interval: (1.29-5.55), I² = 90.1%), primary level of education (adjusted odds ratio = 1.75; 95% confidence interval: (1.39-2.21), I² = 63.8%), secondary education level (adjusted odds ratio = 2.09; 95% confidence interval: (1.32-3.32), I² = 87.8%), being urban resident (adjusted odds ratio = 1.80; 95% confidence interval: (1.22-2.66), I² = 73%), and monthly income (adjusted odds ratio = 3.23; 95% confidence interval: (1.85-5.65), I² = 97%) were positively associated with decision-making autonomy on maternal health service.

CONCLUSION

Decision-making autonomy on maternal health services in low- and middle-income countries was low. Sociodemographic factors also influenced it. Educational accessibility and income generation should have been recommended, enabling women to decide for themselves.

Determinants of continued maternal care seeking during pregnancy, birth and postnatal and associated neonatal survival outcomes in Kenya and Uganda: analysis of cross-sectional, demographic and health surveys data

OBJECTIVES

To examine how maternal and sociodemographic factors determine continued care-seeking behaviour from pregnancy to postnatal period in Kenya and Uganda and to determine associated neonatal survival outcomes.

DESIGN

A population-based analysis of cross-sectional data using multinomial and binary logistic regressions.

SETTING

Countrywide, Kenya and Uganda.

PARTICIPANTS

Most recent live births of 24 502 mothers within 1-59 months prior to the 2014-2016 Demographic and Health Surveys.

OUTCOMES

Care-seeking continuum and neonatal mortality.

RESULTS

Overall, 57% of the mothers had four or more antenatal care (ANC) contacts, of which 73% and 41% had facility births and postnatal care (PNC), respectively. Maternal/paternal education versus no education was associated with continued care seeking in majority of care-seeking classes; relative risk ratios (RRRs) ranged from 2.1 to 8.0 (95% CI 1.1 to 16.3). Similarly, exposure to mass media was generally associated with continued care seekin; RRRs ranged from 1.8 to 3.2 (95% CI 1.2 to 5.4). Care-seeking tendency reduced if a husband made major maternal care-seeking decisions. Transportation problems and living in rural versus urban were largely associated with lower continued care use; RRR ranged from 0.4 to 0.7 (95% CI 0.3 to 0.9). The two lowest care-seeking categories with no ANC and no PNC indicated the highest odds for neonatal mortality (adjusted OR 4.2, 95% CI 1.6 to 10.9). 23% neonatal deaths were attributable to inadequate maternal care attendance.

CONCLUSION

Strategies such as mobile health specifically for promoting continued maternal care use up to postnatal could be integrated in the existing structures. Another strategy would be to develop and employ a brief standard questionnaire to determine a mother's continued care-seeking level during the first ANC visit and to use the information to close the care-seeking gaps. Strengthening the community health workers system to be an integral part of promoting continued care seeking could enhance care seeking as a stand-alone strategy or as a component of aforementioned suggested strategies.

Is improvement in indicators of women's empowerment associated with uptake of WHO recommended IPTp-SP levels in sub-Saharan Africa? A multilevel approach

OBJECTIVES

The global burden of malaria has reduced considerably; however, malaria in pregnancy remains a major public health problem in sub-Saharan Africa (SSA), where about 32 million pregnant women are at risk of acquiring malaria. The WHO has recommended that pregnant women in high malaria transmission locations, including SSA, have intermittent preventive treatment of malaria during pregnancy with at least three doses of sulphadoxine-pyrimethamine (IPTp-SP). Therefore, we investigated the prevalence of IPTp-SP uptake and associated individual-level, community-level and country-level predictors in SSA.

DESIGN

A cross-sectional survey was conducted using recent Demographic and Health Surveys datasets of 20 SSA countries. A total of 96 765 women were included. Optimum uptake of IPTp-SP at most recent pregnancy was the outcome variable. We fitted three-level multilevel models: individual, community and country parameters at 95% credible interval.

RESULTS

In all, 29.2% of the women had optimal IPTp-SP uptake ranging from 55.1% (in Zambia) to 6.9% (in Gambia). The study revealed a high likelihood of optimum IPTp-SP uptake among women with high knowledge (aOR=1.298, Crl 1.206 to 1.398) relative to women with low knowledge. Women in upper-middle-income countries were more than three times likely to have at least three IPTp-SP doses compared with those in low-income countries (aOR=3.268, Crl 2.392 to 4.098). We found that community (σ²=1.999, Crl 1.088 to 2.231) and country (σ²=1.853, Crl 1.213 to 2.831) level variations exist in optimal uptake of IPTp-SP. According to the intracluster correlation, 53.9% and 25.9% of the variation in optimum IPTp-SP uptake are correspondingly attributable to community-level and country-level factors.

CONCLUSIONS

The outcome of our study suggests that low-income SSA countries should increase budgetary allocation to maternal health, particularly for IPTp-SP interventions. IPTp-SP advocacy behavioural change communication strategies must focus on women with low knowledge, rural dwellers, married women and those who do not meet the minimum of eight antenatal care visits.

"My husband is my family." The culture of pregnancy disclosure and its implications on early pregnancy registration in a child nutrition intervention in rural Maharashtra, India

Less than seventeen percent pregnant women in rural India had full antenatal check-ups. Early uptake to maternal and child healthcare services is strongly associated with cultural beliefs and practices around pregnancy and childbirth. This study aims to assess the cultural elements that influence women's behaviours of disclosure of their pregnancy in rural setting in Maharashtra state of India. We conducted 25 In-depth semi structured interviews with pregnant women and two focus groups with Community Health Workers in villages around Nagpur and Bhandara districts. The pregnant women were selected purposively with preference given to those who had a previous pregnancy. The audio recorded interviews were transcribed verbatim and translated into English. An inductive thematic approach was applied for data analysis. According to most respondents, they would only directly disclose their pregnancy to their husband and close relatives. Although, most pregnant women were hesitant towards nonrelatives discovering their pregnancy before completion of three months. The reasons behind delayed disclosure of pregnancy were fear of losing baby due to black magic, and casting of evil eyes by jealous neighbours and people with bad intentions. The Community Health Workers seconded these believes and mentioned that if pregnancy disclosed earlier, the foetus would remain incomplete (adhura). These superstitions prevented the women from availing benefits from the health facility at the earliest. The study identified several local beliefs and perceptions that hinders health care utilization of the women. Interventions that are tailored to the local cultural context can address these obstacles to increase the uptake of antenatal check-up early in pregnancy.

Male partners' participation in birth preparedness and complication readiness in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Maternal and neonatal health outcomes remain a challenge in low- and middle-income countries (LMICs) despite priority given to involving male partners in birth preparedness and complication readiness (BPCR). Men in LMICs often determine women's access to and affordability of health services. This systematic review and meta-analysis determined the pooled magnitude of male partner's participation in birth preparedness and complication readiness in LMICs.

METHODS

Literature published in English language from 2004 to 2019 was retrieved from Google Scholar, PubMed, CINAHL, Scopus, and EMBASE databases. The Joanna Briggs Institute's critical appraisal tool for prevalence and incidence studies were used. A pooled statistical meta-analysis was conducted using STATA Version 14.0. The heterogeneity and publication bias were assessed using the I2 statistics and Egger's test. Duval and Tweedie's nonparametric trim and fill analysis using the random-effect analysis was carried out to validate publication bias and heterogeneity. The random effect model was used to estimate the summary prevalence and the corresponding 95% confidence interval (CI) of birth preparedness and complication readiness. The review protocol has been registered in PROSPERO number CRD42019140752. The PRISMA flow chart was used to show the number of articles identified, included, and excluded with justifications described.

RESULTS

Thirty-seven studies with a total of 17, 148 participants were included. The pooled results showed that 42.4% of male partners participated in BPCR. Among the study participants, 54% reported having saved money for delivery, whereas 44% identified skilled birth attendants. 45.8% of male partners arranged transportation and 57.2% of study participants identified health facility as a place of birth. Only 16.1% of the male partners identified potential blood donors.

CONCLUSIONS

A low proportion of male partners were identified to have participated in BPCR in LMICs. This calls countries in low- and middle-income setting for action to review their health care policies, to remove the barriers and promote facilitators to male partner's involvement in BPCR. Health systems in LMICs must design and innovate scalable strategies to improve male partner's arrangements for a potential blood donor and transportation for complications that could arise during delivery or postpartum haemorrhage.

Pregnant women's experiences with a pelvic floor muscle training program in Nepal

BACKGROUND

In Nepal, pelvic floor disorders affect about 24% of the women in reproductive age whereof 10% suffer from pelvic organ prolapse (POP). Still, many do not seek health care. Strengthening exercises for the pelvic floor muscles for prevention and treatment of POP has shown strong evidence internationally, but for women in Nepal surgery is primarily offered. To amend this, a novel pelvic floor muscle training (PFMT) program for pregnant women was introduced.

OBJECTIVE

To learn about how the PFMT-program was received by the participating women, their understanding of the importance of doing the exercises, and the constraints of daily life for performing the program.

METHODS

A qualitative study design based on a sub-sample (N = 10) from a strategic sample (N = 235) who participated in the PFMT-program. Ten semi-structured in-depth interviews were interpreted according to a phenomenological analytical tradition.

RESULTS

The 10 women were representative for the women who had participated in the PFMT-program with regard to urban residence, socioeconomic, and educational standing. The program was well received and compliance satisfactory. In line with the PFMT's learning outcomes, the women described risk factors, showed knowledge about the pelvic floor muscles, and understood the importance of doing the exercises. They had managed to fit the exercises into their busy daily routines. Meeting peers in exercise groups and understanding from family were positive factors for compliance.

CONCLUSION

The Nepalese women appear interested in self-care and are making an effort to fit the exercises into their busy schedule. Although the communicative validity was satisfactory, the pragmatic validity cannot be generalized to women in rural areas and under less fortunate socioeconomic and educational circumstances.

Women's decision-making power in a context of free reproductive healthcare and family planning in rural Burkina Faso

Background

In 2016, the national user fee exemption policy for women and children under five was introduced in Burkina Faso. It covers most reproductive healthcare services for women including prenatal care, delivery, and postnatal care. In subsequent years, the policy was gradually extended to include family planning. While studies have shown that user fee abolition policies increase visits to health centers and improve access to reproductive healthcare and family planning, there are also indications that other barriers remain, notably women’s lack of decision-making power. The objective of the study is to investigate women’s decision-making power regarding access to reproductive health and family planning in a context of free healthcare in rural Burkina Faso.

Methods

A descriptive qualitative study was carried out in rural areas of the Cascades and Center-West regions. Qualitative data were collected using individual semi-structured interviews (n = 20 participants) and focus groups (n = 15 participants) with Burkinabe women of childbearing age, their husbands, and key informants in the community. Data was analyzed using thematic analysis.

Results

A conceptual framework describing women’s participation in the decision-making process was built from the analysis. Results show that the user fee exemption policy contributes to improving access to reproductive care and family planning by facilitating the negotiation processes between women and their families within households. However, social norms and gender inequalities still limit women’s decision-making power.

Conclusion

In light of these results, courses of action that go beyond the user fee exemption policy should be considered to improve women’s decision-making power in matters of health, particularly with regard to family planning. Interventions that involve men and community members may be necessary to challenge the social norms, which act as determinants of women’s health and empowerment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01411-4.

Female autonomy and intimate partner violence: findings from the Zimbabwe demographic and health survey, 2015

Intimate partner violence is a persistent social problem in Zimbabwe and has been linked to patriarchal attitudes that promote the superiority of men in marital relationships while denying women agency. Using 2015 Zimbabwe Demographic and Health Survey data, we examined the influence of female autonomy on intimate partner violence. Our analysis was restricted to 2847 women who were in some form of sexual union. Consistent with earlier studies, our results show that more than 40% of the women had experienced some form of intimate partner violence. The most prevalent form of intimate partner violence was emotional violence, followed by physical violence and sexual violence. Low levels of economic autonomy and supportive attitudes towards wife-beating increased the risk of intimate partner violence, while late marriage reduced the risk of all forms of intimate partner violence. Findings provide a basis for interventions that may increase economic control and improve decision making for women, although the association between economic violence and economic decision making requires further research that examines the possibility of reverse causality.

Reasons to Pretend Orgasm, Mate Retention, and Relationship Satisfaction in Brazilian Women

We investigated the relationship between Brazilian women's reported reasons for pretending orgasm, their performance of mate retention behaviors, and their relationship satisfaction. Additionally, we secured evidence of the validity and reliability of a Brazilian-Portuguese adaptation of the Reasons to Pretend Orgasm Inventory (RPOI). Participants were 295 Brazilian women in a heterosexual relationship (Mage = 24.9 years, SDage = 5.4 years). Participants completed a Brazilian-Portuguese adaptation of the Mate Retention Inventory-Short Form, and the translated RPOI (the Escala de Razões para Fingir Orgasmo; ERFO). The resulting 47-item ERFO represents well the original 63-item RPOI. The frequency with which Brazilian women pretend orgasm was negatively associated with their relationship satisfaction. Our sample size may not be sufficient to detect small effects. In addition, due to the exploratory nature of the study, the results should be interpreted with caution and future research may attempt to replicate these findings with larger samples and in other countries.

Male partner participation in maternity care and social support for childbearing women: a discussion paper

Male partners/fathers are key support persons for many childbearing women and their involvement in pregnancy, childbirth and the postpartum/postnatal period has beneficial effects on a wide range of outcomes related to maternal and child health and family wellbeing. Social support is implicated in the relevant causal pathway, but has received largely tangential attention in the public health literature. This discussion paper aims to reframe men's participation in maternity care as an opportunity to enhance their readiness and ability to provide social support to women, contributing to the debate on the definition and rationale for male partner involvement, and paving the way for further empirical work. I begin by presenting a theory of change illustrating the causal pathway leading from male partner participation, through the key intermediate step of social support, to improved health and wellbeing for women and children. I proceed by arguing that many people desire male partner participation in maternity care; however, in practice, this is often limited owing to cultural, social and institutional barriers. I use examples from the intervention literature to demonstrate how participation in care can boost men's motivation to support women and enhance their ability to do so by increasing their knowledge and skills. Finally, I draw up general implications for further male partner involvement programmes, suggesting that in order to achieve meaningful and sustainable gains, attention to design is crucial in order to avoid reinforcing patriarchal gender norms. Programmes should be implemented alongside other efforts to improve quality and promote woman-centred care. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

The Effect of Women's Empowerment in the Utilisation of Family Planning in Western Ethiopia: A Structural Equation Modelling Approach

This study examines the associations between women's empowerment and family planning use in Jimma Zone, Western Ethiopia. A total of 746 randomly selected married women of reproductive age were interviewed. The data were employed by structural equation modelling (SEM) to investigate the complex and multidimensional pathways to show women's empowerment domains in family planning utilisation. Results of the study revealed that 72% of married women had used family planning. Younger women, having access to information, having access to health facilities and being aware about family planning methods, living in a rural area, having an older partner and increased household decision-making power were associated with using family planning methods. Women's empowerment is an important determinant of contraceptive use. Women's empowerment dimensions included increased household decision-making power, socio-demographic variables and having access to information about family planning and accessible health facilities. These were found to be important determinants of contraceptive use. Future interventions should focus on integrating women's empowerment into family planning programming, particularly in enhancing women's autonomy in decision making. Further research is warranted on the socio-cultural context of women that influences women's empowerment and family planning use to establish an in-depth understanding and equity of women in society.

Women's empowerment and fertility decision-making in 53 low and middle resource countries: a pooled analysis of demographic and health surveys

OBJECTIVE

Women's empowerment and its association with fertility preference are vital for central-level promotional health policy strategies. This study examines the association between women's empowerment and fertility decision-making in low and middle resource countries (LMRCs).

DESIGN

This cross-sectional study uses the Demographic and Health Survey database.

SETTINGS

53 LMRCs from six different regions for the period ranging from 2006 to 2018.

PARTICIPANTS

The data of women-only aged 35 years and above is used as a unit of analysis. The final sample consists of 91 070 married women.

METHODS

We considered two outcome variables: women's perceived ideal number of children and their ability to achieve preferred fertility desire and the association with women empowerment. Women empowerment was measured by their participation in household decision-making and attitude towards wife-beating. The negative binomial regression model was used to assess women's perceived ideal number of children, and multivariable logistic regression was used to evaluate women's ability to achieve their preferred fertility desire.

RESULTS

Our study found that empowered women have a relatively low ideal number of children irrespective of the measures used to assess women empowerment. In this study, the measures were participation in household decision-making (incidence rate ratio (IRR): 0.92, 95% CI: 0.91 to 0.93) and attitude towards wife-beating (IRR: 0.96, 95% CI: 0.95 to 0.97). In the LMRCs, household decision-making and negative attitude towards wife-beating have been found associated with 1.12 and 1.08 times greater odds of having more than their ideal number of children.

CONCLUSION

Our findings suggest that women's perceived fertility desire can be achieved by enhancing their empowerment. Therefore, a modified community-based family planning programme at the national level is required, highlighting the importance of women's empowerment on reproductive healthcare as a part of the mission to assist women and couples to have only the number of children they desire.

Factors associated with the length of stay at health facilities after childbirth among mothers and newborns in Dhading, Nepal: a cross-sectional study

OBJECTIVE

To measure the length of stay at a health facility after childbirth, identify factors associated with the length of stay and measure the gap between the timings of the last check-up and discharge.

DESIGN

A cross-sectional study.

SETTING

Five public health facilities in Dhading, Nepal.

PARTICIPANTS

351 randomly selected mothers who gave birth at selected health facilities within 1 year of data collection between 10 and 31 August 2018.

OUTCOME MEASURE

Length of stay (hours) at a health facility after childbirth. Adequate length was defined as 24 hours or longer based on the WHO guidelines.

RESULTS

Among 350 mothers (99.7%) out of 351 recruited, 61.7% were discharged within 24 hours after childbirth. Factors associated with shorter length of stay were as follows: travel time less than 30 min to a health facility (incidence rate ratio (IRR)=0.69, 95% CI 0.61 to 0.78); delivery attended by auxiliary staff (IRR=0.86, 95% CI 0.75 to 0.98); and delivery in a primary healthcare centre (IRR=0.67, 95% CI 0.58 to 0.79). Factors associated with longer length of stay were as follows: aged 22 years or above at the first pregnancy (IRR=1.25, 95% CI 1.13 to 1.40); having maternal complications (IRR=2.41, 95% CI 2.16 to 2.70); accompanied by her own family (IRR=1.17, 95% CI 1.03 to 1.34), accompanied by her husband (IRR=1.16, 95% CI 1.04 to 1.29); and delivered at a facility with a physical space where mother and newborn could stay overnight (IRR=1.20, 95% CI 1.07 to 1.34). Among mothers without complications, 32% received the last check-up 3 hours or less before discharge.

CONCLUSIONS

Multiple factors, such as mothers' conditions, health facility characteristics and external support, were associated with the length of stay after childbirth. However, even if mothers stayed long, they might have not necessarily received timely and proper assessment before discharge.

Watering the Plant in Another's Courtyard: An Ethnographic Exploration of Daughters' Devaluation Through Sex-Selected Abortions Among the Rural Married Females in South Punjab, Pakistan

The current study sets forth the cultural underpinnings for daughters' devaluation over son preferences in South Punjab, Pakistan. The major purpose of the present study was to provide an accurate description of women's attitude on different aspects of sex-selected abortions (SSAs). Women, with a rural background, either forced to devalue their female fetus clinically or based on violence, were the targeted participants. Using ethnographic exploration with 161 obtrusive observations, 37 in-depth interviews, and 10 focus group discussions (FGD), comprising of 85 narrated case studies, the attitudes of rural married females toward daughters' devaluation through SSAs were recorded. The findings of study allied the autonomy paradigm with a feminist perspective through argumentation of the lack of women's individual identity in the domestic sphere. In addition, sociocultural legitimization toward patriarchal regimes snatches women's autonomy over their reproductive behavior. Resultantly, daughters' devaluation is analogous to sons' preference, which arose through women's subservience and exposure to violence in the intricate cultural web. Using ethnographic exploration through various anthropological research techniques, it explicates the nuanced feminist regimes for understanding women's reproductive choice and empowerment. In conclusion, women's subordination is the cause of differential power relations and inadequate gender inequality which results in SSAs. The current study exposed gender-biased power discrimination that consequently affects the women's autonomous decision making about their reproductive behavior. Similarly, it highlighted how husband and in-laws (especially mother-in-law) used illegal medicines, dietary practices, traditional methods, or new biotechnological methods to execute the illegal act of SSA. This study may serve as the basic legal framework to check the deep-rooted culture of violence against vulnerable segments of the population.

Pooled prevalence and associated factors of health facility delivery in East Africa: Mixed-effect logistic regression analysis

Background

Many mothers still give birth outside a health facility in Sub-Saharan Africa particularly in East African countries. Though there are studies on the prevalence and associated factors of health facility delivery, as to our search of literature there is limited evidence on the pooled prevalence and associated factors of health facility delivery in East Africa. This study aims to examine the pooled prevalence and associated factors of health facility delivery in East Africa based on evidence from Demographic and Health Surveys.

Methods

A secondary data analysis was conducted based on the most recent Demographic and Health Surveys (DHSs) conducted in the 12 East African countries. A total weighted sample of 141,483 reproductive-age women who gave birth within five years preceding the survey was included. All analyses presented in this paper were weighted for the sampling probabilities and non-response using sampling weight (V005), primary sampling unit (V023), and strata (V021). The analysis was done using STATA version 14 statistical software, and the pooled prevalence of health facility delivery with a 95% Confidence Interval (CI) was presented using a forest plot. For associated factors, the Generalized Linear Mixed Model (GLMM) was fitted to consider the hierarchical nature of the DHS data. The Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), and Likelihood Ratio (LR)-test were done to assess the presence of a significant clustering effect. Besides, deviance (-2LLR) was used for model comparison since the models were nested models. Variables with a p-value of less than 0.2 in the bivariable mixed-effect binary logistic regression analysis were considered for the multivariable analysis. In the multivariable mixed-effect analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to declare the strength and significance of the association between the independent variable and health facility delivery.

Results

The proportion of health facility delivery in East Africa was 87.49% [95% CI: 87.34%, 87.64%], ranged from 29% in Ethiopia to 97% in Mozambique. In the Mixed-effect logistic regression model; country, urban residence [AOR = 2.08, 95% CI: 1.96, 2.17], primary women education [AOR = 1.61, 95% CI: 1.55, 1.67], secondary education and higher [AOR = 2.96, 95% CI: 2.79, 3.13], primary husband education [AOR = 1.19, 95% CI: 1.14, 1.24], secondary husband education [AOR = 1.38, 95% CI: 1.31, 1.45], being in union [AOR = 1.23, 95% CI: 1.18, 1.27], having occupation [AOR = 1.11, 95% CI: 1.07, 1.15], being rich [AOR = 1.36, 95% CI: 1.30, 1.41], and middle [AOR = 2.14, 95% CI: 2.04, 2.23], health care access problem [AOR = 0.76, 95% CI: 0.74, 0.79], having ANC visit [AOR = 1.54, 95% CI: 1.49, 1.59], parity [AOR = 0.56, 95% CI: 0.55, 0.61], multiple gestation [AOR = 1.83, 95% CI: 1.67, 2.01] and wanted pregnancy [AOR = 1.19, 95% CI: 1.13, 1.25] were significantly associated with health facility delivery.

Conclusion

This study showed that the proportion of health facility delivery in East African countries is low. Thus, improved access and utilization of antenatal care can be an effective strategy to increase health facility deliveries. Moreover, encouraging women through education is recommended to increase health facility delivery service utilization.

Does involving male partners in antenatal care improve healthcare utilisation? Systematic review and meta-analysis of the published literature from low- and middle-income countries

BACKGROUND

Although in most low- and middle-income countries (LMICs) men are decision makers and control the household budget, their involvement in maternity care is limited. Reports from high-income countries indicate a beneficial effect of involving men in antenatal and delivery care on birth outcomes.

METHODS

We conducted a systematic review to assess whether similar effects are observed in LMICs. We searched MEDLINE, PubMed, CINAHL, Embase, NCBI, PsycInfo and other relevant databases using a comprehensive search strategy to retrieve relevant articles. A total of 17 articles were included. Meta-analysis of extracted data was performed, using the generic inverse variance method where possible. All studies were conducted in South Asia and Africa.

RESULTS

We found that involving a male partner in antenatal care was associated with skilled birth attendance utilization (pooled OR 3.19 [95% CI 1.55 to 6.55]), having institutional delivery (OR 2.76 [95% CI 1.70 to 4.50]) and post-partum visit uptake (OR 2.13 [95% CI 1.45 to 3.13]). Mother's knowledge of danger signs and modern contraception utilization were also positively affected. However, it had no significant impact on the number of antenatal visits.

CONCLUSIONS

Male involvement in antenatal care had a positive impact on the uptake of maternal health services. Further research needs to investigate whether this translates into improved maternal and newborn health in developing countries.

Duration of birth interval and its predictors among reproductive-age women in Ethiopia: Gompertz gamma shared frailty modeling

Background

The World Health Organization recommended a minimum of 33 months between consecutive live births to reduce the incidence of adverse pregnancy outcomes. Poorly spaced pregnancies are associated with poor maternal and child health outcomes such as low birth weight, stillbirth, uterine rupture, neonatal mortality, maternal mortality, child malnutrition, and maternal hemorrhage. However, there was limited evidence on the duration of birth interval and its predictors among reproductive-age women in Ethiopia. Therefore, this study aimed to investigate the duration of birth interval and its predictors among reproductive-age women in Ethiopia.

Methods

A secondary data analysis was conducted based on the 2016 Ethiopian Demographic and Health Survey data. A total weighted sample of 11022 reproductive-age women who gave birth within five years preceding the survey was included for analysis. To identify the predictors, the Gompertz gamma shared frailty model was fitted. The theta value, Akakie Information Criteria (AIC), Bayesian Information Criteria (BIC), and deviance was used for model selection. Variables with a p-value of less than 0.2 in the bi-variable analysis were considered for the multivariable analysis. In the multivariable Gompertz gamma shared frailty analysis, the Adjusted Hazard Ratio (AHR) with a 95% Confidence Interval (CI) was reported to show the strength and statistical significance of the association.

Results

The median inter-birth interval in Ethiopia was 38 months (95% CI: 37.58, 38.42). Being living in Addis Ababa (AHR = 0.15, 95% CI: 0.03, 0.70), being rural resident (AHR = 1.13, 95% CI: 1.01, 1.23), being Muslim religious follower (AHR = 6.53, 95% CI: 2.35, 18.18), having three birth (AHR = 0.51, 95% CI: 0.10, 0.83), having four birth (AHR = 0.30, 95% CI: 0.09, 0.74), five and above births (AHR = 0.10, 95% CI: 0.02, 0.41), and using contraceptive (AHR = 2.35, 95% CI: 1.16, 4.77) were found significant predictors of duration of birth interval.

Conclusion

The length of the inter-birth interval was consistent with the World Health Organization recommendation. Therefore, health care interventions that enhance modern contraceptive utilization among women in rural areas and Muslim religious followers would be helpful to optimize birth interval.

Spatial clusters distribution and modelling of health care autonomy among reproductive-age women in Ethiopia: spatial and mixed-effect logistic regression analysis

BACKGROUND

While millions of women in many African countries have little autonomy in health care decision-making, in most low and middle-income countries, including Ethiopia, it has been poorly studied. Hence, it is important to have evidence on the factors associated with women's health care decision making autonomy and the spatial distribution across the country. Therefore, this study aimed to investigate the spatial clusters distribution and modelling of health care autonomy among reproductive-age women in Ethiopia.

METHODS

We used the 2016 Ethiopian Demographic and Health Survey (EDHS) data for this study. The data were weighted for design and representativeness using strata, weighting variable, and primary sampling unit to get a reliable estimate. A total weighted sample of 10,223 married reproductive-age women were included in this study. For the spatial analysis, Arc-GIS version 10.6 was used to explore the spatial distribution of women health care decision making and spatial scan statistical analysis to identify hotspot areas. Considering the hierarchical nature of EDHS data, a generalized linear mixed-effect model (mixed-effect logistic regression) was fitted to identify significant determinants of women's health care decision making autonomy. The Intra-Class Correlation (ICC) were estimated in the null model to estimate the clustering effect. For model comparison, deviance (-2LLR), Akakie Information Criteria (AIC), and Bayesian Information Criteria (BIC) parameters were used to choose the best-fitted model. Variables with a p-value < 0.2 in the bivariable analysis were considered for the multivariable analysis. In the multivariable mixed-effect logistic regression analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to declare the strength and significance of the association between women's decision-making autonomy and independent variables.

RESULTS

In this study, about 81.6% (95% CI: 80.6%, 82.2%) of women have autonomy in making health care decisions. The spatial distribution of women's autonomy in making health decisions in Ethiopia was non-random (global Moran's I = 0.0675, p < 0.001). The significant hotspot areas of poor women's autonomy in making health care decisions were found in north Somali, Afar, south Oromia, southwest Somali, Harari, and east Southern Nations Nationalities and Peoples (SNNP) regions. In the mixed-effect logistic regression analysis; being urban (AOR = 1.59, 95% CI: 1.04, 2.45), having secondary education (AOR = 1.60, 95% CI: 1.06, 2.41), having an occupation (AOR = 1.19, 95% CI: 1.01, 1.40) and being from the richest household (AOR = 2.14, 95% CI: 1.45, 3.14) were significantly associated with women autonomy in deciding for health care.

CONCLUSIONS

The spatial distribution of women's autonomy in making the decision for health care was non-random in Ethiopia. Maternal education, residence, household wealth status, region, and maternal occupation were found to influence women's autonomy. Public health interventions targeting the hotspot areas of poor women autonomy through enhancing maternal occupation and employment is needed to improve women empowerment in making decisions for health care.

Exploration of Attendance, Active Participation, and Behavior Change in a Group-Based Responsive Stimulation, Maternal and Child Health, and Nutrition Intervention

Delivery of interventions through group sessions allows for in-depth discussions and creates opportunities for group members to work together to identify and solve common problems. However, low attendance may limit impact. We explored factors affecting attendance, active participation, and behavior change in an integrated group-based child development and maternal and child health intervention in Bangladesh. Community health workers (CHWs) facilitated two sessions a month including material on child stimulation; water, sanitation, and hygiene; nutrition, maternal depression, and lead exposure prevention. Sessions were conducted with 320 pregnant women and mothers with children younger than 24 months, in 16 villages in Kishoreganj district. After 4 and 9 months of intervention, we conducted focus group discussions and in-depth interviews with mothers (n = 55 and n = 48) to identify determinants of attendance and behavior change, and to examine potential for intervention scale-up. Recruiting family members to assist with childcare resulted in improved attention during sessions. Adopting a storytelling format for presentation of session materials resulted in more engaged participation during courtyard sessions. Session attendance and behavior change, especially purchasing decisions, were difficult for participants without the support of male heads of the household. Selecting a rotating leader from among the group members to remind group members to attend sessions and support CHWs in organizing the sessions was not successful. Facilitating self-appraisals and planning for water and sanitation allowed participants to identify areas for improvement and track their progress. Key determinants of a participant’s attendance were identified, and the resulting intervention shows promise for future implementation at scale.

Men's experiences of pregnancy and childbirth in Sierra Leone: Reexamining definitions of "male partner involvement"

In recent decades, global health researchers and policy makers have advocated for men's increased involvement in pregnancy and childbirth with the goal of improving maternal health outcomes. By "involvement," these actors generally refer to narrow-largely Western-definitions of participation: accompanying women to antenatal and postpartum care visits, engaging in childbirth education, or being present during delivery. However, such approaches often fail to account for the culturally valid and gendered ways in which men already are involved in supporting women's reproductive health. This study is based on participant observation, semi-structured interviews, and life histories conducted among 106 fathers in eastern Sierra Leone over the course of 2013-2016. Findings demonstrate that in Sierra Leone, where pregnancy and childbirth are considered to belong to the domain of women, men's primary role is to supply the material resources for a safe and healthy birth: a nutritious diet, transportation to healthcare facilities, medicines and supplies in the case of emergency, and the items to wash and dress the baby. While evidence suggests that gender norms are shifting to include other forms of intimate and emotional involvement, it is important to recognize existing forms of material support as valuable and essential forms of care. By restricting male involvement to biomedical notions of care, global health programs and policies risk discounting other types of socially meaningful support. Rather than disparaging young, African men for falling short of what Western organizations and researchers perceive to be "correct" behaviors, this paper attempts to highlight men's own understandings of involvement, so as to provide a more complete picture of the gendered nature of reproductive health in this context.

Exploring factors influencing pregnant Women's attitudes, perceived subjective norms and perceived behavior control towards male involvement in maternal services utilization: a baseline findings from a community based interventional study from Rukwa, rural Tanzania

Background

Although male involvement enhances obstetric care-seeking behavior, the practice of male involvement in developing countries remains unacceptably low. Male involvement in maternal services utilization can be influenced by the attitude, subjective norm, and perceived behavior control of their female partners. Little is known about factors influencing pregnant women’s attitudes, perceived subjective norms, and perceived behavior control towards male involvement in maternal services utilization.

Methods

A baseline community-based cross-sectional study whose target was pregnant women were performed from 1st June until 30th October 2017. A three-stage probability sampling technique was employed to obtain a sample of 546 pregnant women. A structured questionnaire that hinged the Theory of Planned Behavior was used. The questionnaire explored three main determinants of male involvement, which were: attitudes towards male involvement, perceived subjective norms towards male involvement, and perceived behavior control towards male involvement.

Results

After adjusting for the confounders, factors influencing positive attitude towards male involvement were age at marriage [19 to 24 yrs.,(AOR = 1.568 at 95% CI =1.044–2.353), more than 24 yrs. (AOR = 2.15 at 95% CI = 1.150–1.159)]; education status [primary school (AOR = 1.713 at 95% CI = 1.137–2.58)] and economic status [earning more than one dollar per day (AOR = 1.547 at 95% CI = 1.026–2.332)]. Factors influencing perceived subjective norms was only age at marriage [19 to 24 yrs., (AOR = 1.447 at 95% CI = 0.970–2.159), more than 24 years, (AOR = 2.331 at 95% CI = 1.261–4.308)]; factors influencing perceived behavior control were age at marriage [more than 24 years (AOR = 2.331 at 95%CI = 1.261–4.308)], and the intention to be accompanied by their male partners (AOR = 1.827 at 95%CI = 1.171–2.849).

Conclusion

The study revealed that women who were married at an older age were more likely to have a positive attitude, subjective norms, and perceived behavior control towards male involvement in maternal services utilization than those who were married at a young age. Pregnant women who had primary education and earn more than a dollar per day were more likely to have positive attitudes towards male involvement than poor and uneducated pregnant women. The study recommends an interventional study to evaluate the influence attitude, subjective norms, and perceived behavior control on male involvement in maternal services utilization.

Women's decision-making autonomy in the household and the use of maternal health services: An Indonesian case study

OBJECTIVES

The study aimed to examine the influence of Indonesian women's decision-making within the household regarding the use of maternal health services. It explored whether women who had high involvement in household decision-making experienced a higher likelihood of using antenatal care services, delivery services assisted by skilled birth attendance, and facility-based delivery compared to those with limited autonomy.

METHODS

The study used the individual subset data on women from the 2017 Indonesia Demographic and Health Survey, which included 3435 women of reproductive age (15-49 years) who had given birth within one year preceding the survey. The study also used the Women's Participation Index to measure women's decision-making autonomy in the household. Descriptive statistics and multiple logistic regression analyses were conducted to identify the association of women's autonomy with the use of three key maternal health services.

RESULTS

The Women's Participation Index had a significant positive relationship to adequate antenatal care service use, but no effect on the use of skilled birth attendance and facility-based delivery, after adjusting for maternal and sociodemographic variables. Women with more autonomy experienced 1.7 (95% confidence interval: 1.17-2.45) times higher odds of using adequate antenatal care services. In addition, the likelihood of the utilization of adequate antenatal care services, skilled birth attendance, and facility-based delivery was higher among women who were age ≥35 years at birth, attained a higher education level, and were in the richest quintile compared to their respective counterparts.

CONCLUSION

Women's decision-making autonomy had a significant effect on the use of adequate antenatal care services only. Initiatives that are more gender-sensitive to promote husband involvement should be conducted to increase men's awareness of the importance of maternal health services.

Factors Associated with Utilization of Complete Postnatal Care Service in Baglung Municipality, Nepal

Background

Postnatal period is six weeks after birth. It is critical but is the most neglected period. A large proportion of maternal and neonatal deaths occur during 48 hours following childbirth. The utilization of the recommended three postnatal checkups within seven days after delivery, which plays a vital role in preventing maternal and neonatal deaths, is low in Nepal.

Objective

This study is aimed at identifying the factors associated with the utilization of complete postnatal care (PNC) among mothers.

Method

A cross-sectional study was carried out among 318 mothers in wards 1, 2, 3, and 4 of Baglung municipality, Nepal. Data was collected by semi-structured interviews. Descriptive analysis and comparison of characteristics of women/families with complete vs. partial postnatal checkups using multivariable logistic regression were done.

Results

Among 314 respondents receiving at least one PNC, 78% had partial and 22% had complete PNC. Relatively advantaged caste/ethnicity- Brahman/Chhetri (aOR = 3.18, 95% CI: 1.24-8.12) and Janajati (aOR = 2.87, 95% CI: 1.09-7.53) - compared to Dalits, husbands working as a job holder in Nepal (aOR = 3.49, 95% CI: 1.50-8.13), and delivery in a private hospital (aOR = 11.4, 95% CI: 5.40-24.2) were associated with having complete PNC.

Conclusion

Although PNC attendance at least once was high, utilization of complete PNC was low. More focus to mothers from disadvantaged caste/ethnicity, those whose husbands are in foreign employment, and improvement in quality of care in government health facilities may increase the use of complete PNC.

Male participation in antenatal care and its influence on their pregnant partners' reproductive health care utilization: insight from the 2015 Afghanistan Demographic and Health Survey

Afghanistan has made remarkable progress in reducing maternal mortality over the past few decades, and male participation in their pregnant partner's reproductive health care is crucial for further improvement. This study aimed to examine whether male attendance at antenatal care (ANC) with their pregnant partners might be beneficially associated with the degree of utilization of reproductive health care by the pregnant partners. Data for 2660 couples (women aged 16-49 years) were taken from the 2015 Afghanistan Demographic and Health Survey (AfDHS). Bivariate and multivariate logistic regression models were employed to explore the association between male attendance at ANC with their pregnant partners and reproductive health care utilization outcomes, including adequate utilization (four or more visits) of ANC services, ANC visits during the first trimester (up to 12 weeks) of pregnancy, rate of blood and urine testing during pregnancy, rate of institutional delivery and utilization of postnatal check-up services. The results indicated that the rate of male attendance at ANC with their pregnant partners was 69.4%. After controlling for covariates, pregnant partners who were accompanied to ANC by their male partners were more likely to adequately utilize ANC services (AOR=1.42; 95% CI: 1.18-1.71), commence ANC visits even during the first trimester (AOR=1.21; 95% CI: 1.03-1.42), give birth at a health facility (AOR=1.23; 95% CI: 1.03-1.47) and present themselves for postnatal check-ups (AOR=1.24; 95% CI: 1.04-1.47) than those who were not accompanied by them. The study demonstrated that participation of male partners in ANC was positively associated with their pregnant partners' utilization of reproductive health care services in Afghanistan. The findings suggest that, to improve maternal and child health outcomes in the country, it would be worthwhile implementing interventions to encourage male partners to become more engaged in the ANC of their pregnant partners.

Trends and factors associated with the utilisation of antenatal care services during the Millennium Development Goals era in Tanzania

Background

A detailed understanding of trends, as well as what act as enablers and/or barriers to the utilisation of antenatal care (ANC) among Tanzanian women, is essential to policymakers and health practitioners to guide maternal health efforts. We investigated the trends and factors associated with ANC service use during the Millennium Development Goals (MDG) era in Tanzania between 1999 and 2016.

Methods

The study used the Tanzania Demographic and Health Survey (TDHS) data for the years 1999 (n = 2095), 2004–2005 (n = 5576), 2010 (n = 6903) and 2015–2016 (n = 5392). Multivariate multinomial logistic regression models were used to investigate the association between predisposing, enabling, need and community-level factors and frequency of ANC (1–3 and ≥ 4) visits in Tanzania.

Results

The proportion of women who made one to three ANC visits improved significantly from 26.4% in 1999 to 47.0% in 2016. The percentage of women who make four or more ANC visits declined from 71.1% in 1999 to 51.0% in 2016. Higher maternal education, belonging to wealthier households, being informally employed and listening to the radio were associated with four or more ANC visits. Women who did not desire pregnancy had a lower likelihood to attend four or more ANC visits. Women who had primary or higher education, those who resided in wealthier households and those who were informally employed were more likely to make between one and three ANC visits.

Conclusion

The study showed that there was an improvement in the proportion of Tanzanian women who made one to three ANC visits, but it also indicated a concurrent decrease in the prevalence of four or more ANC visits. Improving uptake of ANC among Tanzanian women is achievable if national health policies and programmes also focus on key amenable maternal factors of education, household wealth and employment.

Men on the move and the wives left behind: the impact of migration on family planning in Nepal

Nepali migration is longstanding, and increased from 2.3% of the total population in 2001 to 7.2% in 2011. The estimated 1.92 million migrants are predominantly men. Consequently, 32% of married women have husbands working abroad. Social structures are complicated as many married women live with their in-laws who typically assume decision-making power, including access to health services. This study compares access to reproductive health services, fertility awareness, and decision-making power among a sample of married women aged 15-24 years (n = 1123) with migrant husbands (n = 485), and with resident husbands (n = 638). Predictably, women with migrant husbands had significantly lower contraceptive use than other married women (9.3% vs 30.3%, respectively), and expressed a higher intention to become pregnant in the next year. Despite their intentions, women with migrant husbands scored lower on a fertility awareness index, were less likely to discuss pregnancy planning with their spouse, and less likely to describe their relationships positively. Decision-making for both groups of married women was dominated by both husbands and in-laws in different ways. Yet, across multiple normative scales, fewer women with migrant husbands felt pressure to conform to existing social norms. Married women with migrant husbands reflect a subset of women, with unique fertility issues and desires. Interventions that increase knowledge of fertility among this subset of women, promote healthy preconception behaviours. Linking women for counselling opportunities throughout the pre and postnatal periods may help improve health outcomes for mothers and children.

Male involvement and associated factors in birth preparedness and complication readiness in Debre Berhan Town, North East Ethiopia

Introduction

Men play indispensable role in health and wellbeing of mothers and children. Their level of involvement with regards to birth preparedness and complication readiness is understudied. This study was therefore carried out to assess male involvement and associated factors in birth preparedness and complication readiness in Debre Berhan town, North East Ethiopia.

Methods

Community based cross-sectional study was conducted from July 1^st - 30^th, 2014 in Debre Berhan town among 806 study participants. Cluster sampling technique was employed to select study participants. Data were collected using a structured and pre-tested questionnaire by face-to-face interview technique. Bivariate and multivariate analyses were performed to check associations and control confounding.

Results

The study showed that male involvement in birth preparedness and complication readiness found to be 51.4%. Educational status of tertiary level (AOR = 4.37 95% (CI: 2.10, 9.13), having 1 or 2 children (AOR = 2.52, 95% CI:1.30,4.87) and 3 or 4 (AOR = 5.19, 95% CI:2.44,11.03), knowledge of danger signs (AOR = 7.71, 95% (CI:5.15, 11.54), knowledge of birth preparedness and complication readiness (AOR = 11.98, 95% CI:7.73,18.56) and attitude (AOR = 2.23, 95% CI: 1.41,3.51) were significantly associated with male involvement in birth preparedness and complication readiness.

Conclusion

Male involvement in birth preparedness and complication readiness found to be low in study area. Education, number of children, knowledge on danger signs, knowledge on birth preparedness and complication readiness and attitude were factors associated with male involvement. Creating awareness on danger signs of pregnancy, birth preparedness and complication readiness both at community and institutional level were recommended in order to increase male involvement in birth preparedness and complication readiness.

Women's Empowerment and HIV Testing Uptake: A Meta-analysis of Demographic and Health Surveys from 33 Sub-Saharan African Countries

BACKGROUND

There is a growing body of evidence suggesting that women's empowerment can help achieve better health behaviours and outcomes. However, few have looked at the impact of women's empowerment on HIV testing in Sub-Saharan Africa (SSA). This study investigated the association between women's empowerment and HIV testing among women in 33 countries across SSA.

METHODS

Cross-sectional data from the most recent Demographic and Health Surveys (2005-2018) of 33 countries in SSA were used. Confounder adjusted logistic regression analysis was completed separately for each of the 33 DHS datasets to produce the adjusted Odds Ratio (OR) for the association between women empowerment and HIV testing. The regression analysis strictly accounted for the three design elements (weight, cluster and strata) to produce an estimate representative of the respective countries. Finally, an Individual Participant Data (IPD) meta-analysis approach was used to statistically pool the effect of women empowerment on HIV testing.

RESULTS

There was a wide variation in the percentage of women who were empowered among the countries studied, with only a few countries such as South Africa, Angola and Ghana having a high prevalence of negative attitudes toward wife beating. HIV testing was higher in Angola, Lesotho, Uganda and South Africa. While participation in one or two of the three decisions had been marginally associated with lower odds of HIV testing across the SSA regions (0.89; 95%CI: 0.83, 0.97); the corresponding prediction interval crossed the null. Being involved in the three decisions (0.92; 95%CI: 0.84, 1.00) and disagreement to wife-beating (0.99; 95%CI: 0.94, 1.05) had no statistical relationship with HIV testing uptake.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

The two indirect indicators of women empowerment could not predict HIV testing uptake. Further studies are recommended to establish the nature of the relationship between HIV testing and women's empowerment that is measured through standard tools.

Perceived barriers to utilization of antenatal care services in northern Uganda: A qualitative study

OBJECTIVE

Antenatal care (ANC) utilization remains a challenge in efforts to reduce maternal mortality and improve maternal health in Uganda. This study aimed to identify perceived barriers to utilization of ANC services in a rural post-conflict area in northern Uganda.

METHODS

A qualitative study using in-depth interviews and focus group discussions of seventeen participants (pregnant women, health workers and a traditional birth attendant). The study was informed through a phenomenological approach to capture perceived barriers to utilization of ANC. The study was carried out in post-conflict Awach sub-county, Gulu District, northern Uganda. Data was analyzed using inductive conventional content analysis.

RESULTS

The main perceived barriers to ANC utilization were identified as: poor quality of care, including poor attitude of health workers; socio-cultural practices not being successfully aligned to ANC; and lack of support from the husband, including difficulties in encouraging him to attend ANC. Additionally, institutional structures and procedures at the health centers in terms of compulsory HIV testing and material requirements and transportation were perceived to prevent some pregnant women from attending ANC.

CONCLUSIONS

Identifying local barriers to ANC utilization are important and should be considered when planning ANC programs. We propose that future efforts should focus on how to ensure a good patient-provider relationship and perceived quality of care, and further how to improve inter-spousal communication and sensitization of husbands for increased involvement in ANC. We recommend more research on how socio-cultural context can meaningfully be aligned to ANC to improve maternal health and reduce maternal mortality.

Supported motherhood? An examination of the cultural context of male participation in maternal health care among tribal communities in India

In many cultural settings worldwide, within families, men tend to be responsible for important choices relating to the allocation of household resources and care-seeking behaviour that directly impact on the health of women and newborns. This study examines the extent of male participation in antenatal care (ANC), delivery, postnatal care (PNC), household chores and providing food to wives among tribal communities in India. In addition, health care providers’ views on male participation in maternal health were examined. Primary data were collected from 385 men aged 15–49 from rural Gadchiroli District in Maharashtra, India. Interviews of 385 men whose wives had delivered a child within the previous 2 years were conducted between November 2014 and March 2015. Bivariate and multivariate analyses were done. The results showed that the tribal men’s participation in maternal health care was minimal. Around 22% of the men reported accompanying their wives to ANC, 25% were present at the time of delivery of their children and 25% accompanied their wives to PNC. Participation in household work, and support for wives in other ways, were slightly better. The main reason given by men for not participating in maternal health care was that they didn’t think it was necessary, believing that all maternal health issues were women’s concern. Health care providers among these tribal communities in India should encourage men to participate in issues related to maternal health care.

Men's roles in care seeking for maternal and newborn health: a qualitative study applying the three delays model to male involvement in Morogoro Region, Tanzania

Background

Increasing the utilization of facility-based care for women and newborns in low-resource settings can reduce maternal and newborn morbidity and mortality. Men influence whether women and newborns receive care because they often control financial resources and household decisions. This influence can have negative effects if men misjudge or ignore danger signs or are unwilling or unable to pay for care. Men can also positively affect their families’ health by helping plan for delivery, supplementing women’s knowledge about danger signs, and supporting the use of facility-based care. Because of these positive implications, researchers have called for increased male involvement in maternal and newborn health. However, data gathered directly from men to inform programs are lacking.

Methods

This study draws on in-depth interviews with 27 men in Morogoro Region, Tanzania whose partners delivered in the previous 14 months. Debriefings took place throughout data collection. Interview transcripts were analyzed inductively to identify relevant themes and devise an analysis questionnaire, subsequently applied deductively to all transcripts.

Results

Study findings add a partner-focused dimension to the three delays model of maternal care seeking. Men in the study often, though not universally, described facilitating access to care for women and newborns at each point along this care-seeking continuum (deciding to seek care, reaching a facility, and receiving care). Specifically, men reported taking ownership of their role as decision makers and described themselves as supportive of facility-based care. Men described arranging transport and accompanying their partners to facilities, especially for non-routine care. Men also discussed purchasing supplies and medications, acting as patient advocates, and registering complaints about health services. In addition, men described barriers to their involvement including a lack of knowledge, the need to focus on income-generating activities, the cost of care, and policies limiting male involvement at facilities.

Conclusion

Men can leverage their influence over household resources and decision making to facilitate care seeking and navigate challenges accessing care for women and newborns. Examining these findings from men and understanding the barriers they face can help inform interventions that encourage men to be positively and proactively involved in maternal and newborn health.

Narratives on why pregnant women delay seeking maternal health care during delivery and obstetric complications in rural Ghana

BACKGROUND

Despite the many maternal healthcare policy programmes in Ghana such as free the antenatal care (ANC) and the fee-exemption policy under the National Health Insurance Scheme, among others, the country has yet to make substantial improvements in addressing low skilled care utilisation in pregnancy and delivery. From previous studies, maternal mortality has been linked to women's healthcare decision-making power at the household level in many low and middle-income countries. Thus, a pregnant women's ability to choose a healthcare provider, act on her preferences, and to be sufficiently financially empowered to take the lead in deciding on reproductive and pregnancy care has significant effects on service utilisation outcomes. Therefore, we explored rural community-level barriers to seeking care related to obstetric complications and delivery from the perspectives of mothers, youth, opinion leaders and healthcare providers in Nadowli-Kaleo and Daffiama-Bussie-Issa districts in the Upper West Region of Ghana.

METHODS

This exploratory qualitative study was based on the narratives of women, health providers and community stakeholders regarding the expectant women's autonomy to decide and utilise maternal care. To achieve maximal diversity of responses, purposive sampling procedures were followed in selecting 16 health professionals, three traditional birth attendants and 240 community members (opinion leaders, youth and non-pregnant women) who participated in individual depth interviews and focus group discussions.

RESULTS

Women's lack of autonomy to seek care without prior permission, perceived quality care of traditional birth attendants, stigmatisation of unplanned pregnancies and cultural beliefs associated with late disclosure of childbirth labour all delayed mothers timely use of skilled care in the study communities. These barriers compounded problems arising from communities that are geographically isolated from hospital care.

CONCLUSIONS

Decisions about seeking maternal care were usually made by the expectant woman's husband and family without providing adequate support to pregnant women during the latter stages of pregnancy and delivery. We conclude that this is primarily a cultural issue. The study recommends a change in the approach to community-level health education campaigns for maximum impacts through the increased involvement of men and families in health service delivery and utilisation.

Factors Associated With Stillbirth Among Pregnant Women in Nepal

OBJECTIVES

Stillbirth is a common adverse pregnancy outcome that represents a distressing and traumatic event for women and their partners. The aim of this study was to identify factors associated with stillbirth in ever-pregnant women in Nepal.

METHODS

This study utilized the individual women's dataset from the Nepal Demographic and Health Survey, conducted in 2016. The dependent variable of interest was whether women had at least 1 stillbirth during their lifetime. The associations between independent variables and the dependent variable of the study were analyzed using a multiple logistic regression model.

RESULTS

Among 8918 ever-pregnant women aged 15-49 years, 488 had experienced at least 1 stillbirth during their lifetime, representing 5.5% of the total. After adjusting each factor for the confounding effects of other factors, maternal age, maternal education, place of residence, and sub-region remained significantly associated with having experienced stillbirth.

CONCLUSIONS

Stillbirth continues to be a major problem among women, especially those with higher maternal age, those who are illiterate, and residents of certain geographical regions. To minimize stillbirth in Nepal, plans and policies should be focused on women with low education levels and residents of rural areas, especially in the western mountain and far-western hill regions.

Health care seeking for maternal and newborn illnesses in low- and middle-income countries: a systematic review of observational and qualitative studies

Background: In low- and middle-income countries, a large number of maternal and newborn deaths occur due to delays in health care seeking. These delays occur at three levels i.e. delay in making decision to seek care, delay in access to care, and delay in receiving care. Factors that cause delays are therefore need to be understand to prevent and avoid these delays to improve health and survival of mothers and babies.   

Methods: A systematic review of observational and qualitative studies to identify factors and barriers associated with delays in health care seeking.

Results: A total of 159 observational and qualitative studies met the inclusion criteria. The review of observational and qualitative studies identified social, cultural and health services factors that contribute to delays in health care seeking, and influence decisions to seek care. Timely recognition of danger signs, availability of finances to arrange for transport and affordability of health care cost, and accessibility to a health facility were some of these factors.

Conclusions: Effective dealing of factors that contribute to delays in health care seeking would lead to significant improvements in mortality, morbidity and care seeking outcomes, particularly in countries that share a major brunt of maternal and newborn morbidity and mortality.

Registration: PROSPERO CRD42012003236.