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

Process Evaluation of Services for HIV-Infected Post-Partum Women and HIV-Exposed Infants in Primary Health Care Blantyre Malawi

HIV testing among HIV-exposed infants (HEI) in Malawi is below global targets and, affected by low utilisation of health services after birth. We conducted a mixed methods evaluation of the implementation of services for early infant diagnosis (EID) of HIV against national guidelines in Blantyre, Malawi, to inform the development of strategies to improve EID services uptake. We estimated coverage of HEI enrolment in HIV care and HIV testing at 6 weeks through a retrospective data review. We qualitatively explored implementation gaps in EID services through process mapping of 8 mother-infant pairs (MIP); and investigated healthcare workers' (HCW) perspectives on the implementation gaps through group interviews with 16 HCWs. We analysed the quantitative data descriptively and conducted a thematic content analysis of qualitative data. Of 163 HEIs born at the study sites, 39 (24%) were enrolled in an HIV care clinic before post-natal discharge, and 85 (52%) received HIV testing by 6 weeks. The median time for MIP to receive EID services was 4 (1-8) hours. The implementation gaps observed during process mapping included: failure to identify and enrol HEI in HIV care clinic; lack of immunisation, counselling for HEI testing, HIV testing, drug refilling, and family planning; and different appointment dates for mother and infant. HCWs reported delays and gaps influencing optimal service provision including: lack of screening to identify MIP, limited supervision for student HCWs when providing services, inadequate capacity of point of care machines, challenges with integrating services, and role confusion. Use of unique identifiers for MIP and establishing a booking system to schedule appointments to suit point of care machine capacity were primary service improvement recommendations. This study identified suboptimal EID services in Malawi due to process, capacity, and system factors. Context-appropriate interventions accommodating systems thinking are needed to enhance service provision.

Development and psychometric testing of a Chinese version of the postnatal care experience scale for postpartum women

BACKGROUND

Postnatal period is a critical transitional phase in the lives of mothers and newborn babies. In recent years the importance on promoting a positive experience of care following childbirth is increasingly emphasized. Yet published evidence of the methodological and psychometric quality of instruments to evaluate women's experience of comprehensive postnatal care is still lacking.

OBJECTIVE

This study aimed to develop and validate a unique scale (the Chinese version of the Postnatal Care Experience Scale, PCES) to measure women's overall experience of care during postnatal periods.

METHODS

The PCES instrument was developed and validated over three phases, including item development, scale development, and scale evaluation. The item pool of the PCES was generated through existing literature and in-depth semi-structured interviews, followed by assessment of content validity and rating of importance and feasibility of items through two-round Delphi surveys. Psychometric properties were examined in a convenience sample of 736 postpartum women. Both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to assess the construct validity of the developed PCES. The relationship between the total PCES score and the global item construct was estimated using Pearson product-moment coefficient. Reliability was assessed using Cronbach's alpha and Spearman Brown coefficients.

RESULTS

The content validity index of the Chinese version PCES was 0.867. Following item reduction analysis, this instrument consisted of 30 five-point Likert items. The Kaiser-Meyer-Olkin statistic was 0.964 and the chi-square value of the Bartlett spherical test was 11665.399 (P < .001). The scale explained 75.797% of the total variance and consisted of three subscales, including self-management, social support, and facility- and community-based care. The Pearson correlation coefficient between the total PCES score and the global item construct was 0.909. The CFA showed that the 3-factor model had suitable fitness for the data. Cronbach's alpha value and Spearman-Brown Split-half reliability for the total scale were 0.979 and 0.941, respectively.

CONCLUSIONS

The newly developed 30-item PCES is a psychometrically reliable and valid instrument that assesses women's overall experience of postnatal care. Future research should aim to use the PCES in various populations to obtain further evidence for its validity and reliability.

Factors affecting the provision of high-quality postnatal care services in Zanzibar: a qualitative study

BACKGROUND

In Sub-Saharan Africa, the postnatal period is associated with high mortality and accounts for a substantial proportion of maternal deaths. Although postnatal care has been identified as critical in reducing maternal mortality, the quality of care provided is often inadequate. Tanzania and Zanzibar have not made sufficient progress towards achieving the Sustainable Development Goals on maternal health, and there is limited knowledge about the utilization and quality of postnatal follow-up. The aim of this study was therefore to explore factors affecting the provision of high-quality postnatal care services in the urban area of Zanzibar.

METHODS

Five focus group discussions were performed in Swahili with 25 healthcare providers from primary healthcare units in urban Zanzibar. Interviews were audio-recorded, transcribed verbatim, translated into English, and analysed using qualitative content analysis with an inductive approach.

RESULTS

Factors affecting provision of high-quality postpartum care services could be divided into three generic categories. Difficulty achieving high attendance comprised three subcategories: long waiting times, low awareness among women, and out-of-pocket payment. Lack of basic resources also comprised three subcategories: shortage of healthcare providers, lack of adequate space, and inadequate medical equipment. Insufficient care routines comprised two subcategories: lack of guidelines and deficient chain of information.

CONCLUSIONS

The present findings suggest that the women's perceptions of postnatal care do not align with the intended purpose of routine postnatal care. Instead, the postnatal period primarily leads to visits to health facilities only when urgent care is required, and there is a lack of awareness about the importance of postnatal care. Moreover, limited resources, including equipment, staff, and space, as well as long waiting times, hinder the delivery of high-quality care and contribute to a negative reputation of postnatal care services. To effectively reach all women and improve postnatal care, it is necessary to increase basic resources, modify health education approaches, and enhance the flow of information between different levels of care using context-specific strategies.

Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries

BACKGROUND

Persistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region.

METHODS

We conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality.

RESULTS

The percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor.

CONCLUSIONS

Addressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed.

Factors that influence the uptake of postnatal care among adolescent girls: a qualitative evidence synthesis

BACKGROUND

Adolescent pregnancy is associated with increased risk of maternal and child morbidity and mortality globally. Access to safe, appropriate and affordable antenatal, childbirth and postnatal care (PNC) is essential in mitigating this risk. PNC is an often undervalued, underused, and understudied component of the continuum of maternal health services; however, it provides an important opportunity for adolescent girls to have access to health information and resources as they navigate the transition to motherhood and/or recovery from childbirth. This qualitative evidence synthesis seeks to highlight the experiences and perspectives of adolescent girls and their partners in accessing and using routine PNC.

METHODS

Papers were selected from a primary review on PNC where a global search of databases was conducted to identify studies with qualitative data focused on PNC utilisation. Within this primary review, a subset of studies focused on adolescents was tagged for subanalysis. A data extraction form drawing on an a priori framework was used to extract data from each study. Review findings were grouped across studies and mapped onto relevant themes, which were then adapted, as appropriate, to best reflect emergent themes from included studies.

RESULTS

Of 662 papers identified for full text review, 15 were included in this review on adolescents' experiences. Fourteen review findings were mapped onto four themes including: resources and access, social norms, experiences of care, and tailored support needs.

CONCLUSION

Improving uptake of PNC by adolescent girls requires multipronged approaches in improving availability of and access to adolescent-sensitive maternal health services and reducing feelings of shame and stigma in the postpartum period. Much should be done to address structural barriers to access, but tangible steps to improving the quality and responsiveness of available services can be taken immediately.

PROSPERO REGISTRATION NUMBER

CRD42019139183.

What women want: A mixed-methods study of women's health priorities, preferences, and experiences in care in three Rwandan rural districts

OBJECTIVE

To explore Rwandan women's experiences, priorities, and preferences in accessing health care for non-pregnancy-related conditions and inform development of healthcare services related to these conditions among women of reproductive age at district hospitals and health centers in Rwanda.

METHODS

We used a mixed-methods, exploratory sequential design. Semi-structured qualitative interviews were conducted with Rwandan women and coded thematically. A cross-sectional quantitative survey based on the qualitative data was administered to women attending health centers.

RESULTS

Seventeen interviews and 150 surveys were conducted. Women identified conditions including back pain, gynecologic cancers, and abnormal vaginal bleeding as concerns. They generally reported positive experiences while accessing health care and knowledge of accessing health care. Barriers to care were identified, including transportation costs and inability to miss work. Women expressed a desire for more control over their care and the importance of maintaining their dignity while accessing health care.

CONCLUSION

These findings provide useful insights to inform development of non-pregnancy-related healthcare services for women in Rwanda according to their priorities and preferences. The reported end-user health concerns, barriers to care, and diminished control over their care point to a need to evolve health systems around user-tailored needs and design interventions optimizing access whilst promoting dignified care.

Postnatal care services in rural Zambia: a qualitative exploration of user, provider, and community perspectives on quality of care

BACKGROUND

Postnatal care (PNC) is an important set of services offered to the mother and her newborn baby immediately after birth for the first six weeks to prevent maternal and neonatal complications and death. This qualitative study explored user and provider perspectives on quality of PNC services in the selected health facilities within the context of the Maternity Homes Access in Zambia project in the Saving Mothers Giving Life districts in rural Zambia.

METHODS

Between October 2018 and February 2019, forty focus group discussions (FGDs) (n = 160 participants) and twelve in-depth interviews (IDIs) were conducted in four districts in Southern and Eastern provinces. FGDs comprised women who delivered within the last year, fathers, community elders, and volunteers. IDIs comprised health workers at facility, district, and provincial levels. Data were analysed using content analysis guided by the international quality of care domains derived from the World Health Organization quality of care framework. Findings were triangulated to understand perceptions.

RESULTS

Overall, study participants perceived PNC services to be beneficial. Nevertheless, respondents had mixed feelings on the quality of PNC services and expressed a stark difference in their perception of factors affecting service quality. Service users described challenges arising from ineffective communication about the new PNC guidelines, and non-adherence of service providers to quality standards regarding respect, preservation of dignity and emotional support. Other factors were long waiting hours, small examination rooms providing inadequate privacy, and low levels of confidentiality. In contrast, service providers attributed poor service quality to various health system-related factors including low staffing levels, dysfunctional referral services, low supply of essential medicines, supplies, vaccines and equipment for optimal routine emergency obstetric and newborn care and management of complications.

CONCLUSION

These findings highlight important intervention opportunities to improve quality of PNC services in Zambia through better communication and raising awareness on PNC guidelines, respect, preservation of dignity and emotional support to mothers. Interventions should also focus on addressing contextual health system challenges including staffing levels, supply chain for essential medicines and commodities, shortening waiting time, and ensuring functional referral system.

Factors that influence uptake of routine postnatal care: Findings on women's perspectives from a qualitative evidence synthesis

BACKGROUND

Effective postnatal care is important for optimal care of women and newborns-to promote health and wellbeing, identify and treat clinical and psychosocial concerns, and to provide support for families. Yet uptake of formal postnatal care services is low and inequitable in many countries. As part of a larger study examining the views of women, partners, and families requiring both routine and specialised care, we analysed a subset of data on the views and experiences of women related to routine postnatal care.

METHODS

We undertook a qualitative evidence synthesis, using a framework analysis approach. We included studies published up to December 2019 with extractable qualitative data, with no language restriction. We focused on women in the general population and their accounts of routine postnatal care utilization. We searched MEDLINE, PUBMED, CINAHL, EMBASE, EBM-Reviews, and grey literature. Two reviewers screened each study independently; inclusion was agreed by consensus. Data abstraction and scientific quality assessment were carried out using a study-specific extraction form and established quality assessment tools. The analysis framework was developed a priori based on previous knowledge and research on the topic and adapted. Due to the number of included texts, the final synthesis was developed inductively from the initial framework by iterative sampling of the included studies, until data saturation was achieved. Findings are presented by high versus low/middle income country, and by confidence in the finding, applying the GRADE-CERQual approach.

FINDINGS

Of 12,678 papers, 512 met the inclusion criteria; 59 articles were sampled for analysis. Five themes were identified: access and availability; physical and human resources; external influences; social norms; and experience of care. High confidence study findings included the perceived low value of postnatal care for healthy women and infants; concerns around access and quality of care; and women's desire for more emotional and psychosocial support during the postnatal period. These findings highlight multiple missed opportunities for postnatal care promotion and ensuring continuity of care.

CONCLUSIONS

Factors that influence women's utilization of postnatal care are interlinked, and include access, quality, and social norms. Many women recognised the specific challenges of the postnatal period and emphasised the need for emotional and psychosocial support in this time, in addition to clinical care. While this is likely a universal need, studies on mental health needs have predominantly been conducted in high-income settings. Postnatal care programmes and related research should consider these multiple drivers and multi-faceted needs, and the holistic postpartum needs of women and their families should be studied in a wider range of settings.

REGISTRATION

This protocol is registered in the PROSPERO database for systematic reviews: CRD42019139183.

Why did performance-based financing in Burkina Faso fail to achieve the intended equity effects? A process tracing study

In recent years, performance-based financing (PBF) has attracted attention as a means of reforming provider payment mechanisms in low- and middle-income countries. Particularly in combination with demand-side interventions, PBF has been assumed to benefit also the most vulnerable and disadvantaged groups. However, impact evaluations have often found this not to be the case. In Burkina Faso, PBF was coupled with specific equity measures to enhance healthcare utilization among the ultra-poor, but failed to produce the expected effects. Our study used the process tracing methodology to unravel the reasons for the lack of impact produced by the equity measures. We relied on published evidence, secondary data analysis, and findings from a qualitative study to support or invalidate the hypothesized causal mechanism, that is the reconstructed theory of change of the equity measures. Our findings show how various contextual, design, and implementation challenges hindered the causal mechanism from unfolding as planned. These included issues with the identification and exemption of the ultra-poor on the demand side, and with financial issues and considerations on the supply side. In broader terms, our findings underline the difficulty in improving access to care for the ultra-poor, given the multifaceted and complex nature of barriers to care the most vulnerable face. From a methodological point of view, our study demonstrates the value and applicability of process tracing in complementing other forms of evaluation for complex interventions in global health.

Timing of maternal mortality and severe morbidity during the postpartum period

Objective:

The objective of this review was to determine the timing of overall and cause-specific maternal mortality and severe morbidity during the postpartum period.

Introduction:

Many women continue to die or experience adverse health outcomes in the postpartum period; however, limited work has explored the timing of when women die or present complications during this period globally.

Inclusion criteria:

This review considered studies that reported on women after birth up to 6 weeks postpartum and included data on mortality and/or morbidity on the first day, days 2–7, and days 8–42. Studies that reported solely on high-risk women (eg, those with antenatal or intrapartum complications) were excluded, but mixed population samples were included (eg, low-risk and high-risk women).

Methods:

MEDLINE, Embase, Web of Science, and CINAHL were searched for published studies on December 20, 2019, and searches were updated on May 11, 2021. Critical appraisal was undertaken by 2 independent reviewers using standardized critical appraisal instruments from JBI. Quantitative data were extracted from included studies independently by at least 2 reviewers using a study-specific data extraction form. Quantitative data were pooled, where possible. Identified studies were used to obtain the summary estimate (proportion) for each time point. Maternal mortality was calculated as the maternal deaths during a given period over the total number of maternal deaths known during the postpartum period. For cause-specific analysis, number of deaths due to a specific cause was the numerator, while the total number of women who died due to the same cause in that period was the denominator. Random effects models were run to pool incidence proportion for relative risk of overall maternal deaths. Subgroup analysis was conducted according to country income classification and by date (ie, data collection before or after 2010). Where statistical pooling was not possible, the findings were reported narratively.

Results:

A total of 32 studies reported on maternal outcomes from 17 reports, all reporting on mixed populations. Most maternal deaths occurred on the first day (48.9%), with 24.5% of deaths occurring between days 2 and 7, and 24.9% occurring between days 8 and 42. Maternal mortality due to postpartum hemorrhage and embolism occurred predominantly on the first day (79.1% and 58.2%, respectively). Most deaths due to postpartum eclampsia and hypertensive disorders occurred within the first week (44.3% on day 1 and 37.1% on days 2–7). Most deaths due to infection occurred between days 8 and 42 (61.3%). Due to heterogeneity, maternal morbidity data are described narratively, with morbidity predominantly occurring within the first 2 weeks. The mean critical appraisal score across all included studies was 85.9% (standard deviation = 13.6%).

Conclusion:

Women experience mortality throughout the entire postpartum period, with the highest mortality rate on the first day. Access to high-quality care during the postpartum period, including enhanced frequency and quality of postpartum assessments during the first 42 days after birth, is essential to improving maternal outcomes and to continue reducing maternal mortality and morbidity worldwide.

Systematic review registration number:

PROSPERO CRD42020187341