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Osaki H, Sørensen JB, Maaløe N, Mbekenga C, Skovdal M. "It is because the treatment of this lady is a cascade": Accumulation of delays and the occurrence of obstetric emergencies in an urban maternity unit in Tanzania. Midwifery 2024; 130:103926. [PMID: 38217929 DOI: 10.1016/j.midw.2024.103926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/11/2023] [Accepted: 01/08/2024] [Indexed: 01/15/2024]
Abstract
OBJECTIVE To explore healthcare workers' and women's experiences of providing and seeking childbirth care in a busy urban maternity facility in Tanzania. DESIGN A qualitative study with observations, in-depth interviews, and informal conversations, using thematic network analysis. SETTING This study was conducted in a busy urban maternity unit in Dar es Salaam, Tanzania which is a low-resource setting with a need to improve childbirth care. PARTICIPANTS Six frontline healthcare providers and four hospital managers from the facility, along with six postpartum women who gave birth at the facility. FINDINGS Delays were observed throughout the childbirth care cascade, encompassing various stages. During antenatal care, timely provision of care was hindered by a high patientto-provider ratio, resulting in inadequate monitoring of risk factors. At the onset of labor, women delayed seeking care, sometimes, attempting a trial of labor after a previous Caesarean section. Within the facility, delays in care decision-making and patient management were evident due to insufficient resources. The accumulation of these delays over time influenced the quality of care provided and challenged the management of obstetric emergencies at the study facility. KEY CONCLUSIONS The study findings show that delays are prevalent throughout the entire childbirth care cascade. The accumulation of these delays over time has influenced the quality of care provided at the facility and increased the vulnerability of women experiencing obstetric emergencies. To effectively address the imperative of reducing maternal mortality in low-resource settings, it is essential to develop appropriate interventions that span the entire spectrum of childbirth care. Additionally, further research is needed to delve into the complexities of care decision-making and the quality of care delivered within urban maternal facilities. IMPLICATIONS FOR PRACTICE Our findings stress the need for comprehensive childbirth interventions and contextspecific guidelines to address challenges across the care cascade, particularly in lowresource settings. Urgent attention is required to prioritize care during patient triage and address systemic challenges within the healthcare system to improve birth outcomes and ensure effective facility-based care provision. TRIAL REGISTRATION NUMBER NCT04685668 Date of initial trial registration: December 28th, 2020.
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Affiliation(s)
- Haika Osaki
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark; School of Nursing and Midwifery, Agha Khan University, Dar es Salaam, Tanzania.
| | | | - Nanna Maaløe
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark; School of Nursing and Midwifery, Agha Khan University, Dar es Salaam, Tanzania
| | - Columba Mbekenga
- School of Nursing and Midwifery, Agha Khan University, Dar es Salaam, Tanzania; Faculty of Nursing, Hubert Kairuki Memorial University, Dar es Salaam, Tanzania
| | - Morten Skovdal
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Miller FA, Dulal S, Rai A, Gram L, Harris-Fry H, Saville NM. "Can't live willingly": A thematic synthesis of qualitative evidence exploring how early marriage and early pregnancy affect experiences of pregnancy in South Asia. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002279. [PMID: 37871001 PMCID: PMC10593245 DOI: 10.1371/journal.pgph.0002279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/13/2023] [Indexed: 10/25/2023]
Abstract
In South Asia, early marriage has been associated with a range of adverse outcomes during pregnancy and infancy. This may partly be explained by early marriage leading to a younger maternal age, however it remains unclear which other factors are involved. This review aimed to synthesise the qualitative evidence on experiences of pregnancy following early marriage or early pregnancy in South Asia, to inform our understanding of the mechanisms between early marriage and adverse pregnancy outcomes. We searched MEDLINE, EMBASE, Scopus, Global Index Medicus, CINAHL, PsycINFO, Web of Science, and grey literature on 29/11/2022 to identify papers on experiences of pregnancy among those who married or became pregnant early in South Asia (PROSPERO registration number: CRD42022304336, funded by an MRC doctoral training grant). Seventy-nine papers from six countries were included after screening. We appraised study quality using an adapted version of the Critical Appraisal Skills Programme tool for qualitative research. Reporting of reflexivity and theoretical underpinnings was poor. We synthesised findings thematically, presenting themes alongside illustrative quotes. We categorised poor pregnancy experiences into: care-seeking challenges, mental health difficulties, and poor nutritional status. We identified eight inter-connected themes: restrictive social hierarchies within households, earning social position, disrupted education, social isolation, increased likelihood of and vulnerability to abuse, shaming of pregnant women, normalisation of risk among younger women, and burdensome workloads. Socioeconomic position and caste/ethnic group also intersected with early marriage to shape experiences during pregnancy. While we found differences between regions, the heterogeneity of the included studies limits our ability to draw conclusions across regions. Pregnancy experiences are largely determined by social hierarchies and the quality of relationships within and outside of the household. These factors limit the potential for individual factors, such as education and empowerment, to improve experiences of pregnancy for girls married early.
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Affiliation(s)
- Faith A. Miller
- Institute for Global Health, University College London, London, United Kingdom
| | - Sophiya Dulal
- School of Health Sciences, Western Sydney University, Sydney, Australia
| | - Anjana Rai
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Lu Gram
- Institute for Global Health, University College London, London, United Kingdom
| | - Helen Harris-Fry
- Department of Population Health, The London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Naomi M. Saville
- Institute for Global Health, University College London, London, United Kingdom
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Ononge S, Magunda A, Balaba D, Waiswa P, Okello D, Kaula H, Zalwango S, Bua DA, Ayebare A, Kaharuza F, Bennett C, Sulzbach S, Keller B, Mugerwa Y. Strengthening Kampala's Urban Referral System for Maternal and Newborn Care Through Establishment of an Emergency Call and Dispatch Center. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200332. [PMID: 37348939 DOI: 10.9745/ghsp-d-22-00332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 05/03/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION Most pregnant women living in urban slum communities in Uganda deliver at public health centers that are not equipped to provide emergency obstetric and newborn care. When obstetric emergencies occur, pregnant women are referred to a higher-level facility and are responsible for arranging and paying for their own transport. The Kampala Slum Maternal Newborn (MaNe) project developed and tested an emergency call and ambulance dispatch center and a mobile application to request, deploy, and track ambulances. We describe the development of these 2 interventions and findings on the feasibility, acceptability, and sustainability of the interventions. METHODS MaNe conducted a mixed-method feasibility study that included an assessment of the acceptability and demand of the interventions. In-depth interviews (N=26) were conducted with facility proprietors, health providers, ambulance drivers, Kampala Capital City Authority officers, and community members to understand the successes and challenges of establishing the call center and developing the mobile application. Thematic content analysis was done. Quantitative data from the call center dispatch logs were analyzed descriptively to complement the qualitative findings. FINDINGS Between April 2020 and June 2021, 10,183 calls were made to the emergency call and dispatch center. Of these, 25% were related to maternal and newborn health emergencies and 14% were COVID-19 related. An ambulance was dispatched to transfer or evacuate a patient in 35% of the calls. Participants acknowledged that the call center and mobile application allowed for efficient communication, coordination, and information flow between health facilities. Supportive district leadership facilitated the establishment of the call center and has taken over the operating costs of the center. CONCLUSION The call center and referral application improved the coordination of drivers and ambulances and allowed facilities to prepare for and treat cases more efficiently.
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Affiliation(s)
- Sam Ononge
- Makerere University College of Health Sciences, Kampala, Uganda.
| | - Andrew Magunda
- Population Services International Uganda, Kampala, Uganda
| | - Dorothy Balaba
- Population Services International Uganda, Kampala, Uganda
| | - Peter Waiswa
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Henry Kaula
- Population Services International Uganda, Kampala, Uganda
| | | | | | - Amable Ayebare
- Population Services International Uganda, Kampala, Uganda
| | | | - Cudjoe Bennett
- Office of Maternal and Child Health and Nutrition, Bureau of Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - Sara Sulzbach
- Office of Maternal and Child Health and Nutrition, Bureau of Global Health, U.S. Agency for International Development, Washington, DC, USA
| | - Brett Keller
- Population Services International Uganda, Kampala, Uganda
| | - Yvonne Mugerwa
- Population Services International Uganda, Kampala, Uganda
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Sule FA, Uthman OA, Olamijuwon EO, Ichegbo NK, Mgbachi IC, Okusanya B, Makinde OA. Examining vulnerability and resilience in maternal, newborn and child health through a gender lens in low-income and middle-income countries: a scoping review. BMJ Glob Health 2022; 7:bmjgh-2021-007426. [PMID: 35443936 PMCID: PMC9024279 DOI: 10.1136/bmjgh-2021-007426] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 03/20/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Gender lens application is pertinent in addressing inequities that underlie morbidity and mortality in vulnerable populations, including mothers and children. While gender inequities may result in greater vulnerabilities for mothers and children, synthesising evidence on the constraints and opportunities is a step in accelerating reduction in poor outcomes and building resilience in individuals and across communities and health systems. METHODS We conducted a scoping review that examined vulnerability and resilience in maternal, newborn and child health (MNCH) through a gender lens to characterise gender roles, relationships and differences in maternal and child health. We conducted a comprehensive search of peer-reviewed and grey literature in popular scholarly databases, including PubMed, ScienceDirect, EBSCOhost and Google Scholar. We identified and analysed 17 published studies that met the inclusion criteria for key gendered themes in maternal and child health vulnerability and resilience in low-income and middle-income countries. RESULTS Six key gendered dimensions of vulnerability and resilience emerged from our analysis: (1) restricted maternal access to financial and economic resources; (2) limited economic contribution of women as a result of motherhood; (3) social norms, ideologies, beliefs and perceptions inhibiting women's access to maternal healthcare services; (4) restricted maternal agency and contribution to reproductive decisions; (5) power dynamics and experience of intimate partner violence contributing to adverse health for women, children and their families; (6) partner emotional or affective support being crucial for maternal health and well-being prenatal and postnatal. CONCLUSION This review highlights six domains that merit attention in addressing maternal and child health vulnerabilities. Recognising and understanding the gendered dynamics of vulnerability and resilience can help develop meaningful strategies that will guide the design and implementation of MNCH programmes in low-income and middle-income countries.
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Affiliation(s)
- Fatima Abdulaziz Sule
- Department of Research and Development, Viable Helpers Development Organization, Abuja, Federal Capital Territory, Nigeria
| | | | - Emmanuel Olawale Olamijuwon
- Department of Research and Development, Viable Helpers Development Organization, Abuja, Federal Capital Territory, Nigeria
| | - Nchelem Kokomma Ichegbo
- Department of Research and Development, Viable Helpers Development Organization, Abuja, Federal Capital Territory, Nigeria
| | - Ifeanyi C Mgbachi
- Department of Research and Development, Viable Helpers Development Organization, Abuja, Federal Capital Territory, Nigeria
| | - Babasola Okusanya
- Department of Obstetrics and Gynaecology, University of Lagos College of Medicine, Lagos, Nigeria
| | - Olusesan Ayodeji Makinde
- Department of Research and Development, Viable Helpers Development Organization, Abuja, Federal Capital Territory, Nigeria .,Department of Research and Development, Viable Knowledge Masters, Gwarinpa, Federal Capital Territory, Nigeria
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Camacho EM, Smyth R, Danna VA, Kimaro D, Kuzenza F, Laisser R, Mdoe P, Nsemwa L, Shayo H, Lavender T. Women's preferences for antenatal care in Tanzania: a discrete choice experiment. BMC Pregnancy Childbirth 2022; 22:296. [PMID: 35392853 PMCID: PMC8991681 DOI: 10.1186/s12884-022-04634-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 03/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background The stillbirth rate in Tanzania remains high. Greater engagement with antenatal care may help to reduce stillbirths. We investigated which characteristics of antenatal care clinics are preferred by pregnant women in Tanzania. Methods We conducted an unlabelled discrete choice experiment (DCE) with think-aloud interviews. Participants were pregnant women, regardless of parity/gestation, from the Mwanza and Manyara regions of Tanzania. We asked participants to choose which of two hypothetical antenatal clinics they would rather attend. Clinics were described in terms of transport mode, cleanliness, comfort, visit content, and staff attitude. Each participant made 12 choices during the experiment, and a purposively selected sub-set simultaneously verbalised the rationale for their choices. We analysed DCE responses using a multinomial logit model adjusted for study region, and think-aloud data using the Framework approach. Results We recruited 251 participants split evenly between the 2 geographical regions. Staff attitude was the most important attribute in clinic choice and dominated the think-aloud narratives. Other significant attributes were mode of transport (walking was preferred) and content of clinic visit (preference was stronger with each additional element of care provided). Cleanliness of the clinic was not a significant attribute overall and the think-aloud exercise identified a willingness to trade-off cleanliness and comfort for respectful care. Conclusion Women would prefer to attend a clinic with kind staff which they can access easily. This study suggests that exploration of barriers to providing respectful care, and enabling staff to deliver it, are important areas for future investment. The DCE shows us what average preferences are; antenatal care that is aligned with identified preferences should increase uptake and engagement versus care which does not acknowledge them. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04634-x.
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Affiliation(s)
| | - Rebecca Smyth
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Valentina Actis Danna
- Centre for Childbirth, Women's and Newborn Health, Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Deborah Kimaro
- Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Flora Kuzenza
- Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Rose Laisser
- Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Paschal Mdoe
- Department of Research, Haydom Lutheran Hospital, Mbulu, Tanzania
| | - Livuka Nsemwa
- Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Happiness Shayo
- Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Tina Lavender
- Centre for Childbirth, Women's and Newborn Health, Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Laisser R, Woods R, Bedwell C, Kasengele C, Nsemwa L, Kimaro D, Kuzenza F, Lyangenda K, Shayo H, Tuwele K, Wakasiaka S, Ringia P, Lavender T. The tipping point of antenatal engagement: A qualitative grounded theory in Tanzania and Zambia. SEXUAL & REPRODUCTIVE HEALTHCARE 2021; 31:100673. [PMID: 34775355 DOI: 10.1016/j.srhc.2021.100673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 09/06/2021] [Accepted: 10/20/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Effective antenatal care is fundamental to the promotion of positive maternal and new-born outcomes. International guidance recommends an initial visit in the first trimester of pregnancy, with a minimum of four antenatal visits in total: the optimum schedule being eight antenatal contacts. In low- and middle-income countries, many women do not access antenatal care until later in pregnancy and few have the recommended number of contacts. AIM To gain understanding of women's antenatal experiences in Tanzania and Zambia, and the factors that influence antenatal engagement. METHODS The study was underpinned by Strauss's grounded theory methodology. Interviews were conducted with 48 women, 16 partners, 21 health care providers and 11 stakeholders, and analysed using constant comparison. FINDINGS The core category was 'The tipping point of antenatal engagement', supported by four categories: awareness of health benefits, experiential motivators, influential support, and environmental challenges. Although participants recognised the importance of antenatal care to health outcomes, individual motivations and external influences determined attendance or non-attendance. The 'tipping point' for antenatal engagement occurred when women believed that any negative impact could be offset by tangible gain. For some women non-attendance was a conscious decision, for others it was an unchallenged cultural norm. CONCLUSION A complex interplay of factors determines antenatal engagement. Short-term modifiable factors to encourage attendance include the development of strategies for increasing respectful care; use of positive women's narratives, and active community engagement. Further research is required to develop innovative, cost-effective care models that improve health literacy and meet women's needs.
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Affiliation(s)
- Rose Laisser
- Midwifery and Women's Health, Archibishop Antony Mayalla School of Nursing, Catholic University of Health and Allied Sciences, PO Box 1464, Bugando, Mwanza, Tanzania.
| | - Rebecca Woods
- Midwifery and Women's Health, Archibishop Antony Mayalla School of Nursing, Catholic University of Health and Allied Sciences, PO Box 1464, Bugando, Mwanza, Tanzania
| | - Carol Bedwell
- Midwifery and Women's Health, Archibishop Antony Mayalla School of Nursing, Catholic University of Health and Allied Sciences, PO Box 1464, Bugando, Mwanza, Tanzania
| | - Chowa Kasengele
- Midwifery and Women's Health, Archibishop Antony Mayalla School of Nursing, Catholic University of Health and Allied Sciences, PO Box 1464, Bugando, Mwanza, Tanzania
| | - Livuka Nsemwa
- Midwifery and Women's Health, Archibishop Antony Mayalla School of Nursing, Catholic University of Health and Allied Sciences, PO Box 1464, Bugando, Mwanza, Tanzania
| | - Debora Kimaro
- Midwifery and Women's Health, Archibishop Antony Mayalla School of Nursing, Catholic University of Health and Allied Sciences, PO Box 1464, Bugando, Mwanza, Tanzania
| | - Flora Kuzenza
- Midwifery and Women's Health, Archibishop Antony Mayalla School of Nursing, Catholic University of Health and Allied Sciences, PO Box 1464, Bugando, Mwanza, Tanzania
| | - Kutemba Lyangenda
- Midwifery and Women's Health, Archibishop Antony Mayalla School of Nursing, Catholic University of Health and Allied Sciences, PO Box 1464, Bugando, Mwanza, Tanzania
| | - Happiness Shayo
- Midwifery and Women's Health, Archibishop Antony Mayalla School of Nursing, Catholic University of Health and Allied Sciences, PO Box 1464, Bugando, Mwanza, Tanzania
| | - Khuzuet Tuwele
- Midwifery and Women's Health, Archibishop Antony Mayalla School of Nursing, Catholic University of Health and Allied Sciences, PO Box 1464, Bugando, Mwanza, Tanzania
| | - Sabina Wakasiaka
- Midwifery and Women's Health, Archibishop Antony Mayalla School of Nursing, Catholic University of Health and Allied Sciences, PO Box 1464, Bugando, Mwanza, Tanzania
| | - Prisca Ringia
- Midwifery and Women's Health, Archibishop Antony Mayalla School of Nursing, Catholic University of Health and Allied Sciences, PO Box 1464, Bugando, Mwanza, Tanzania
| | - Tina Lavender
- Midwifery and Women's Health, Archibishop Antony Mayalla School of Nursing, Catholic University of Health and Allied Sciences, PO Box 1464, Bugando, Mwanza, Tanzania
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Bedwell C, Blaikie K, Actis Danna V, Sutton C, Laisser R, Tembo Kasengele C, Wakasiaka S, Victor S, Lavender T. Understanding the complexities of unexplained stillbirth in sub-Saharan Africa: a mixed-methods study. BJOG 2021; 128:1206-1214. [PMID: 33319470 PMCID: PMC8248405 DOI: 10.1111/1471-0528.16629] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 01/10/2023]
Abstract
Objective To understand the complexities surrounding unexplained stillbirth for the development and implementation of culturally acceptable interventions to underpin care in Tanzania and Zambia. Design Mixed‐methods study. Setting Tertiary, secondary and primary care facilities in Mansa, Zambia, and Mwanza, Tanzania. Sample Quantitative: 1997 women giving birth at two tertiary care facilities (one in each country). Qualitative: 48 women and 19 partners from tertiary, secondary and primary care facilities. Methods Case review using data from a target of 2000 consecutive case records. Qualitative interviews with a purposive sample of women and partners, using a grounded theory approach. Results A total of 261 stillbirths were recorded, with a rate of 16% in Tanzania and 10% in Zambia, which is higher than the previous estimates of 2.24 and 2.09%, respectively, for those countries. Women in both countries who reported a previous stillbirth were more likely to have stillbirth (RR 1.86, 95% CI 1.23–2.81). The cause of death was unexplained in 28% of cases. Qualitative findings indicated that not knowing what caused the baby to be stillborn prevented women from grieving. This was compounded by the poor communication skills of health professionals, who displayed little empathy and skill when counselling bereaved families. Conclusions The stillbirth risk in both facilities was far higher than the risk recorded from national data, with women reporting a previous stillbirth being at higher risk. Women want to know the cause of stillbirth and an exploration of appropriate investigations in this setting is required. Providing health professionals with support and continuing training is key to improving the experiences of women and future care. Tweetable abstract Stillbirths receive little investigation and are often unexplained. Communication with women about the death of their baby is limited. Stillbirths receive little investigation and are often unexplained. Communication with women about the death of their baby is limited.
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Affiliation(s)
- C Bedwell
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - K Blaikie
- School of Health Sciences, University of Manchester, Manchester, UK
| | - V Actis Danna
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - C Sutton
- School of Health Sciences, University of Manchester, Manchester, UK
| | - R Laisser
- Archbishop Antony Mayala School of Nursing, Catholic University of Health and Allied Health Sciences, Mwanza, Tanzania
| | - C Tembo Kasengele
- Department of Public Health and Research, Ministry of Health Headquarters, Lusaka, Zambia
| | | | - S Victor
- Perinatal Imaging and Health, King's College London, London, UK
| | - T Lavender
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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