Quality maternity care for every woman, everywhere: a call to action

Husband's intention to support during pregnancy for the use of maternity waiting home in Jimma Zone, Southwest, Ethiopia: a community-based cross-sectional study

Background

Husbands are the primary decision-makers about the place of childbirth. Lack of husbands' support for maternal health care is associated with low maternal waiting home utilization and less is known about the husbands' intention to support their wife's use of maternal waiting homes (MWHs) and underlying beliefs in Ethiopia. This community-based cross-sectional survey aimed to study husbands' intention to support during pregnancy through the use of maternity waiting homes in Jimma Zone, Southwest Ethiopia.

Method

A cross-sectional study was conducted among 396 randomly selected husbands whose wives were pregnant. Interviewer-administered, a structured questionnaire developed based on the Theory of Planned Behavior (TPB) was used to collect the data. Multivariable logistic regression analyses were used to examine the association between behavioral intention and constructs of the theory of planned behavior.

Results

Of the 396 husbands who took part in the study, 42.7% intend to support their partner's use of a maternity waiting home. Intention to support a wife to use a maternity waiting home was associated with subjective norm [AOR = 1.303, 95% CI (1.054, 1.611)] and perceived behavioral control [AOR = 1.446, 95% CI (1.234, 1.695)]. Among the control beliefs, "having childcare"; "having a person who stays with a wife at a maternity waiting home"; and "availability of quality service provided to a wife in the maternity waiting home" significantly separated intenders and non-intenders.

Conclusion

The findings suggest that husbands who perceived more social pressure and felt in control of barriers were more likely to intend to support their partner in using a maternity waiting home. Intervention should focus on underlying normative and control beliefs to improve the husband's intention.

Women's health and rights in the twenty-first century

In the twenty-first century, the complex relationship between women's health and rights has been influenced by a range of interconnected challenges, including gender inequity, reproductive health disparities, maternal mortality and morbidity, and women's inability to access life-saving, high-quality healthcare services including family planning. Going forward, the world needs to find ways to implement the unfinished agenda of the International Conference on Population and Development (ICPD) 1994 and the Sustainable Development Goals (SDGs), thus prioritizing health and rights for women and girls as essential not only to their survival but also to their progress, agency and empowerment. It is also important to consider the interconnection between women's health and rights and climate change, with its disproportionate impact on the well-being of girls and women, and to address the impact and opportunities afforded by digital technologies. By embracing a holistic approach, societies might be able to advance the cause of women's health and rights in a more inclusive and sustainable manner.

A cluster randomized controlled trial to assess the impact of the 'Caring for Providers to Improve Patient Experience' intervention on person-centered maternity care in Kenya and Ghana: Study Protocol

Background

Poor person-centered maternal care (PCMC) contributes to high maternal mortality and morbidity, directly and indirectly, through lack of, delayed, inadequate, unnecessary, or harmful care. While evidence on poor PCMC prevalence, as well as inequities, expanded in the last decade, there is still a significant gap in evidence-based interventions to address PCMC. We describe the protocol for a trial to test the effectiveness of the "Caring for Providers to Improve Patient Experience" (CPIPE) intervention, which includes five strategies for provider behavior change, targeting provider stress and bias as intermediate factors to improve PCMC and to address inequities.

Methods

The trial will assess the effect of CPIPE on PCMC, as well as on intermediate and distal outcomes, using a two-arm cluster randomized controlled trial in 40 health facilities in Migori and Homa Bay Counties in Kenya and Upper East and Northeast Regions in Ghana. Twenty facilities in each country will be randomized to 10 intervention and 10 control sites. The primary intervention targets are all healthcare workers who provide maternal health services. The intervention impact will also be assessed first among providers, and then among women who give birth in health facilities. The primary outcome is PCMC measured with the PCMC scale, via multiple cross-sectional surveys of mothers who gave birth in the preceding 12 weeks in study facilities at baseline (prior to the intervention), midline (6 months after intervention start), and endline (12 months post-baseline) (N = 2000 across both countries at each time point). Additionally, 400 providers in the study facilities across both countries will be followed longitudinally at baseline, midline, and endline, to assess intermediate outcomes. The trial incorporates a mixed-methods design; survey data alongside in-depth interviews (IDIs) with healthcare facility leaders, providers, and mothers to qualitatively explore factors influencing the outcomes. Finally, we will collect process and cost data to assess intervention fidelity and cost-effectiveness.

Discussion

This trial will be the first to rigorously assess an intervention to improve PCMC that addresses both provider stress and bias and will advance the evidence base for interventions to improve PCMC and contribute to equity in maternal and neonatal health.

Magnitude, disparity, and predictors of poor-quality antenatal care service: A systematic review and meta-analysis

Background

Antenatal care is directed toward ensuring healthy pregnancy outcomes. Quality antenatal care increases the likelihood of receiving an effective intervention to maintain maternal, fetal, and neonatal well-being, while poor quality is linked to poor pregnancy outcomes. However, owing to the complex nature of quality, researchers have followed several approaches to systematically measure it. The evidence from these variable approaches appears inconsistence and poses challenges to programmers and policymakers. Hence, it is imperative to obtain a pooled estimate of the quality of antenatal care. Therefore, considering the scarcity of evidence on the quality of antenatal care, this study aimed to review, synthesize, and bring pooled estimates of accessible evidence.

Objective

This study aimed to estimate the pooled magnitude and predictors of quality of antenatal care services and compare regional disparity.

Method

We conducted a comprehensive systematic three-step approach search of published and unpublished sources from 2002 to 2022. The methodological quality of eligible studies was checked using Joanna Briggs Institute critical appraisal tool for cross-sectional studies. Meta-analysis was carried out using STATA version 16. Statistical heterogeneity was assessed using Cochran's Q test. In the presence of moderate heterogeneity (I2 more than 50%), sensitivity and subgroup analyses were conducted and presented in a forest plot. Effect size was reported using standardized mean difference and its 95% confidence interval. Funnel plots and Egger's regression test were used to measure publication bias at the 5% significance level. A trim-and-fill analysis was conducted to adjust for publication bias. Pooled estimates were computed using random-effects models and weighted using the inverse variance method in the presence of high heterogeneity among studies. A 95% CI and 5% significance level were considered to declare significance variables.

Results

The global pooled poor-quality antenatal care was 64.28% (95% CI: 59.58%-68.98%) (I2 = 99.97%, p = 0.001). The identified pooled predictors of good-quality antenatal care service were: number of antenatal care visits (fourth and above antenatal care visit) (Adjusted odds ratio (AOR) = 2.6, 95% CI: 1.37-3.84), family wealth index (AOR = 2.72, 95% CI: 1.89-3.55), maternal education attainment (AOR = 3.03, 95% CI: 2.24-3.82), residence (urban dwellers) (AOR = 4.06, 95% CI: 0.95-7.17), and confidentiality antenatal care (AOR = 2.23, 95% CI: -0.36 to -4.82).

Conclusions

The study found regional and country-level disparities in the quality of antenatal care services for pregnant women, where poor-quality antenatal care services were provided for more than two-thirds to three-fourths of antenatal care attendants. Therefore, policymakers and health planners should put a great deal of emphasis on addressing the quality of antenatal care services.

Interventions to improve the quality of maternal care in Ethiopia: a scoping review

Introduction

Quality improvement interventions have been part of the national agenda aimed at reducing maternal and neonatal morbidities and mortality. Despite different interventions, neonatal mortality and morbidity rates remain steady. This review aimed to map and synthesize the evidence of maternal and newborn quality improvement interventions in Ethiopia.

Methods

A scoping review was reported based on the reporting items for systematic reviews and meta-analysis extensions for the scoping review checklist. Data extraction, collation, and organization were based on the Joanna Briggs Institute manual of the evidence synthesis framework for a scoping review. The maternal and neonatal care standards from the World Health Organization and the Donabedian quality of health framework were used to summarize the findings.

Results

Nineteen articles were included in this scoping review. The review found that the studies were conducted across various regions of Ethiopia, with the majority published after 2013. The reviewed studies mainly focused on three maternal care quality interventions: mobile and electronic health (eHealth), quality improvement standards, and human resource mobilization. Moreover, the reviewed studies explored various approaches to quality improvement, such as providing training to healthcare workers, health extension workers, traditional birth attendants, the community health development army, and mothers and supplying resources needed for maternal and newborn care.

Conclusion

In conclusion, quality improvement strategies encompass community involvement, health education, mHealth, data-driven approaches, and health system strengthening. Future research should focus on the impact of physical environment, culture, sustainability, cost-effectiveness, and long-term effects of interventions. Healthcare providers' knowledge, skills, attitudes, satisfaction, and adherence to guidelines should also be considered.

Stakeholder opinions on perceived sub-standard emergency obstetric and newborn care in Ghana

BACKGROUND

Sub-Saharan Africa is unlikely to achieve sustainable development goal (SDG) 3 on maternal and neonatal health due to perceived sub-standard maternal and newborn care in the region. This paper sought to explore the opinions of stakeholders on intricacies dictating sub-standard emergency obstetric and newborn care (EmONC) in health facilities in Northern Ghana.

METHODS

Drawing from a qualitative study design, data were obtained from six focus group discussions (FGDs) among 42 health care providers and 27 in-depth interviews with management members, clients and care takers duly guided by the principle of data saturation. Participants were purposively selected from basic and comprehensive level facilities. Data analysis followed Braun and Clarke's qualitative thematic analysis procedure.

RESULTS

Four themes and 13 sub-themes emerged as root drivers to sub-standard care. Specfically, the findings highlight centralisation of EmONC, inadequate funding, insufficient experiential training, delay in recruitment of newly trained essential staff and provider disinterest in profession.

CONCLUSION

Setbacks in the training and recruitment systems in Ghana, inadequate investment in rural health coupled with extent of health provider inherent disposition to practice may be partly responsible for sub-standard obstetric care in the study area. Interventions targeting the afore-mentioned areas may reduce events of sub-standard care.

Midwife continuity of care models versus other models of care for childbearing women

BACKGROUND

Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016.

OBJECTIVES

To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies.

SELECTION CRITERIA

All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence.

MAIN RESULTS

We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women. Primary outcomes Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate-certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate-certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate-certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low-certainty evidence). We arevery uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low-certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low-certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low-certainty evidence). Secondary outcomes When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate-certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low-certainty evidence). When compared to other models of care, midwife continuity of care models likelyresult in little to no difference inpostpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate-certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate-certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low-certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low-certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low-certainty evidence). We are very uncertain about the effect of midwife continuity of care models compared to other models of care onthird or fourth-degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low-certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low-certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low-certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low-certainty evidence) andfetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low-certainty evidence). No maternal deaths were reported across three studies. Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates. There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more. Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models.

AUTHORS' CONCLUSIONS

Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates. Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low- and middle-income countries.

Determinants of public institutional births in India: An analysis using the National Family Health Survey (NFHS-5) factsheet data

Background

Institutional births ensure deliveries happen under the supervision of skilled healthcare personnel in an enabling environment. For countries like India, with high neonatal and maternal mortalities, achieving 100% coverage of institutional births is a top policy priority. In this respect, public health institutions have a key role, given that they remain the preferred choice by most of the population, owing to the existing barriers to healthcare access. While research in this domain has focused on private health institutions, there are limited studies, especially in the Indian context, that look at the enablers of institutional births in public health facilities. In this study, we look to identify the significant predictors of institutional birth in public health facilities in India.

Method

We rely on the National Family Health Survey (NFHS-5) factsheet data for analysis. Our dependent variable (DV) in this study is the % of institutional births in public health facilities. We first use Welch's t-test to determine if there is any significant difference between urban and rural areas in terms of the DV. We then use multiple linear regression and partial F-test to identify the best-fit model that predicts the variation in the DV. We generate two models in this study and use Akaike's Information Criterion (AIC) and adjusted R2 values to identify the best-fit model.

Results

We find no significant difference between urban and rural areas (P = 0.02, α =0.05) regarding the mean % of institutional births in public health facilities. The best-fit model is an interaction model with a moderate effect size (Adjusted2 = 0.35) and an AIC of 179.93, lower than the competitive model (AIC = 183.56). We find household health insurance (β = -0.29) and homebirth conducted under the supervision of skilled healthcare personnel (β = -0.56) to be significant predictors of institutional births in public facilities in India. Additionally, we observe low body mass index (BMI) and obesity to have a synergistic impact on the DV. Our findings show that the interaction between low BMI and obesity has a strong negative influence (β = -0.61) on institutional births in public health facilities in India.

Conclusion

Providing households with health insurance coverage may not improve the utilisation of public health facilities for deliveries in India, where other barriers to public healthcare access exist. Therefore, it is important to look at interventions that minimise the existing barriers to access. While the ultimate objective from a policy perspective should be achieving 100% coverage of institutional births in the long run, a short-term strategy makes sense in the Indian context, especially to manage the complications arising during births outside an institutional setting.

Differences in Antenatal Care Policies in England, Finland, and the Netherlands: A Framing analysis

BACKGROUND AND PURPOSE

The World Health Organization (WHO) states that good quality antenatal care should strive for both mother and child achieving their best possible health. On a policy level, in Europe these goals are reached with varying approaches. This research offers a fresh look on the underlying assumptions embedded in the ANC policies in three European countries.

METHODS

A framing analysis was conducted to publicly available ANC policies on uncomplicated pregnancies in Finland, England, and the Netherlands. Analysis was guided by van Hulst and Yanowa and included the following phases: a) Sense-making, b) Selecting, naming, and categorizing and c) Storytelling.

MAIN FINDINGS

Findings of this study demonstrate how ANC is organized with distinct frames. The Finnish ANC policies emphasized equity in care and instead of focusing on women, the ANC focused on the family. In England the pregnant woman was central, and it is seen as her responsibility to understand the ANC protocols. The ANC in the Netherlands focused on the pregnant woman's pregnancy experience and freedom.

CONCLUSION

The three studied countries had individual priorities and values guiding ANC provision. Despite each country being in line with the WHO ANC recommendations, areas requiring improvement should not be overlooked.

A systematic review of behaviour change interventions to improve maternal health outcomes in sub-Saharan Africa

The rate of decline in the global burden of avoidable maternal deaths has stagnated and remains an issue of concern in many sub-Saharan Africa countries. As per the most recent evidence, an average maternal mortality ratio (MMR) of 223 deaths per 100,000 live births has been estimated globally, with sub-Saharan Africa's average MMR at 536 per 100,000 live births-more than twice the global average. Despite the high MMR, there is variation in MMR between and within sub-Saharan Africa countries. Differences in the behaviour of those accessing and/or delivering maternal healthcare may explain variations in outcomes and provide a basis for quality improvement in health systems. There is a gap in describing the landscape of interventions aimed at modifying the behaviours of those accessing and delivering maternal healthcare for improving maternal health outcomes in sub-Saharan Africa. Our objective was to extract and synthesise the target behaviours, component behaviour change strategies and outcomes of behaviour change interventions for improving maternal health outcomes in sub-Saharan Africa. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Our protocol was published a priori on PROSPERO (registration number CRD42022315130). We searched ten electronic databases (PsycINFO, Cochrane Database of Systematic Reviews, International Bibliography of Social Sciences, EMBASE, MEDLINE, Scopus, CINAHL PLUS, African Index Medicus, African Journals Online, and Web of Science) and included randomised trials and quasi-experimental studies. We extracted target behaviours and specified the behavioural interventions using the Action, Actor, Context, Time, and Target (AACTT) framework. We categorised the behaviour change strategies using the intervention functions described in the Behaviour Change Wheel (BCW). We reviewed 52 articles (26 randomized trials and 26 quasi-experimental studies). They had a mixed risk of bias. Out of these, 41 studies (78.8%) targeted behaviour change of those accessing maternal healthcare services, while seven studies (13.5%) focused on those delivering maternal healthcare. Four studies (7.7%) targeted mixed stakeholder groups. The studies employed a range of behaviour change strategies, including education 37 (33.3%), persuasion 20 (18%), training 19 (17.1%), enablement 16 (14.4%), environmental restructuring 8 (7.2%), modelling 6 (5.4%) and incentivisation 5 (4.5%). No studies used restriction or coercion strategies. Education was the most common strategy for changing the behaviour of those accessing maternal healthcare, while training was the most common strategy in studies targeting the behaviour of those delivering maternal healthcare. Of the 52 studies, 40 reported effective interventions, 7 were ineffective, and 5 were equivocal. A meta-analysis was not feasible due to methodological and clinical heterogeneity across the studies. In conclusion, there is evidence of effective behaviour change interventions targeted at those accessing and/or delivering maternal healthcare in sub-Saharan Africa. However, more focus should be placed on behaviour change by those delivering maternal healthcare within the health facilities to fast-track the reduction of the huge burden of avoidable maternal deaths in sub-Saharan Africa.

Compliance towards WHO recommendations on antenatal care for a positive pregnancy experience: Timeliness and adequacy of antenatal care visit in Sub-Saharan African countries: Evidence from the most recent standard Demographic Health Survey data

BACKGROUND

Timely and adequate antenatal care (ANC) visits are known to reduce maternal mortality by 20%. Despite the World Health Organization updating its recommendations from four to eight antenatal care contacts, data reporting in the SSA region focused primarily on four visits, and evidence on the timing and adequacy of ANC based on the current recommendation was limited. Hence, this study aimed at assessing the level of timely and adequate ANC visits and their determinants in the 18 Sub-Saharan African countries with the most recent DHS report (2016-2021).

METHODS

The data for this study were pooled from the most recent standardized Demographic and Health Survey data of sub-Saharan African countries from 2016-2021. A total of 171,183 (with a weighted frequency of 171,488) women were included and analyzed by using STATA version 16. To account for data clustering, a multivariable multilevel mixed-effect logistic regression analysis was run to determine the effects of each predictor on the receipt of timely and adequate ANC. Adjusted odds ratio with its corresponding 95% confidence interval was used to declare the statistical significance of the independent variables.

RESULTS

The receipt of timely and adequate antenatal care visits was 41.2% (95% CI: 40.9, 41.4) and 10.4% (95% CI: 9.9, 10.2), respectively. Wontedness of pregnancy [AOR = 1.18; 95% CI: 1.13, 1.24], being 1st birth order [AOR = 1.48; 95% CI: 1.41, 2.54], having a mobile phone [AOR = 1.49; 95% CI: 1.26, 2.32], and enrolled in Health insurance schemes [AOR = 2.03; 95% CI: 1.95, 2.42] were significantly associated with early initiation of ANC. Living in a lower community poverty level[AOR = 2.23; 95% CI: 1.90,2.66], being in the richest wealth quintile [AOR = 1.49; 95% CI: 1.36, 1.62], higher educational level [AOR = 3.63; 95% CI: 3.33, 3.96], the timing of ANC visit [AOR = 4.26; 95% CI: 4.08, 4.44], being autonomous in decision making [AOR = 2.29; 95% CI: 1.83, 2.54] and having a mobile phone [AOR = 1.89; 95% CI: 1.76, 2.52] were identified as significant predictors of adequate ANC uptake.

CONCLUSION

The findings revealed a low coverage of timely and adequate ANC visits in SSA countries. Governments and healthcare managers in sub-Saharan African countries should leverage their efforts to prioritize and implement activities and interventions that increase women's autonomy, and economic capability, to improve their health-seeking behavior during pregnancy. More commitment is needed from governments to increase mobile phone distribution across countries, and then work on integrating mHealth into their health system. Finally, efforts should be made to increase the coverage of health insurance schemes enrolment for the citizens.

Antenatal care of women who use opioids: a qualitative study of practitioners' perceptions of strengths and challenges of current service provision in Scotland

BACKGROUND

The increasing rise of women using opioids during pregnancy across the world has warranted concern over the access and quality of antenatal care received by this group. Scotland has particularly high levels of opioid use, and correspondingly, pregnancies involving women who use opioids. The purpose of this study was to investigate the different models of antenatal care for women using opioids during pregnancy in three Scottish Health Board Areas, and to explore multi-disciplinary practitioners' perceptions of the strengths and challenges of working with women who use opioids through these specialist services.

METHODS

Thirteen semi-structured interviews were conducted with health and social care workers who had experience of providing antenatal and postnatal care to women who use drugs across three Scottish Health Board Areas: NHS Greater Glasgow and Clyde, NHS Lothian, and NHS Tayside. Framework Analysis was used to analyse interview data. The five stages of framework analysis were undertaken: familiarisation, identifying the thematic framework, indexing, charting, and mapping and interpretation.

RESULTS

Each area had a specialist antenatal pathway for women who used substances. Pathways varied, with some consisting of specialist midwives, and others comprising a multidisciplinary team (e.g. midwife, mental health nurse, social workers, and an obstetrician). Referral criteria for the specialist service differed between health board areas. These specialised pathways presented several key strengths: continuity of care with one midwife and a strong patient-practitioner relationship; increased number of appointments, support and scans; and highly specialised healthcare professionals with experience of working with substance use. In spite of this, there were a number of limitations to these pathways: a lack of additional psychological support for the mother; some staff not having the skills to engage with the complexity of patients who use substances; and problems with patient engagement.

CONCLUSIONS

Across the three areas, there appears to be high-quality multi-disciplinary antenatal services for women who use opioids during pregnancy. However, referral criteria vary and some services appear more comprehensive than others. Further research is needed into the perceptions of women who use opioids on facilitators and barriers to antenatal care, and provision in rural regions of Scotland.

Caring for providers to improve patient experience (CPIPE): intervention development process

A growing body of research has documented disrespectful, abusive, and neglectful treatment of women in facilities during childbirth, as well as the drivers of such mistreatment. Yet, little research exists on effective interventions to improve Person-Centred Maternal Care (PCMC)-care that is respectful and responsive to individual women's preferences, needs, and values. We sought to extend knowledge on interventions to improve PCMC, with a focus on two factors - provider stress and implicit bias - that are driving poor PCMC and contributing to disparities in PCMC. In this paper we describe the process towards the development of the intervention. The intervention design was an iterative process informed by existing literature, behaviour change theory, formative research, and continuous feedback in consultation with key stakeholders. The intervention strategies were informed by the Social Cognitive Theory, Trauma Informed System framework, and the Ecological Perspective. This process resulted in the 'Caring for Providers to Improve Patient Experience (CPIPE)' intervention, which has 5 components: provider training, peer support, mentorship, embedded champions, and leadership engagement. The training includes didactic and interactive content on PCMC, stress, burnout, dealing with difficult situations, and bias, with some content integrated into emergency obstetric and neonatal care (EmONC) simulations to enable providers apply concepts in the context of managing an emergency. The other components create an enabling environment for ongoing individual behavior and facility culture change. The pilot study is being implemented in Migori County, Kenya. The CPIPE intervention is an innovative theory and evidence-based intervention that addresses key drivers of poor PCMC and centers the unique needs of vulnerable women as well as that of providers. This intervention will advance the evidence base for interventions to improve PCMC and has great potential to improve equity in PCMC and maternal and neonatal health.

Unlocking big data to understand health services usage and government funding during pregnancy and early childhood, evidence in Australia

BACKGROUND

Maternity care is a high-volume and high-cost area of health care, which entails various types of service use throughout the course of the pregnancy. Thus, the aim of this study was to explore the most common reasons and related costs of health services used by women and babies from pregnancy to 12-month postbirth.

METHODS

We used linked administrative data from one state of Australia, which contained all births in Queensland between 01/07/2017 and 30/06/2018. Descriptive analyses were used to identify the 10 most frequent reasons and related costs for accessing inpatient, outpatient, emergency department, and Medicare services. These are reported separately for women and babies in different periods.

RESULTS

We included 58,394 births in our data set. The results have highlighted that there was relatively uniform use of inpatient, outpatient, and Medicare services by women and babies, with the 10 most common services accounting for more than half of the total services accessed. However, the emergency department service use was more diverse. Medicare services accounted for the greatest volume (79.21%) of service events but only 10.21% of the overall funding, compared with inpatient services, which accounted for less volume (3.62%) but the highest amount of overall funding (75.19%).

CONCLUSION

Study findings provide empirical evidence about the full spectrum of services used by birthing families and their babies, and could assist health providers and managers to understand the services women and infants actually access during pregnancy, birth, and postbirth.

Perceptions and experiences of the prevention, detection, and management of postpartum haemorrhage: a qualitative evidence synthesis

BACKGROUND

Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent complications of PPH with timely and appropriate detection and management. However, implementing the best methods of PPH prevention, detection and management can be challenging, particularly in low- and middle-income countries.

OBJECTIVES

Our overall objective was to explore the perceptions and experiences of women, community members, lay health workers, and skilled healthcare providers who have experience with PPH or with preventing, detecting, and managing PPH, in community or health facility settings.

SEARCH METHODS

We searched MEDLINE, CINAHL, Scopus, and grey literature on 13 November 2022 with no language restrictions. We then performed reference checking and forward citation searching of the included studies.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored perceptions and experiences of PPH prevention, detection, and management among women, community members, traditional birth attendants, healthcare providers, and managers.

DATA COLLECTION AND ANALYSIS

We used three-stage maximum variation sampling to ensure diversity in terms of relevance of the study to the review objectives, richness of data, and coverage of critical contextual elements: setting (region, country income level), perspective (type of participant), and topic (prevention, detection, management). We extracted data using a data extraction form designed for this review. We used thematic synthesis to analyse and synthesise the evidence, and we used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. To identify factors that may influence intervention implementation, we mapped each review finding to the Theoretical Domains Framework (TDF) and the Capability, Motivation, and Opportunity model of Behaviour change (COM-B). We used the Behaviour Change Wheel to explore implications for practice.

MAIN RESULTS

We included 67 studies and sampled 43 studies for our analysis. Most were from low- or middle-income countries (33 studies), and most included the perspectives of women and health workers. We downgraded our confidence in several findings from high confidence to moderate, low, or very-low confidence, mainly due to concerns about how the studies were conducted (methodological limitations) or concerns about missing important perspectives from some types of participants or in some settings (relevance). In many communities, bleeding during and after childbirth is considered "normal" and necessary to expel "impurities" and restore and cleanse the woman's body after pregnancy and birth (moderate confidence). In some communities, people have misconceptions about causes of PPH or believe that PPH is caused by supernatural powers or evil spirits that punish women for ignoring or disobeying social rules or for past mistakes (high confidence). For women who give birth at home or in the community, female family members or traditional birth attendants are the first to recognise excess bleeding after birth (high confidence). Family members typically take the decision of whether and when to seek care if PPH is suspected, and these family members are often influenced by trusted traditional birth attendants or community midwives (high confidence). If PPH is identified for women birthing at home or in the community, decision-making about the subsequent referral and care pathway can be multifaceted and complex (high confidence). First responders to PPH are not always skilled or trained healthcare providers (high confidence). In health facilities, midwives may consider it easy to implement visual estimation of blood loss with a kidney dish or under-pad, but difficult to accurately interpret the amount of blood loss (very low confidence). Quantifying (rather than estimating) blood loss may be a complex and contentious change of practice for health workers (low confidence). Women who gave birth in health facilities and experienced PPH described it as painful, embarrassing, and traumatic. Partners or other family members also found the experience stressful. While some women were dissatisfied with their level of involvement in decision-making for PPH management, others felt health workers were best placed to make decisions (moderate confidence). Inconsistent availability of resources (drugs, medical supplies, blood) causes delays in the timely management of PPH (high confidence). There is limited availability of misoprostol in the community owing to stockouts, poor supply systems, and the difficulty of navigating misoprostol procurement for community health workers (moderate confidence). Health workers described working on the maternity ward as stressful and intense due to short staffing, long shifts, and the unpredictability of emergencies. Exhausted and overwhelmed staff may be unable to appropriately monitor all women, particularly when multiple women are giving birth simultaneously or on the floor of the health facility; this could lead to delays in detecting PPH (moderate confidence). Inadequate staffing, high turnover of skilled health workers, and appointment of lower-level cadres of health workers are key challenges to the provision of quality PPH care (high confidence). Through team-based simulation training, health workers of different cadres (doctors, midwives, lay health workers) can develop a shared mental model to help them work quickly, efficiently, and amicably as a team when managing women with PPH (moderate confidence).

AUTHORS' CONCLUSIONS

Our findings highlight how improving PPH prevention, detection, and management is underpinned by a complex system of interacting roles and behaviours (community, women, health workers of different types and with different experiences). Multiple individual, sociocultural, and environmental factors influence the decisions and behaviours of women, families, communities, health workers, and managers. It is crucial to consider the broader health and social systems when designing and implementing PPH interventions to change or influence these behaviours. We have developed a set of prompts that may help programme managers, policymakers, researchers, and other key stakeholders to identify and address factors that affect implementation and scale-up of interventions to improve PPH prevention, detection, and management.

Evaluating equity across the continuum of care for maternal health services: analysis of national health surveys from 25 sub-Saharan African countries

BACKGROUND

Ensuring access to the continuum of care for maternal, neonatal, and child health is an effective strategy for reducing maternal and child mortality. We investigated the extent of dropout, wealth-related inequalities, and drivers of inequality in the continuum of care for maternal health services in sub-Saharan Africa.

METHODS

We analysed Demographic and Health Surveys (DHS) conducted between 2013 and 2019 across 25 sub-Saharan African countries. We defined the continuum of care for maternal health services as women who had received at least four ANC contacts (ANC 4 + contacts), skilled care at birth, and immediate postnatal care (PNC). We used concentration index to estimate wealth-related inequalities across the continuum of care. Multilevel logistic regression models were used to identify predictors of inequality in completing the continuum of care.

RESULTS

We included data on 196,717 women with the most recent live birth. About 87% of women reported having at least one ANC contact, but only 30% of women received the recommended care package that includes ANC 4 + contacts, skilled care at birth, and PNC. The proportion of women who had completed the continuum of care ranged from 6.5% in Chad to 69.5% in Sierra Leone. Nearly 9% of women reported not having contact with the health system during pregnancy or childbirth; this ranged from 0.1% in Burundi to 34% in Chad. Disadvantaged women were more likely to have no contact with health systems and less likely to have the recommended care package than women from wealthier households. Women with higher education levels, higher exposure to mass media (radio and TV), and higher household wealth status had higher odds of completing the continuum of care.

CONCLUSIONS

Persistent and increasing inequalities were observed along the continuum of care from pregnancy to the postnatal period, with socioeconomically disadvantaged women more likely to drop out of care. Improving access to and integration of services is required to improve maternal health. Initiatives and efforts to improve maternal health should prioritise and address the needs of communities and groups with low coverage of maternal health services.

A qualitative study of infection prevention and control practices in the maternal units of two Ghanaian hospitals

INTRODUCTION

Healthcare-associated infections (HAIs) remain a common challenge in healthcare delivery, with a significant burden in low- and middle-income countries. Preventing HAIs has gained enormous attention from policy makers and healthcare managers and providers, especially in resource-limited settings. Despite policies to enforce infection prevention and control (IPC) measures to prevent HAIs, IPC compliance remains a challenge in hospital settings. In this study, we explore the experiences of healthcare providers and women in the post-natal phase and investigate factors influencing IPC practices in two hospitals in Ghana.

METHODS

The study used a qualitative approach involving semi-structured interviews, focus group discussions, and observations among healthcare providers and women in the postnatal phase in two maternity units from January 2019 to June 2019. Interviews were recorded and transcribed verbatim for thematic analysis. The data sets were uploaded into the qualitative software NVivo 12 to facilitate coding and analysis.

FINDINGS

Healthcare providers were driven by the responsibility to provide medical care for their patients and at the same time, protect themselves from infections. IPC facilitators include leadership commitment and support, IPC training and education. Women were informed about IPC in educational talks during antenatal care visits, and their practices were also shaped by their background and their communities. IPC barriers include the poor documentation or 'invisibility' of HAIs, low prioritization of IPC tasks, lack of clear IPC goals and resources, discretionary use of guidelines, and communication-related challenges. The findings demonstrate the need for relevant power holders to position themselves as key drivers of IPC and develop clear goals for IPC. Hospital managers need to take up the responsibility of providing the needed resources and leadership support to facilitate IPC. Patient engagement should be more strategic both within the hospital and at the community level.

Individual interactions in a multi-country implementation-focused quality of care network for maternal, newborn and child health: A social network analysis

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) was established to build a cross-country platform for joint-learning around quality improvement implementation approaches to reduce mortality. This paper describes and explores the structure of the QCN in four countries and at global level. Using Social Network Analysis (SNA), this cross-sectional study maps the QCN networks at global level and in four countries (Bangladesh, Ethiopia, Malawi and Uganda) and assesses the interactions among actors involved. A pre-tested closed-ended structured questionnaire was completed by 303 key actors in early 2022 following purposeful and snowballing sampling. Data were entered into an online survey tool, and exported into Microsoft Excel for data management and analysis. This study received ethical approval as part of a broader evaluation. The SNA identified 566 actors across the four countries and at global level. Bangladesh, Malawi and Uganda had multiple-hub networks signifying multiple clusters of actors reflecting facility or district networks, whereas the network in Ethiopia and at global level had more centralized networks. There were some common features across the country networks, such as low overall density of the network, engagement of actors at all levels of the system, membership of related committees identified as the primary role of actors, and interactions spanning all types (learning, action and information sharing). The most connected actors were facility level actors in all countries except Ethiopia, which had mostly national level actors. The results reveal the uniqueness and complexity of each network assessed in the evaluation. They also affirm the broader qualitative evaluation assessing the nature of these networks, including composition and leadership. Gaps in communication between members of the network and limited interactions of actors between countries and with global level actors signal opportunities to strengthen QCN.

Evaluation of woman-centred care status by Iranian midwives and providing strategies to improve women-centred care: A sequential explanatory mixed method study protocol

AIM

The present study aimed to evaluate the status of WCC provided by Iranian midwives.

DESIGN

A sequential explanatory mixed method study protocol.

METHODS

The present study was conducted in three phases: quantitative, qualitative and mixed. The first phase is a cross-sectional study that will be performed on midwives working in health centres, public and private hospitals in Iranian. The second phase is a qualitative study, in which purposeful sampling will be used, meaning that the midwives who are part of the extreme cases according to the results of quantitative phase and are willing and able to express their own experiences regarding WCC will be selected. Also, pregnant and parturient women under their cover will also be interviewed. Finally, in the mixed phase, we will use a combination of two quantitative and qualitative studies, a literature review and expert opinion using a Delphi method to provide strategies to improve and promote WCC in midwives.

RESULTS

Achieving this goal is expected to provide positive outcomes such as strengthening the midwives professional relationship with women and reducing health care costs. No Patient or Public Contribution.

Midwife Educators' perceptions of the efficacy of the Objective Structured clinical assessment of life-saving interventions - a qualitative interview study in Bangladesh

INTRODUCTION

Objective Structured Clinical Assessment (OSCA) is a way of evaluating students or clinicians in how they are carrying out their duties. The aim of this study was to examine how midwifery educators in Bangladesh perceived using OSCA as an assessment device in midwifery education for student performance in life-saving midwifery interventions.

METHOD

Individual interviews were conducted with 47 academic midwives and clinical midwives using purposive sampling at 38 education institutions in Bangladesh. Content analysis inspired by Elo and Kyngas was used to analyze the data.

RESULTS

The ability of students to perform effectively in the OSCA-evaluated simulation of life-saving skills was related to the educators' understanding of the concept of midwifery. The overarching main category of this study showed that for midwifery educators to be able to effectually teach professional, evidence-based midwifery, they need to be able to synthesize the delivery of practical and theoretical skills with pedagogical skills and knowledge. To implement the OSCA tool more effectively, midwifery educators need to understand the underpinning principles of midwifery values and philosophy including leadership, ownership, responsibility, and personal engagement.

CONCLUSION

There is potential to improve the efficacy of using OSCA to deliver the teaching of life-saving skills. Team sessions with midwives and physicians aiming to practice teamwork and role divisions in life-saving interventions are recommended.

Predictors of childbirth experience: Prospective observational study in eastern Spain

BACKGROUND

In recent years, birth experience has been highlighted by national and international organisations as a relevant value in measuring maternal health care quality. According to a standardised tool, we aimed to assess which clinical indicators had the most significant influence on the birth experience.

METHODS

This prospective observational study was carried out in fourteen hospitals in eastern Spain. 749 women consented to the collection of birth variables at discharge, and subsequently, at 1-4 months, data were collected on the birth experience as measured by the Spanish version of the Childbirth Experience Questionnaire. Next, a linear regression analysis was performed to determine which clinical birth indicators greatly influence the birth experience measure.

RESULT

The study sample (n = 749) was predominantly Spanish and primipara, with 19.5% vaginal births. The predictors that emerged in the linear regression model were to have a birth companion (B = 0.250, p = 0.028), drink fluids during labour (B = 0.249, p < 0.001), have early skin-to-skin contact (B = 0.213, p < 0.001) and being transferred to a specialised room for the second stage of labour (B = 0.098, p = 0.016). The episiotomy (B = -0.100, p < 0.015) and having an operative birth (B = -0.128, p < 0.008) showed a negative influence.

CONCLUSION

Our study supports that intrapartum interventions recommended according to clinical practice guidelines positively influence the mother's birth experience. Episiotomy and operative birth should not be used routinely as they negatively influence the birth experience.

Socio-demographic and antenatal care-related factors associated with early post-partum family planning use in Ethiopia: evidence from Ethiopian Demographic and Health Survey 2016 data

Introduction

Initiation of family planning in the early post-partum period is a strategic move to reduce maternal, neonatal, and child mortality due to the negative consequences of short interbirth interval and the complications of unintended pregnancy. Antenatal care (ANC) is the noteworthy predictor of scaling up early initiation of post-partum family planning (PPFP) and preventing unintended pregnancy before menses resume. Despite the great role of ANC, information is scant about the effect of content, timing, and the number of ANC visits on the early initiation of PPFP in Ethiopia.

Objective

This study aimed to assess the association of ANC services with the early initiation of PPFP in Ethiopia.

Methods

The study was based on Ethiopian Demographic and Health Survey 2016 data, which was a cross-sectional survey from 18 January 2016 to 27 June 2016. A total weighted sample size of 2,920 post-partum women was included. A multilevel logistic regression model was used because of the hierarchical data, and variables with a p-value of ≤0.2 in the bivariable multilevel analysis were taken to multivariable multilevel analysis. An adjusted odds ratio with a 95% confidence interval (CI) was used to declare both the direction and strength of the association, and variables with a p-value of <0.05 were considered as statistically significant for the outcome variable.

Results

The early initiation of PPFP was 20.4%. Women with at least four ANC visits [adjusted odds ratio (AOR) = 1.31; CI 1.12-2.32], women who started ANC within the first trimester (AOR = 1.25; CI 1.10-2.23), complete routine ANC (AOR = 1.11; CI 1.01-2.03), post-natal care (AOR = 1.45; CI 1.19-1.87), resumption of menses (AOR = 1.67; CI 1.18-1.93), urban residency (AOR = 2.14; CI 1.18-2.51), and high community women's education (AOR = 1.71; CI 1.51-2.11) were variables significantly associated with the early initiation of PPFP.

Conclusion

The early initiation of PPFP in Ethiopia was very low. Attention needs to be given to the quality of ANC, post-natal care, resumption of menses, residency, and community-level education of women to increase the prevalence of the early initiation of PPFP in Ethiopia. Therefore, the government should design a program targeting the quality of ANC in rural communities, considering women without menses and scaling up the education of women at the community level to the culture of the early initiation of PPFP in order to achieve reduced maternal, neonatal, and child mortality.

Research prioritisation on prevention and management of preterm birth in low and middle-income countries (LMICs) with a special focus on Bangladesh using the Child Health and Nutrition Research Initiative (CHNRI) method

Background

Fifteen million babies are born preterm globally each year, with 81% occurring in low- and middle-income countries (LMICs). Preterm birth complications are the leading cause of newborn deaths and significantly impact health, quality of life, and costs of health services. Improving outcomes for newborns and their families requires prioritising research for developing practical, scalable solutions, especially in low-resource settings such as Bangladesh. We aimed to identify research priorities related to preventing and managing preterm birth in LMICs for 2021-2030, with a special focus on Bangladesh.

Methods

We adopted the Child Health and Nutrition Research Initiative (CHNRI) method to set research priorities for preventing and managing preterm birth. Seventy-six experts submitted 490 research questions online, which we collated into 95 unique questions and sent for scoring to all experts. A hundred and nine experts scored the questions using five pre-selected criteria: answerability, effectiveness, deliverability, maximum potential for burden reduction, and effect on equity. We calculated weighted and unweighted research priority scores and average expert agreement to generate a list of top-ranked research questions for LMICs and Bangladesh.

Results

Health systems and policy research dominated the top 20 identified priorities for LMICs, such as understanding and improving uptake of the facility and community-based Kangaroo Mother Care (KMC), promoting breastfeeding, improving referral and transport networks, evaluating the impact of the use of skilled attendants, quality improvement activities, and exploring barriers to antenatal steroid use. Several of the top 20 questions also focused on screening high-risk women or the general population of women, understanding the causes of preterm birth, or managing preterm babies with illnesses (jaundice, sepsis and retinopathy of prematurity). There was a high overlap between research priorities in LMICs and Bangladesh.

Conclusions

This exercise, aimed at identifying priorities for preterm birth prevention and management research in LMICs, especially in Bangladesh, found research on improving the care of preterm babies to be more important in reducing the burden of preterm birth and accelerating the attainment of Sustainable Development Goal 3 target of newborn deaths, by 2030.

Spatial distribution, and predictors of late initiation of first antenatal care visit in Ethiopia: Spatial and multilevel analysis

BACKGROUND

Despite the proven benefit of early initiation of first antenatal care visits as a means to achieve good maternal and neonatal health outcomes through early detection and prevention of risks during pregnancy, shreds of evidence showed that most of the women in Ethiopia start their ANC visits lately.

OBJECTIVE

To determine the spatial distribution and predictors of late initiation of first antenatal care visits among reproductive-age women in Ethiopia.

METHOD

The 2019 Ethiopian Mini Demographic and Health Survey (EMDHS) data were used. A total weighted sample of 2,935 reproductive-age women who gave birth in the five years preceding the survey and who had antenatal care visits for their last child was included. To check the nature of the distribution of late initiation of ANC visits, the global Moran's I statistics were applied. Gettis-OrdGi statistics and spatial interpolation using the Ordinary Kriging method were done to identify the spatial locations and to predict unknown locations of late initiation of first ANC visits, respectively. For the predictors, a multilevel mixed-effect logistic regression model was applied. Finally, statistical significance was declared at a p-value < 0.05.

RESULTS

The prevalence of late initiation of first ANC visits in Ethiopia was 62.6%. The spatial analysis showed that the late initiation of first ANC visits significantly varied across regions of Ethiopia. The spatial interpolation predicted the highest rates of late initiation of first ANC visits in the eastern SNNPRs, southern and western Oromia, and some parts of the Somalia region. Being rural residents, attending higher education, having medium wealth status, richer wealth status, richest wealth status, having ≥ 5 family size, a household headed by male, living in SNNPRs, and Oromia regions were significant predictors of late initiation of first ANC visits.

CONCLUSION

A clustered pattern of areas with high rates of late initiation of the first ANC visit was detected in Ethiopia. Public health intervention targeting the identified hotspot areas, and women's empowerment would decrease the late start of the first ANC visit. Furthermore, the identified predictors should be underscored when designing new policies and strategies.

Implementation research priorities for addressing the maternal health crisis in the USA: results from a modified Delphi study among researchers

BACKGROUND

Maternal health outcomes in the USA are far worse than in peer nations. Increasing implementation research in maternity care is critical to addressing quality gaps and unwarranted variations in care. Implementation research priorities have not yet been defined or well represented in the plans for maternal health research investments in the USA.

METHODS

This descriptive study used a modified Delphi method to solicit and rank research priorities at the intersection of implementation science and maternal health through two sequential web-based surveys. A purposeful, yet broad sample of researchers with relevant subject matter knowledge was identified through searches of published articles and grant databases. The surveys addressed five implementation research areas in maternal health: (1) practices to prioritize for broader implementation, (2) practices to prioritize for de-implementation, (3) research questions about implementation determinants, (4) research questions about implementation strategies, and (5) research questions about methods/measures.

RESULTS

Of 160 eligible researchers, 82 (51.2%) agreed to participate. Participants were predominantly female (90%) and White (75%). Sixty completed at least one of two surveys. The practices that participants prioritized for broader implementation were improved postpartum care, perinatal and postpartum mood disorder screening and management, and standardized management of hypertensive disorders of pregnancy. For de-implementation, practices believed to be most impactful if removed from or reduced in maternity care were cesarean delivery for low-risk patients and routine discontinuation of all psychiatric medications during pregnancy. The top methodological priorities of participants were improving the extent to which implementation science frameworks and measures address equity and developing approaches for involving patients in implementation research.

CONCLUSIONS

Through a web-based Delphi exercise, we identified implementation research priorities that researchers consider to have the greatest potential to improve the quality of maternity care in the USA. This study also demonstrates the feasibility of using modified Delphi approaches to engage researchers in setting implementation research priorities within a clinical area.

Women's utilisation of quality antenatal care, intrapartum care and postnatal care services in Ethiopia: a population-based study using the demographic and health survey data

OBJECTIVE

This study sought to investigate the level and determinants of receiving quality antenatal care (ANC), intrapartum care, and postnatal care (PNC) services by women in Ethiopia. The quality of care a woman receives during ANC, intrapartum care, and PNC services affects the health of the woman and her child and her likelihood of seeking care in the future.

METHODS

Data from the nationally representative Ethiopia Mini Demographic and Health Survey 2019 were analysed for 5,527 mothers who gave birth within five years preceding the survey. We defined quality ANC as having: blood pressure measurement, urine and blood tests, informed of danger signs, iron supplementation, and nutritional counselling during ANC services; quality intrapartum care as having: a health facility birth, skilled birth assistance, and a newborn put to the breast within one hour of birth during intrapartum care services; and quality PNC as having: PNC within two days; cord examination; temperature measurement, and counselling on danger signs and breastfeeding of the newborn; and healthcare provider's observation of breastfeeding during PNC services. We used multilevel mixed-effects logistic regression analyses specifying three-level models: a woman/household, a cluster, and an administrative region to determine predictors of each care quality. The analyses employed sampling weights and were adjusted for sampling design.

RESULTS

Thirty-six percent (n = 1,048), 43% (n = 1,485), and 21% (n = 374) women received quality ANC, intrapartum care and PNC services, respectively. Private healthcare facilities provided higher-quality ANC and PNC but poor-quality intrapartum care, compared to public health facilities. Having four or more ANC visits, commencing ANC during the first trimester, and higher women's education levels and household wealth indices were positive predictors of quality ANC use. Government health posts were less likely to provide quality ANC. Wealthier, urban-residing women with education and four or more ANC contacts were more likely to receive quality intrapartum care. Women who received quality ANC and skilled birth assistance were more likely to receive quality PNC. Teenage mothers were more likely to receive quality intrapartum care, but were less likely to receive quality PNC than mothers aged 20-49.

CONCLUSIONS

We recommend standardizing the contents of ANC provided in all healthcare facilities; and promoting early and four or more ANC contacts, effectiveness, sensitivity and vigilance of care provided to teenage mothers, and women's education and economic empowerment.

Association between the person-centered maternity care experience and mental health after delivery in urban and rural Dhading, Nepal: a cross-sectional study

BACKGROUND

Person-centered maternity care is a component of quality care, which includes effective communication, respect, and dignity. Supportive care has a positive effect on mothers' perinatal experience. In contrast, negative childbirth experiences can cause psychological problems. However, the impact of person-centered maternity care experience on mothers' mental health after delivery remains unknown. Therefore, in this study, we examined the association between person-centered maternity care experience at healthcare facilities and maternal mental health after delivery among Nepali women.

METHODS

We conducted a cross-sectional study in urban and rural areas in Dhading District, Nepal. Participants were women who gave birth at public healthcare facilities, and their baby's age was between 1 and 12 months. After purposively selecting the target areas, we recruited the women from July to August 2019 and interviewed them using questionnaires. We conducted multiple regression analyses to analyze the association between delivery care experience and depressive symptoms and the association between delivery care experience and mental well-being.

RESULTS

In total, 595 women were included in the data analysis. The experience of better person-centered maternity care was associated with lower depressive symptom scores in urban (unstandardized coefficient [B]= - 0.09, p < 0.001) and rural areas (B= - 0.10, p < 0.001). Moreover, the experience of better person-centered maternity care was associated with higher mental well-being scores in both urban (B= 0.30, p < 0.001) and rural areas (B= 0.15, p = 0.017).

CONCLUSIONS

Person-centered maternity care was associated with lower depressive symptom scores and higher mental well-being, regardless of the setting in Nepal. Person-centered maternity care during childbirth can potentially improve mental health after delivery. Maternity care should be improved with more attention to person-centered maternity care aspects.

Mental health penalties of having a child: findings from the China family panel studies

In recent years, the birth rate in China has rapidly declined. While much research has been done on the penalties in earnings that women incur when they fall behind men in the labor market due to childbirth, there has been little to no research on the mental health effects. This study addresses the gap in current literature by examining the mental health penalties that women experience after having a child in comparison to men. We applied econometric modeling to data collected from China Family Panel Studies (CFPS) and found that women experienced a significant, immediate, and long-run decline (4.3%) in life satisfaction after their first child, while men were unaffected. We also found that women experienced a significant increase in depression after their first child. This suggests mental health penalties since the mental health risk proxied by these two measurements is only significant for women. This is likely related to child penalties in labor market performance and childbirth-related physical health issues. When countries adopt multiple tools to stimulate the birth rate for economic growth, they must consider the implicit burden on women-especially the long-term negative effects on mental health.

Perceived treatment of respectful maternity care among pregnant women at healthcare facilities in the Kingdom of Saudi Arabia: A cross-sectional study

BACKGROUND

Mistreatment of women during childbirth is a global issue and a violation of fundamental human rights. Respectful maternity care has been affirmed as a universal right of childbearing women. However, little is known about the level of respect experienced by women in the Kingdom of Saudi Arabia (KSA); which is undergoing key reforms in the scope of its healthcare provision. We explored the occurrence of respect perceived by women giving birth in the KSA and compared results between national healthcare sectors, as well as with previous international studies.

METHOD

We conducted a cross-sectional study using an online survey. The online questionnaire included demographic questions, a translation of the internationally validated Mother on Respect index (MORi) scale, which we adapted to investigate KSA women's experiences, and questions to further investigate women's experiences (e.g. respect of privacy). Women who gave birth within five years at a Saudi healthcare facility were recruited through social media using a snowballing approach.

RESULTS

Overall, 586 participants were recruited, 54% of whom had been cared for in government hospitals, 65% were aged between 25 and 34, and almost 79% had a BSc or higher qualification. Overall, women's perception about respectful maternity care was positive, however, opinions varied between governmental and private sectors. Women cared for in the government sector reported significantly lower levels of respect compared to those cared for in the private sector (β = -.132, p = .001). The results also highlighted an issue of concern: one in five women (21.8%) reported having been physically abused. Our participants perceived their childbirth experiences to be less respectful compared to those in other high-income countries.

CONCLUSION

Women birthing in the private sector reported a more respectful experience, which may be explained by the private sector being more consumer-focused. Women who gave birth in the KSA perceived their care to be less respectful than women giving birth in Canada and the USA. Beginning to understand what has provoked the occurrences of mistreatment in childbirth worldwide will inevitably contribute to the development of a solution. Respectful maternity care should be focused on providing women-centred care and quality of care which meets the WHO vision for women's and their families' needs being fulfilled and respected.

'I believe respect means providing necessary treatment on time' - a qualitative study of health care providers' perspectives on disrespect and abuse during childbirth in Southwest Ethiopia

BACKGROUND

The majority of maternal deaths occur in low-income countries, and facility-based childbirth is recognised as a strategy to reduce maternal mortality. However, experiences of disrespect and abuse during childbirth are reported as deterrents to women's utilisation of health care facilities. Health care providers play a critical role in women's experiences during childbirth; yet, there is limited research on service providers' views of disrespect and abuse in Ethiopia. Therefore, this study aimed to explore providers' perspectives on disrespect and abuse during childbirth in a teaching hospital in Southwest Ethiopia.

METHOD

Qualitative study was conducted in a tertiary teaching hospital in Jimma Ethiopia. In-depth interviews were conducted with 32 purposefully selected health care providers, including midwives, obstetrics and genecology resident's, senior obstetricians and nurses. Interviews were audio-recorded, transcribed and thematically analysed using the qualitative data analysis software program MAXQDA.

RESULTS

Three major themes were identified from the health care providers' perspectives: (1) respectful and abuse-free care, (2) recognised disrespect and abuse; and (3) drivers of women's feelings of disrespect and abuse. The first theme indicates that most of the participants perceived that women were treated with respect and had not experienced abuse during childbirth. The second theme showed that a minority of the participants recognised that women experienced disrespect and abuse during childbirth. The third theme covered situations in which providers thought that drivers for women felt disrespected.

CONCLUSION

Most providers perceived women's experiences as respectful, and they normalized, and rationalized disrespect and abuse. The effect of teaching environment, the scarcity of resources has been reported as a driver for disrespect and abuse. To ensure respectful maternity care, a collaborative effort of administrators, teaching institutions, professional associations and researchers is needed. Such collaboration is essential to create a respectful teaching environment, ensure availability of resources, sustained in-service training for providers, and establishing an accountability mechanism for respectful maternity care.

Midwives' experiences with a safe childbirth checklist: A grounded theory study

OBJECTIVE

The aim of this study was to explore midwives' experiences with a safe childbirth checklist used in handover situations from birth to hospital discharge. Quality of care and patient safety is highly recognised and a priority within health services globally. In handover situations, checklists have proven to reduce unwanted variation by standardising processes, which in turn contribute to increased quality of care. To improve the quality of care, a safe childbirth checklist was implemented at a large maternity hospital in Norway.

DESIGN

We conducted a Glaserian grounded theory (GT) study.

SETTING AND PARTICIPANTS

A total of 16 midwives were included. We included three midwives in one focus group and conducted 13 individual interviews. Years of experience as midwives ranged from one to 30 years. All included midwives worked in a large maternity hospital in Norway.

FINDINGS

The main concern faced by the midwives who used the checklist included no common understanding of the purpose of the checklist nor consensus on how to use the checklist. The generated grounded theory, individualistic interpretation of the checklist, involved the following three strategies that all seemed to explain how the midwives solved their main concern: 1) not questioning the checklist, 2) constantly evaluating the checklist, and 3) distancing oneself from the checklist. Experiencing an unfortunate event concerning the healthcare of both mother or newborn was a condition that could alter the midwives understanding and use of the checklist.

KEY CONCLUSIONS

The findings in this study showed that a general lack of common understanding and consensus on the rationale for implementing a safe childbirth checklist led to variations between midwives in how and whether the checklist was used. The safe childbirth checklist was described as long and detailed. It was not necessarily the midwife who was expected to sign the checklist who had carried out the tasks signed for. To ensure patient safety, recommendations for future practice include securing that separate sections of a safe childbirth checklist are limited to a specific time-point and midwife.

IMPLICATIONS FOR PRACTICE

Findings emphasise the importance of implementation strategies supervised by the leaders of the healthcare services. Further research should explore the understanding of organisational and cultural context when implementing a safe childbirth checklist to clinical practice.

Factors in the Provision of High Quality Midwifery Care: A Qualitative Content Analysis

Introduction: In recent years, health care has faced many changes. Thereupon, it would be beneficial to investigate the quality of midwifery care and its related factors. Many factors contribute to the provision of quality care, and recognizing factors to ensure the quality of midwifery care. This qualitative study was conducted to explain the factors that affect the provision and quality of midwifery care. Methods: This qualitative study with content analysis approach was conducted between June 2017 and February 2018 on 15 midwives working in private and public maternity hospitals in the city of Qom. The participants were selected by purposeful sampling. Semi-structured and in-depth interviews were performed with open ended questions to find out how midwives describe high quality midwifery care. Data were analyzed by conventional content analysis method through MAXQDA-11 software. Results: The findings of this study revealed two main themes, including individual factors (personal efficiency, staffs' psychological status, value-centeredness, cultural-educational issues, and professional attachment), and professional-organizational factors (professional characteristics, patient characteristics, personal-professional welfare, professional empowerment system, value-centered culture of organization, and organizational monitoring and evaluation). Conclusion: The results of this study showed that individual and professional factors are associated with the quality of midwifery care. Midwives who participated in this study believed that providing high quality midwifery care requires a broad range of prerequisites. Since high quality midwifery care decreases maternal and infant mortality and morbidity, it is imperative for policymakers to pay attention to all the factors that contribute to the quality of midwifery care.

Quality intrapartum care expectations and experiences of women in sub-Saharan African Low and Low Middle-Income Countries: a qualitative meta-synthesis

BACKGROUND

Woman-centred maternity care is respectful and responsive to women's needs, values, and preferences. Women's views and expectations regarding the quality of health services during pregnancy and childbirth vary across settings. Despite the need for context-relevant evidence, to our knowledge, no reviews focus on what women in sub-Saharan African Low and Low Middle-Income Countries (LLMICs) regard as quality intrapartum care that can inform quality guidelines in countries.

METHODS

We undertook a qualitative meta-synthesis using a framework synthesis to identify the experiences and expectations of women in sub-Saharan African LLMICs with quality intrapartum care. Following a priori protocol, we searched eight databases for primary articles using keywords. We used Covidence to collate citations, remove duplicates, and screen articles using a priori set inclusion and exclusion criteria. Two authors independently screened first the title and abstracts, and the full texts of the papers. Using a data extraction excel sheet, we extracted first-order and second-order constructs relevant to review objectives. The WHO framework for a positive childbirth experience underpinned data analysis.

RESULTS

Of the 7197 identified citations, 30 articles were included in this review. Women's needs during the intrapartum period resonate with what women want globally, however, priorities regarding the components of quality care for women and the urgency to intervene differed in this context given the socio-cultural norms and available resources. Women received sub-quality intrapartum care and global standards for woman-centred care were often compromised. They were mistreated verbally and physically. Women experienced poor communication with their care providers and non-consensual care and were rarely involved in decisions concerning their care. Women were denied the companion of choice due to cultural and structural factors.

CONCLUSION

To improve care seeking and satisfaction with health services, woman-centred care is necessary for a positive childbirth experience. Women must be meaningfully engaged in the design of health services, accountability frameworks, and evaluation of maternal services. Research is needed to set minimum indicators for woman-centred outcomes for low-resource settings along with actionable strategies to enhance the quality of maternity care based on women's needs and preferences.

Determinants of early initiation of first antenatal care visit in Ethiopia based on the 2019 Ethiopia mini-demographic and health survey: A multilevel analysis

BACKGROUND

Early initiation of the first antenatal care visit provides a critical opportunity for health promotion, disease prevention, and curative care for women and their unborn fetuses. However, in developing countries, including Ethiopia, it is underutilized and most of the pregnant women didn't attend antenatal care visits during the first trimester (early). Therefore, the objective of this study was to estimate the prevalence of early initiation of antenatal care visits and its determinants among reproductive-age women in Ethiopia.

METHODS

A secondary data analysis was done based on the 2019 intermediate Ethiopian demographic health survey. The data were weighted by sampling weight for probability sampling and non-response to restore the representativeness of the data and have valid statistical estimates. Then, a total weighted sample of 2,935 women aged 15-49 years who gave birth in the five years preceding the survey and who had antenatal care visits for their last child was included. A multilevel mixed-effects logistic regression model was fitted to examine the determinants of early initiation of first antenatal care visits. Finally, statistical significance was declared at a p-value < 0.05.

RESULTS

In this study, the overall magnitude of early initiation of the first antenatal care visit was 37.4% (95%CI: 34.6-40.2%). Women who attend higher education (AOR = 2.26: 95%CI; 1.36-3.77), medium wealth status (AOR = 1.80: 95%CI; 1.17-2.76), richer wealth status (AOR = 1.86: 95%CI; 1.21, 2.85), richest wealth status (AOR = 2.34: 95%CI; 1.43-3.83), living in Harari region (AOR = 2.24: 95%CI; 1.16-4.30), and living at Dire-Dawa city (AOR = 2.24: 95%CI; 1.16-4.30) were higher odds of early initiation of first ANC visits. However, women who were rural resident (AOR = 0.70: 95%CI; 0.59-0.93), household headed by male (AOR = 0.87: 95%CI; 0.72, 0.97), having ≥ 5 family size (AOR = 0.71: 95%CI; 0.55-0.93), and living in SNNPRs (AOR = 0.44: 95%CI; 0.23-0.84) were lower odds of early initiation of first ANC visits.

CONCLUSION

The prevalence of early initiation of first antenatal care remains low in Ethiopia. Women's education, residence, wealth status, household head, having ≥ 5 family sizes, and region were determinants of early initiation of first antenatal care visits. Improving female education and women's empowerment through economic transitions with special attention given to rural and SNNPR regional state residents could maximize the early initiation of first antenatal care visits. Furthermore, to increase early antenatal care uptake, these determinants should be considered when designing new policies or updating policies and strategies on antenatal care uptake to help increase early attendance, which can help in the reduction of maternal and neonatal mortality and to achieve sustainable development goals 3 by 2030.

Levels and determinants of quality antenatal care in Bangladesh: Evidence from the Bangladesh Demographic and Health Survey

BACKGROUND

Assessing the quality of antenatal care (ANC) is imperative for improving care provisions during pregnancy to ensure the health of mother and baby. In Bangladesh, there is a dearth of research on ANC quality using nationally representative data to understand its levels and determinants. Thus, the current study aimed to assess ANC quality and identify the sociodemographic factors associated with the usage of quality ANC services in Bangladesh.

METHODS

Secondary data analysis was conducted using the last two Bangladesh Demographic and Health Surveys (BDHSs) from 2014 and 2017-18. A total of 8,277 ever-married women were included in the analysis (3,631 from 2014 and 4,646 from 2017-18). The quality ANC index was constructed using a principal component analysis on the following ANC components: weight and blood pressure measurements, blood and urine test results, counselling about pregnancy complications and completion of a minimum of four ANC visits, one of which was performed by a medically trained provider. Multinomial logistic regression was used to determine the strength of the association.

RESULTS

The percentage of mothers who received all components of quality ANC increased from about 13% in 2014 to 18% in 2017-18 (p < 0.001). Women from the poorest group, those in rural areas, with no education, a high birth order and no media exposure were less likely to receive high-quality ANC than those from the richest group, those from urban areas, with a higher level of education, a low birth order and media exposure, respectively.

CONCLUSION

Although the quality of ANC improved from 2014 to 2017-18, it remains poor in Bangladesh. Therefore, there is a need to develop targeted interventions for different socio-demographic groups to improve the overall quality of ANC. Future interventions should address both the demand and supply-side perspectives.

Prevalence and risk factors of sub-health and circadian rhythm disorder of cortisol, melatonin, and temperature among Chinese midwives

Objective

This study aimed to explore the influencing factors of sub-health and circadian rhythm disorder among midwives and whether circadian rhythm disorder was associated with sub-health.

Methods

A multi-center cross-sectional study was conducted among 91 Chinese midwives from six hospitals through cluster sampling. Data were collected by demographic questionnaire, Sub-Health Measurement Scale version 1.0, and circadian rhythm detection. Minnesota single and population mean cosine methods were used to analyze the rhythm of cortisol, melatonin, and temperature. Binary logistic regression, nomograph model, and forest plot were performed to identify variables associated with midwives' sub-health.

Results

There were 65 midwives with sub-health and 61, 78, and 48 midwives with non-validation of circadian rhythms of cortisol, melatonin, and temperature among 91 midwives, respectively. Midwives' sub-health was significantly related to age, duration of exercise, weekly working hours, job satisfaction, cortisol rhythm, and melatonin rhythm. Based on these six factors, the nomogram was presented with significant predictive performance for sub-health. Furthermore, cortisol rhythm was significantly associated with physical, mental, and social sub-health, whereas melatonin rhythm was significantly correlated with physical sub-health.

Conclusion

Sub-health and circadian rhythm disorder were generally common among midwives. Nurse administrators are supposed to pay attention and take measures to prevent sub-health and circadian rhythm disorder among midwives.

Understanding women's decision-making process for birth location in Tanzania based on individual women's reproductive pathways: a life-course perspective

Background

Determinants for women’s care seeking for birth in low-income setting are multifactorial and remain poorly understood. A life course approach can assist to structure the interplay of the different factors that lead to women seeking care or not.

Objective

In this study we aimed to explore individual women’s reproductive pathways, and increase understanding of how important life events including previous pregnancy and birth experiences can help us to understand individual choices made for care seeking during childbirth.

Methods

The study took place in Tanzania between 2015 and 2017. 14 women were followed throughout their pregnancy, birth and postpartum period through participant observation and in-depth interviews. In total 94 in-depth interviews were held (between 5–7 interviews per woman). Analysis occurred continuous throughout the data collection period resulting in detailed narratives of crucial events across women’s life course, with specific attention to their current pregnancy.

Results

Of the 14 women, seven had a facility birth, six a home birth and one woman gave birth at the home of a local birth attendant. Four different story plots were identified: expected home birth, expected facility birth, unexpected facility birth and unexpected home birth. Birth narratives of four women representative of the different story plots are presented. Narratives illustrate women’s individual reproductive pathways including the various factors influencing women’s expectations and justifications for their actions during their pregnancy and birth.

Conclusion

Women’s agency, including women’s perception of self, the self in relation to the social environment and reflection on risks associated with the range of options, influences the final decision made for birth. Women’s narratives suggest that quality of care can function as a primary pull factor for facility birth. As long as home birth is by some perceived to be a better alternative, achieving skilled care for all will be difficult to achieve.

Kidanto H, Wolf Meyrowitsch D. Scaling up context-tailored clinical guidelines and training to improve childbirth care in urban, low-resource maternity units in Tanzania: A protocol for a stepped-wedged cluster randomized trial with embedded qualitative and economic analyses (The PartoMa Scale-Up Study)

While facility births are increasing in many low-resource settings, quality of care often does not follow suit; maternal and perinatal mortality and morbidity remain unacceptably high. Therefore, realistic, context-tailored clinical support is crucially needed to assist birth attendants in resource-constrained realities to provide best possible evidence-based and respectful care. Our pilot study in Zanzibar suggested that co-created clinical practice guidelines (CPGs) and low-dose, high-frequency training (PartoMa intervention) were associated with improved childbirth care and survival. We now aim to modify, implement, and evaluate this multi-faceted intervention in five high-volume, urban maternity units in Dar es Salaam, Tanzania (approximately 60,000 births annually). This PartoMa Scale-up Study will include four main steps: I. Mixed-methods situational analysis exploring factors affecting care; II. Co-created contextual modifications to the pilot CPGs and training, based on step I; III. Implementation and evaluation of the modified intervention; IV. Development of a framework for co-creation of context-specific CPGs and training, of relevance in comparable fields. The implementation and evaluation design is a theory-based, stepped-wedged cluster-randomised trial with embedded qualitative and economic assessments. Women in active labour and their offspring will be followed until discharge to assess provided and experienced care, intra-hospital perinatal deaths, Apgar scores, and caesarean sections that could potentially be avoided. Birth attendants' perceptions, intervention use and possible associated learning will be analysed. Moreover, as further detailed in the accompanying article, a qualitative in-depth investigation will explore behavioural, biomedical, and structural elements that might interact with non-linear and multiplying effects to shape health providers' clinical practices. Finally, the incremental cost-effectiveness of co-creating and implementing the PartoMa intervention is calculated. Such real-world scale-up of context-tailored CPGs and training within an existing health system may enable a comprehensive understanding of how impact is achieved or not, and how it may be translated between contexts and sustained.Trial registration number: NCT04685668.

Gaps and opportunities for the integrated delivery of mother-child care, postpartum family planning and nutrition services in Burkina Faso, Côte d’Ivoire and Niger

Background

Maternal and infant deaths can be prevented through integrated service delivery during pregnancy, postpartum, and early childhood. Our study analyses the gaps and opportunities associated with integrating maternal, newborn, and child health (MNCH) services with postpartum family planning (PPFP) and nutrition services at different points of contact in health facilities in a preintervention context in west Africa.

Methods

We conducted a qualitative study from June to July 2018 in Burkina Faso, Côte d’Ivoire and Niger. The points of contact studied at the health facility level were the prenatal care, postpartum care and immunisation/growth monitoring services. Individual in-depth interviews were used to collect data from key informants (providers, community health workers and mother-child health programme managers). To measure the degree of service integration, we used the dimensions and indicators included in the Integra Initiative framework concerning four aspects of integration: physical (the availability of multiple services in the health facility), temporal (the availability of care more than one day per week), provider level, and functional (the receipt of integrated services by the client).

Results

The findings of this study show that the integrated delivery of MNCH, PPFP, and nutrition services is configured in similar ways in Burkina Faso, Côte d’Ivoire and Niger and is insufficient at all points of contact. Physical integration is high. However, the study found important gaps in temporal, functional and provider-level integration. The main barriers to integrated service delivery are the shortage of providers, the lack of training in integrated service delivery, and insufficient service organisation. However, the availability of multiple services throughout the week, the multiple points of contact between the mother-child pair and the health system, and the multiple skills of providers represent opportunities for functional integration through the establishment of a formal referral system between the different care units with follow-up and feedback among service providers.

Conclusions

The provision of training and the development of a well-organised referral system in different health facilities, taking into account the specific characteristics of each health facility (urban/rural, primary health facility/district hospital), can improve the delivery of integrated MNCH, PPFP, and nutrition care to the mother-child pair.

The prevalence of respectful maternity care during childbirth and its determinants in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Respectful maternity care is the provision of woman-centered health care during childbirth that is friendly, abuse-free, timely, and discrimination-free. Although several epidemiological studies on the magnitude and determinants of Respectful maternity care in Ethiopia have been conducted, the results have been inconsistent and varied. This makes drawing equivocal conclusions and evidence at the national level harder. Hence, this systematic review and meta-analysis aimed at estimating the pooled prevalence of respectful maternity care and its determinants in Ethiopia.

METHODS

Studies conducted from 2013 to June 30, 2022, were searched by using PubMed, Google Scholar, Science Direct, Scopus, ProQuest, Web of Science, Cochrane Library, and Direct of Open Access Journals. Searching was carried out from May 15- June 30, 2022. In total, sixteen studies were considered in the final analysis. The data were extracted using Microsoft Excel and analyzed using STATA 16 software. The methodological quality of included studies was assessed by using Joanna Briggs Institute's critical appraisal checklist for prevalence studies. To estimate the pooled national prevalence of respectful maternity care, a random effect model with a DerSimonian Laird method was used. To assess the heterogeneity of the included studies, the Cochrane Q test statistics and I2 tests were used. To detect the presence of publication bias, a funnel plot and Begg's and Egger's tests were used.

RESULTS

Sixteen studies were eligible for this systematic review and meta-analysis with a total of 6354 study participants. The overall pooled prevalence of respectful maternity care in Ethiopia was 48.44% (95% CI: 39.02-57.87). Receiving service by CRC-trained health care providers [AOR: 4.09, 95% CI: 1.73, 6.44], having ANC visits [AOR: 2.34, 95% CI: 1.62, 3.06], planning status of the pregnancy [AOR = 4.43, 95% CI: 2.74, 6.12], giving birth during the daytime [AOR: 2.61, 95% CI: 1.92, 3.31], and experiencing an obstetric complication[AOR: 0.46, 95% CI: 0.30, 0.61] were identified as determinants of RMC.

CONCLUSION

As per this meta-analysis, the prevalence of respectful maternity care in Ethiopia was low. Managers in the health sector should give due emphasis to the provision of Compassionate, Respectful, and Care(CRC) training for healthcare providers, who work at maternity service delivery points. Stakeholders need to work to increase the uptake of prenatal care to improve client-provider relationships across a continuum of care. Human resource managers should assign an adequate number of health care providers to the night-shift duties to reduce the workload on obstetric providers.

Maternity care during a pandemic: Can a hybrid telehealth model comprising group interdisciplinary education support maternal psychological health?

Background

The transition to parenthood is one of the most challenging across the life course, with profound changes that can impact psychological health. In response to the coronavirus disease 2019 (COVID-19), came the rapid implementation of remote antenatal care, i.e., telehealth, with fewer in-person consultations. A change in service delivery in addition to the cancellation of antenatal education represented a potential threat to a woman’s experience – with likely adverse effects on mental health and wellbeing.

Aim

To explore a hybrid model of pregnancy care, i.e., telehealth and fewer in-person health assessments, coupled with concurrent small group interdisciplinary education delivered via video conferencing, extending into the postnatal period.

Methods

Using a quasi-experimental design with an interrupted time series and a control group, this population-based study recruited low-risk women booking for maternity care at one community health site affiliated with a large public hospital in Victoria, Australia.

Findings

Whilst there was no difference in stress and anxiety scores, a significant interactive effect of the hybrid model of care with time was seen in the DASS depression score (−1.17, 95% CI: −1.81, −0.53) and the EPDS (−0.83, 95% CI: −1.5, −0.15).

Discussion

The analyses provide important exploratory findings regarding the positive effects of a hybrid model of care with interdisciplinary education in supporting mental health of first-time mothers.

Conclusion

This study demonstrates that small group online education scheduled in conjunction with individual pregnancy health assessments can be executed within a busy antenatal clinic with promising results and modest but dedicated staff support.

Implementation of the Afya conditional cash transfer intervention to retain women in the continuum of care: a mixed-methods process evaluation

OBJECTIVES

We report the results of a mixed-methods process evaluation that aimed to provide insight on the Afya conditional cash transfer (CCT) intervention fidelity and acceptability.

INTERVENTION, SETTING AND PARTICIPANTS

The Afya CCT intervention aimed to retain women in the continuum of maternal healthcare including antenatal care (ANC), delivery at facility and postnatal care (PNC) in Siaya County, Kenya. The cash transfers were delivered using an electronic card reader system at health facilities. It was evaluated in a trial that randomised 48 health facilities to intervention or control, and which found modest increases in attendance for ANC and immunisation appointments, but little effect on delivery at facility and PNC visits.

DESIGN

A mixed-methods process evaluation was conducted. We used the Afya electronic portal with recorded visits and payments, and reports on use of the electronic card reader system from each healthcare facility to assess fidelity. Focus group interviews with participants (N=5) and one-on-one interviews with participants (N=10) and healthcare staff (N=15) were conducted to assess the acceptability of the intervention. Data analyses were conducted using descriptive statistics and qualitative content analysis, as appropriate.

RESULTS

Delivery of the Afya CCT intervention was negatively affected by problems with the electronic card reader system and a decrease in adherence to its use over the intervention period by healthcare staff, resulting in low implementation fidelity. Acceptability of cash transfers in the form of mobile transfers was high for participants. Initially, the intervention was acceptable to healthcare staff, especially with respect to improvements in attaining facility targets for ANC visits. However, acceptability was negatively affected by significant delays linked to the card reader system.

CONCLUSIONS

The findings highlight operational challenges in delivering the Afya CCT intervention using the Afya electronic card reader system, and the need for greater technology readiness before further scale-up.

TRIAL REGISTRATION NUMBER

NCT03021070.

Methodological reflections on health system oriented assessment of maternity care in 16 hospitals in sub-Saharan Africa: an embedded case study

Health Facility Assessments (HFAs) assessing facilities' readiness to provide services are well-established. However, HFA questionnaires are typically quantitative and lack depth to understand systems in which health facilities operate-crucial to designing context-oriented interventions. We report lessons from a multiple embedded case study exploring the experiences of HFA data collectors in implementing a novel HFA tool developed using systems thinking approach. We assessed 16 hospitals in four countries (Benin, Malawi, Tanzania, and Uganda) as part of a quality improvement implementation research. Our tool was organized in 17 sections and included dimensions of hospital governance, leadership, and financing; maternity care standards and procedures; ongoing quality improvement practices; interactions with communities; and mapping of the areas related to maternal care. Data for this study was collected using in-depth interviews with senior experts who conducted the HFA in the countries one to three months after completion of the HFAs. Data were analyzed using the inductive thematic analysis approach. Our HFA faced challenges in logistics (accessing key hospital-based respondents, high turnover of managerial staff, and difficulty accessing information considered sensitive in the context) and methodology (response bias, lack of data quality, and data entry into an electronic platform). Data elements of governance, leadership, and financing were the most affected. Opportunities and strategies adopted aimed at enhancing data collection (building on prior partnerships, understanding local and institutional bureaucracies) and enhancing data richness (identifying respondents with institutional memory, learning from experience, and conducting observations at various times). Moreover, HFA data collectors conducted abstraction of records and interviews in a flexible and adaptive way to enhance data quality. Lessons and new skills learned from our HFA could be used as inputs to respond to the growing need of integrating the systems thinking approach in HFA to improve contextual understanding of operations and structure.

Effect of integrating maternal and child health services, nutrition and family planning services on postpartum family planning uptake at 6 months post-partum in Burkina Faso, Cote d’Ivoire and Niger: a quasi-experimental study protocol

Background

Although several interventions integrating maternal, neonatal, child health and nutrition with family planning have been implemented and tested, there is still limited evidence on their effectiveness to guide program efforts and policy action on health services integration. This study aims to assess the effectiveness of a service delivery model integrating maternal and child health services, nutrition and family planning services, compared with the general standard of care in Burkina Faso, Cote d'Ivoire, and Niger.

Methods

This is a quasi experimental study with one intervention group and one control group of 3 to 4 health facilities in each country. Each facility was matched to a control facility of the same level of care that had similar coverage on selected reproductive health indicators such as family planning and post-partum family planning. The study participants are pregnant women (up to 28 weeks of gestational age) coming for their first antenatal care visit. They will be followed up to 6 months after childbirth, and will be interviewed at each antenatal visit and also during visits for infant vaccines. The analyzes will be carried out by intention to treat, using generalized linear models (binomial log or log Poisson) to assess the effect of the intervention on the ratio of contraceptive use prevalence between the two groups of the study at a significance level of 5%, while taking into account the cluster effect and adjusting for potential confounding factors (socio-demographic characteristics of women unevenly distributed at inclusion).

Discussion

This longitudinal study, with the provision of family planning services integrated into the whole maternal care continuum, a sufficiently long observation time and repeated measurements, will make it possible to better understand the timeline and the factors influencing women’s decision-making on the use of post-partum family planning services. The results will help to increase the body of knowledge regarding the impact of maternal and child health services integration on the utilization of post-partum family planning taking into account the specific context of sub-Saharan Africa French speaking countries where such information is very needed.

One strategy to improve the utilization of health services by mothers and their children is the integration of maternal and child health services. For instance, a pregnant woman coming for an antenatal care visit would also receive counseling on post-partum family planning services and maternal nutrition. Similarly, a woman coming for her infant’s vaccines would be offered counseling on post-partum family planning, maternal nutrition and breastfeeding. Although several interventions have been implemented and tested, there is still limited evidence on the conditions and factors required for successful maternal and child health services integration strategies. This study aims to assess the effectiveness of an intervention integrating maternal and child health services, nutrition and family planning services. For the purpose of the evaluation, 2 distincts groups of health facilities will be selected in each country, one group of 3 or 4 health facilities where the intervention will be implemented, and another group of 3 or 4 health facilities with the general standard of care. The study participants are pregnant women (up to 28 weeks of gestational age), coming for their first antenatal care visit, who will be followed up to 6 months after childbirth.The analyzes will be carried out to assess the effect of the intervention on contraceptive use prevalence between the two groups of health facilities. This study will make it possible to better understand the timeline and the factors influencing women’s decision-making on the use of post-partum family planning services.

Quality of intrapartum care at Public Health Institutions of North Achefer District, North West Ethiopia: a mixed method study

Background

Ending preventable maternal, and neonatal morbidity and mortality cannot be achieved without quality care interventions during the intrapartum and postpartum period. Poor quality care during the intrapartum and postpartum period contributes high burden of maternal and neonatal morbidity. Therefore, the current study aimed to assess the quality of intrapartum care and its associated factors in public health facilities in North Achefer District, North West Ethiopia.

Method

A mixed-type institution-based cross-sectional study design was conducted from November 7 to December 6, 2019. Simple random sampling and purposive sampling were used to select study participants for quantitative and qualitative studies respectively. Data were coded and entered into Epi data version 4.4.2 software and exported to SPSS version 25 for analysis. Variables with a p-value of less than and equal to 0.25 were entered into multivariable regression analysis and variables with p values < 0.05 were considered statistically significant factors of the quality of intrapartum care. The qualitative data were analyzed by using thematic content analysis. Finally, qualitative findings were used to supplement the quantitative result.

Result

The finding showed that, 27.3% (95% CI: 26.6–28) of mothers received good quality intrapartum care. Presence of long-distance (AOR = 0.19; 95% CI = 0.06, 0.66), health care facility (AOR = 0.07; 95% CI = 0.02, 0.20), and partograph utilization (AOR = 4.9; 95% CI = 1.82, 13.14) were factors associated with the quality of intrapartum care.

Conclusion

The proportion of intrapartum quality care was low. Distance, partograph utilization, and type of health facility were factors associated with quality of intrapartum care. The district, zonal health offices, and regional health bureau should provide capacity building and follow up on partograph utilization, and increase the accessibility of ambulances.

Experiences of a dedicated Heart and Maternal Health Service providing multidisciplinary care to pregnant women with cardiac disease in a tertiary centre in Namibia

Objectives

Methods

Results

Conclusions

“Do we even have a voice?” Health providers’ perspective on the patient accommodation strategies in Bangladesh

Objective

In a resource-constrained setting like Bangladesh, effective patient-provider communication is critical to the delivery of maternal healthcare services. Using communication accommodation theory, this study tried to understand how providers perceive, engage, and accommodate patients’ needs in maternity wards.

Methods

This qualitative exploratory study used a semi-structured interview guide to conduct in-depth face-to-face interviews of ten healthcare providers in two government-funded public health facilities in Bangladesh. The interview data were analyzed using MAXQDA 2020 software.

Results

The thematic analyses revealed that nurses and midwives faced conceivable neglect from patients and their attendees due to possible service and facility constraints, indicating their low status and control within the service operation. Despite efforts to address patients’ emotional and psychological concerns, providers appear to avoid (divergence strategy) confronting patients and their irate visitors. Unimodal convergence emerged when providers accepted patients’ arguments about the systematic inadequacy of service facilities. Providers have employed interpretability tactics to communicate medical opinions and applied nonverbal cues where necessary.

Conclusion

A lack of open communication between healthcare providers and patients necessitated various forms of accommodation. Integrated strategies addressing service restrictions and initiatives fostering patient understanding and cooperation may improve patient-provider communication.