Examining vulnerability and resilience in maternal, newborn and child health through a gender lens in low-income and middle-income countries: a scoping review

Mapping maternal and infant health in Morocco: A global scoping review of themes, gaps, and the "unseen" in the published health research literature, 2000-2022

Global efforts to reduce Maternal Mortality Rates (MMR) have been significant, but researchers are exploring new approaches to address stalled progress and enduring health inequities. This scoping review offers an analytic synthesis of maternal and infant health (MIH) research in the low-middle income North African Islamic country of Morocco over 22 years, a mapping of the themes, research gaps, geographies, and methodologies, 2000-2022. Morocco is an official MIH success story with excellent health indicators, yet indicators do not address local contexts, gender issues, or health disparities. To understand how medical research has reflected social reality over the past 22 years, we explored not just what is known, but how it is known, where it is known, what remained unseen, and why. Four databases were searched: OVID: MEDLINE, Embase, APA PsycINFO, and EBSCO: CINAHL. 4590 abstracts were identified, 3131 abstracts screened, and 402 full MIH articles and 128 sub-group articles identified and subject to data extraction. The 402 full MIH articles were subject to qualitative thematic analysis, classified by 34 primary research themes and explored especially for gender, health equity, and methodology. Findings included significant geographic research disparities; four regions were the location of 75% of research and many regions remained virtually "unseen" by research. The best-equipped urban public hospitals in higher-income regions produced the most research, creating an urban, hospital-based research perspective. Maternal health articles predominated, often >50% more than articles published about infant health. Infants studied were mostly neonates. Socially marginalized women were often invisible to research, as were private healthcare, NGO care (non-governmental civic organizations), and healthcare in community. In articles, researchers recommended new policies, new laws, health system reform, and government actions to advocate for patients. Three solutions emerged to broaden the research perspective: increase geographic breadth, address missing topics and populations, and embrace interdisciplinary methods.

Impact evaluation of invisible intimate partner violence on maternal healthcare utilization in Pakistan

INTRODUCTION

Existing research has shown that intimate partner violence (IPV) may hinder maternal access to healthcare services, thereby affecting maternal and child health. However, current studies have ignored whether emotional intimate partner violence (EV) could negatively affect maternal healthcare use. This study aims to evaluate the impact of invisible IPV on maternal healthcare utilization in Pakistan.

METHODS

We analyzed nationally representative data from the Pakistan Demographic and Health Survey database from 2012-2013 and 2017-2018. Exposure to physical intimate partner violence (PV) and EV was the primary predictor. Based on women's last birth records, outcomes included three binary variables indicating whether women had inadequate antenatal care (ANC) visits, non-institutional delivery, and lack of postnatal health check-ups. A logistic regression model was established on weighted samples.

RESULTS

Exposure to EV during pregnancy was significantly associated with having inadequate ANC visits (aOR = 2.16, 95% CI: 1.06 to 4.38, p = 0.033) and non-institutional delivery (aOR = 2.24, 95% CI: 1.41 to 3.57, p = 0.001). Lifetime exposure to EV was associated with increased risks of inadequate ANC visits (aOR = 1.48, 95% CI: 1.00 to 2.19, p = 0.049). Lifetime exposure to low-scale physical intimate partner violence (LSPV) (adjusted OR (aOR) = 1.73, 95% CI: 1.29 to 2.31, p < 0.001) was associated with increased risks of having no postnatal health check-ups.

CONCLUSIONS

Pregnant women who experienced EV and LSPV are at greater risk of missing maternal healthcare, even if the violence occurred before pregnancy. Therefore, in countries with high levels of IPV, early screening for invisible violence needs to be integrated into policy development, and healthcare providers need to be trained to identify EV and LSPV.

Vulnerabilities and reparative strategies during pregnancy, childbirth, and the postpartum period: moving from rhetoric to action

Maternal outcomes throughout pregnancy, childbirth, and the postnatal period are influenced by interlinked and interdependent vulnerabilities. A comprehensive understanding of how various threats and barriers affect maternal and perinatal health is critical to plan, evaluate and improve maternal health programmes. This paper builds on the introductory paper of the Series on the determinants of maternal health by assessing vulnerabilities during pregnancy, childbirth, and the postnatal period. We synthesise and present the concept of vulnerability in pregnancy and childbirth, and map vulnerability attributes and their dynamic influence on maternal outcomes in early and late pregnancy and during childbirth and the postnatal period, with a particular focus on low-income and middle-income countries (LMICs). We summarise existing literature and present the evidence on the effects of various reparative strategies to improve pregnancy and childbirth outcomes. Lastly, we discuss the implications of the identified vulnerability attributes and reparative strategies for the efforts of policymakers, healthcare professionals, and researchers working towards improving outcomes for women and birthing people in LMICs.

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

Factors Associated With Initiating Breastfeeding and Continuing it for At Least 4 Months in Consuelo, a Rural Town in the Dominican Republic

Objective. We assessed the proportion of and factors associated with mothers initiating and continuing breastfeeding (BF) for ≥4 months in a rural town of the Dominican Republic. Methods. A survey was administered to 190 mothers of children cared for at a free clinic in Consuelo. Modified bivariate and multivariable Poisson regressions were utilized in data analysis. Results. BF was initiated in 89.5% of cases and continued ≥4 months in 81.7% of cases. Maternal education beyond secondary school [adjusted RR = 1.13, 95% CI: (1.04-1.24), 0.010], and visiting both public and private antenatal clinics [adjusted RR = 1.25; 95% CI: (1.10-1.37), 0.010] were associated with BF initiation. Public and private antenatal clinic attendance [adjusted RR = 1.01, 95% CI: (0.45-2.23), 0.020], Cesarean section [adjusted RR = 0.81, 95% CI: (0.68-0.98), 0.026], number of biological children [adjusted RR = 0.95, 95% CI: (0.90-1.00), 0.032] and maternal employment [adjusted RR = 0.89, 95% CI: (0.79-0.99), 0.048] were associated with BF continuation. Conclusions. These results provide valuable insights for targeting specific populations in future breastfeeding education interventions.

Community-based tuberculosis contact management: Caregiver experience and factors promoting adherence to preventive therapy

Delivery of tuberculosis preventive therapy (TPT) for children with household exposure to tuberculosis is a globally supported intervention to reduce the impact of tuberculosis disease (TB) in vulnerable children; however, it is sub-optimally implemented in most high-burden settings. As part of a community-based household contact management program, we evaluated predictors of adherence to community based TPT in children and performed qualitative assessments of caregiver experiences. The Vikela Ekhaya (Protect the Home) project was a community-based household contact management program implemented between 2019 and 2020 in the Hhohho Region of Eswatini. At home visits, contact management teams screened children for TB, initiated TPT when indicated and performed follow-up assessments reviewing TPT adherence. TPT non-adherence was defined as either two self-reported missed doses or a pill count indicating at least two missed doses, and risk factors were evaluated using multivariate clustered Cox regression models. Semi-structured interviews were performed with caregivers to assess acceptability of home visits for TPT administration. In total, 278 children under 15 years initiated TPT and 96% completed TPT through the Vikela Ekhaya project. Risk factors for TPT non-adherence among children initiating 3HR included low family income (adjusted hazard ratio (aHR) 2.3, 95%CI 1.2-4.4), female gender of the child (aHR 2.5, 95% CI 1.4-5.0) and an urban living environment (aHR 3.1, 95%CI 1.6-6.0). Children with non-adherence at the first follow-up visit were 9.1 fold more likely not to complete therapy. Caregivers indicated an appreciation for community services, citing increased comfort, reduced cost, and support from community members. Our results are supportive of recent World Health Organization (WHO) recommendations for decentralization of TB preventive services. Here, we identify populations that may benefit from additional support to promote TPT adherence, but overall demonstrate a clear preference for and excellent outcomes with community based TPT delivery.

Vulnerability in maternal, new-born, and child health in low- and middle-income countries: Findings from a scoping review

Objectives

To identify and synthesise prevailing definitions and indices of vulnerability in maternal, new-born and child health (MNCH) research and health programs in low- and middle-income countries.

Design and setting

Scoping review using Arksey and O’Malley’s framework and a Delphi survey for consensus building.

Participants

Mothers, new-borns, and children living in low- and middle-income countries were selected as participants.

Outcomes

Vulnerability as defined by the authors was deduced from the studies.

Results

A total of 61 studies were included in this scoping review. Of this, 22 were publications on vulnerability in the context of maternal health and 40 were on new-born and child health. Definitions used in included studies can be broadly categorised into three domains: biological, socioeconomic, and environmental. Eleven studies defined vulnerability in the context of maternal health, five reported on the scales used to measure vulnerability in maternal health and only one study used a validated scale. Of the 40 included studies on vulnerability in child health, 19 defined vulnerability in the context of new-born and/or child health, 15 reported on the scales used to measure vulnerability in child health and nine reported on childhood vulnerability indices. As it was difficult to synthesise the definitions, their keywords were extracted to generate new candidate definitions for vulnerability in MNCH.

Conclusion

Included studies paid greater attention to new-born/ child vulnerability than maternal vulnerability, with authors defining the terms differently. A definition which helps in improving the description of vulnerability in MNCH across various programs and researchers was arrived at. This will further help in streamlining research and interventions which can influence the design of high impact MNCH programs.

Scoping review registration

The protocol for this review was registered in the open science framework at the registered address (https://osf.io/jt6nr).

Association of Male Partners' Gender-Equitable Attitudes and Behaviors with Young Mothers' Postpartum Family Planning and Maternal Health Outcomes in Kinshasa, DRC

Inequitable gender norms can contribute to rapid repeat pregnancies and adverse maternal health outcomes among adolescent girls and young women. This study examined associations between male partners' gender-equitable attitudes and behaviors and postpartum family planning (FP) and maternal and newborn health (MNH) outcomes among first-time mothers aged 15-24 in Kinshasa, Democratic Republic of the Congo. Participants were 1335 couples who were successfully interviewed in the Momentum project's 2018 baseline and 2020 endline surveys. Multivariable regression models were used to analyze predictors of postpartum FP discussion and use, shared MNH decision making, completion of the maternal health continuum of care, and exclusive breastfeeding. Male involvement in maternal health was significantly associated with FP discussion and shared decision making. Male partners' willingness to be involved in routine childcare and shared decision making were significant positive predictors of exclusive breastfeeding. Postpartum FP outcomes were shaped by the intersection of marital status and male partners' gender-equitable attitudes, intimate partner violence perpetration, and willingness to engage in routine childcare activities to constitute advantage for some outcomes and disadvantage for others. Interventions must use multiple measures to better understand how young mothers' health outcomes are shaped by their male partners' gender-related attitudes and behaviors.