Barriers and facilitators to health care seeking behaviours in pregnancy in rural communities of southern Mozambique

Assessing Maternal Satisfaction: Patient-Centered Care, Hospital Environment, and Information-Seeking in Chanika Hospital in Tanzania

This study examined the impact of patient-centered care, satisfaction with the hospital environment, and maternal information-seeking on maternal healthcare satisfaction in Tanzania. A total of 707 mothers who delivered at Chanika Hospital in Tanzania were surveyed using a structured questionnaire. Multiple regression analyses were conducted to identify factors related to maternal satisfaction. Only 9.9% of the participants reported that they "usually" or "always" felt involved in treatment decisions. High levels of satisfaction were found for hospital cleanliness (93.6%) and safety (94.9%). However, there was a significant gap in satisfaction regarding the adequacy of water quality for medical services, with only 8.1% expressing satisfaction. Limited use of digital platforms was observed in terms of information-seeking behavior for fetal development, with only 19.5% of the participants using the internet and 14.3% using mobile apps. Patient-centered experiences with healthcare providers, especially midwives, had a significant positive impact on maternal satisfaction (β = 0.11, p = 0.021). Other significant variables were satisfaction with the hospital environment (β = 0.25, p < 0.001) and satisfaction with hospital water (β = 0.13, p < 0.001). It is recommended that healthcare improvements focus on patient-centered experiences and water quality for drinking and medical services to improve patient satisfaction.

Perspectives of women on availing antenatal services in urban poor areas of Rishikesh, Uttarakhand

Background Antenatal care (ANC) is the essential regular care of women that prevents potential health problems during pregnancy. In India, the proportion of women who received four or more antenatal visits was only 51% (National Family Health Survey, 2015-2016). An even worse situation prevails in urban areas where women from poor communities face greater health risks. We assessed various barriers women residing in these areas come across in availing ANC services. Methods This study is a part of a mixed-methods, community-based study, and we report its qualitative component. We conducted the study at the residence of the study participants in September-October 2019. The study participants were women who had less than four antenatal visits throughout the pregnancy. Twelve in-depth interviews were conducted based on data saturation. Data were transcribed and themes were drawn concerning the gender analysis framework. Results Through this study, we found how gender relations affect the utilization of antenatal services concerning access to resources, division of labour, social norms including the belief of husband and other family members towards pregnancy and decision-making power of women. Conclusion Our findings underline the importance of making the urban health system gender-sensitive and responsive to the needs of women during pregnancy. There is a need to educate men regarding maternal health so as to allay such social norms that label pregnancy as a woman's responsibility and encouraging them to accompany their wives during pregnancy visits, thus making men a part of antenatal services.

Health care seeking behaviors of pregnant women in rural Amhara, Ethiopia: a qualitative study of perceptions of pregnant women, community members, and health care providers

Introduction

in Ethiopia, increasing access to basic antenatal and neonatal health services may improve maternal and newborn survival. This study examined perceptions regarding antenatal health seeking behaviors from pregnant women, their families, community members, and health care providers in rural Amhara, Ethiopia.

Methods

the study was conducted in four rural districts of the Amhara region of Ethiopia. A total of forty participants who were living and working within the catchment areas of the selected health centres were interviewed from October 3rd through October 14th, 2018. A phenomenological qualitative study design was used to understand participants' perceptions and experiences about pregnant women's health care seeking behaviors.

Results

early disclosure of pregnancy status was not common in the study area. However, the data from the present study further provided new information, suggesting that some women did disclose their pregnancy status early but preferentially only to their partners and close relatives. Most women did not seek care unless sick or experienced new discomfort or pain. Some reasons for the low utilization of available antenatal services include long distance to health facilities, lack of transportation, difficult topography, and discomfort with male providers.

Conclusion

despite the rapid expansion of health posts and deployment of health extension workers since 2003, there are still critical barriers to accessing facility-based care that limit women's health care seeking practices.

Exploring Knowledge about Fang Traditional Medicine: An Informal Health Seeking Behaviour for Medical or Cultural Afflictions in Equatorial Guinea

This study explores a range of informal health-seeking behaviors, including the use of Fang Traditional Medicine (FTM) for medical or cultural afflictions in Equatorial Guinea (EQ), the therapeutic methods used, the health problems handled, the learning process, traditional medicine user profiles and the social images of Fang Traditional Healers (FTHs). Ethnography was employed as a qualitative strategy using emic–etic approaches. Semi-structured interviews were conducted with 45 individuals, including 6 community leaders, 19 tribal elders, 7 healthcare professionals, 11 FTHs and 2 relatives of traditional healers in 5 districts of EQ. FTM offers a cure for malaria and treatments for reproductive health issues, bone fractures and cultural illnesses. Several methods used to learn FTM are based on empirical observation, and without the need for traditional schooling, unlike with Western medical professionals: for example, watching a family member, or the spirits or ancestors, can reveal healing knowledge. Materials from forests, including tree barks and plants, and rituals are used to keep Fang populations healthy; in addition, two rituals known as “osuiñ” and “etoak” (infusions of tree barks with the blood of sacrificed animals) are the most commonly used treatments. In addition, elders and women are the most active consumers of FTM. FTM plays a relevant role in curing medical and cultural afflictions in Fang communities. The informal health-seeking behavior among the Fang community is conditioned by the explanation model of illness.

Neurological disorders in pregnant women in low- and middle-income countries-Management gaps, impacts, and future prospects: A review perspective

Neurological disorders during pregnancy are a substantial threat to women's health, particularly in low- and middle-income countries. Furthermore, a critical shortage of mental health workers and neurologists exacerbates the already pressing issue, where a lack of coordination of respective healthcare among multidisciplinary teams involved in managing these conditions perpetuates the current state of affairs. Financial restrictions and societal stigmas associated with neurological disorders in pregnancy amplify the situation. Addressing these difficulties would necessitate a multifaceted approach comprising investments in healthcare infrastructure, healthcare professional education and training, increased government support for research, and the implementation of innovative care models. Improving access to specialized treatment and coordinated management of antenatal neurological diseases will precipitate improved health outcomes for women and their families in low- and middle-income countries.

Barriers and strategies needed to improve maternal health services among pregnant adolescents in Uganda: a qualitative study

BACKGROUND

In Uganda, the uptake of maternal health services is very low, with only 41.1% of pregnant adolescent girls attending the eight antenatal visits that are recommended by the World Health Organisation. Uptake of maternal health services is essential in reducing the current level of adolescent pregnancies as well as its adverse effects on adolescent mothers and their babies, such as preterm deliveries, prolonged labour, death during pregnancy, and childbirth. No previous study has described pregnant adolescents' experiences with maternal health services in Uganda.

OBJECTIVE

This study aimed to describe the barriers and strategies needed to improve maternal health services among pregnant adolescents in Uganda.

METHODS

Data were collected in the Naguru Teenage Information and Health Centre in Uganda through individual interviews involving 31 pregnant adolescents. The transcribed interviews were inductively analysed through content analysis.

RESULTS

The pregnant adolescents described difficulty in reaching, as well as lack of financial support to visit, the Naguru Teenage Information and Health Centre, which is a clinic providing youth friendly services. Feelings of being discriminated against and disrespected by health workers, and lack of privacy when receiving health services was major barriers that hindered their access to maternal health services. Pregnant adolescents' access to these services can be enhanced by improving health workers' working conditions, accelerating community and health worker awareness on ways to mitigate these barriers, and developing policies that encourage men's involvement in maternal health services.

CONCLUSION

Adolescents in Uganda face considerable barriers to accessing improved and quality maternal health services. To mitigate these barriers, according to the adolescents, considerable efforts are required to tackle health workers' working conditions and sensitise the community on the importance of, as well as securing the availability of, maternal health services for pregnant adolescents. Future research should focus on pregnant adolescents who receive family support.

The social dimensions of community delivery of intermittent preventive treatment of malaria in pregnancy in Madagascar, Mozambique, Nigeria and the Democratic Republic of the Congo

INTRODUCTION

Intermittent preventive treatment in pregnancy with sulphadoxine pyrimethamine (IPTp) is a key malaria prevention strategy in sub-Saharan African countries. We conducted an anthropological study as part of a project aiming to evaluate a community-based approach to the delivery of IPTp (C-IPTp) through community health workers (CHWs) in four countries (the Democratic Republic of Congo, Madagascar, Mozambique and Nigeria), to understand the social context in order to identify key factors that could influence C-IPTp acceptability.

METHODS

A total of 796 in-depth interviews and 265 focus group discussions were undertaken between 2018 and 2021 in the four countries with pregnant women, women of reproductive age, traditional and facility-based healthcare providers, community leaders, and relatives of pregnant women. These were combined with direct observations (388) including both community-based and facility-based IPTp delivery. Grounded theory guided the overall study design and data collection, and data were analysed following a combination of content and thematic analysis.

RESULTS

A series of key factors were found to influence acceptability, delivery and uptake of C-IPTp in project countries. Cross-cutting findings include the alignment of the strategy with existing social norms surrounding pregnancy and maternal health-seeking practices, the active involvement of influential and trusted actors in implementation activities, existing and sustained trust in CHWs, the influence of husbands and other relatives in pregnant women's care-seeking decision-making, the working conditions of CHWs, pregnant women's perceptions of SP for IPTp and persistent barriers to facility-based antenatal care access.

CONCLUSIONS

The findings provide evidence on the reported acceptability of C-IPTp among a wide range of actors, as well as the barriers and facilitators for delivery and uptake of the intervention. Overall, C-IPTp was accepted by the targeted communities, supporting the public health value of community-based interventions, although the barriers identified should be examined if large-scale implementation of the intervention is considered.

The role of informational support from women's social networks on antenatal care initiation: qualitative evidence from pregnant women in Uganda

BACKGROUND

Early and appropriate use of antenatal care services is critical for reducing maternal and neonatal mortality and morbidity. Yet most women in sub-Saharan Africa, including Uganda, do not seek antenatal care until later during pregnancy. This qualitative study explored pregnant women's reliance on social ties for information about initiation of antenatal care.

METHODS

We conducted semi-structured, in-depth interviews with 30 pregnant women seeking their first antenatal care visit at Kawempe Referral Hospital in Kampala, Uganda. Recruitment was done purposively to obtain variation by parity and whether women currently had a male partner. Study recruitment occurred from August 25^th 2020 - October 26^th, 2020. We used thematic analysis following a two-stage coding process, with both deductive and inductive codes. Deductive codes followed the key domains of social network and social support theory.

RESULTS

We found that the most important source of information about antenatal care initiation was these women's mothers. Other sources included their mothers-in-law, female elders including grandmothers, and male partners. Sisters and female friends were less influential information sources about antenatal initiation. One of the primary reasons for relying on their own mothers, mothers-in-law, and elder women was due to these women's lived experience with pregnancy and childbirth. Trust in the relationship was also an important factor. Some pregnant women were less likely to rely on their sisters or female friends, either due to lack of trust or these women's lack of experience with pregnancy and childbirth. The advice that pregnant women received from their mothers and others on the ideal timing for antenatal care initiation varied significantly, including examples of misinformation about when to initiate antenatal care. Pregnant women seemed less likely to delay care when more than one social tie encouraged early antenatal care.

CONCLUSIONS

Educating women's social networks, especially their mothers, mothers-in-law, and community elders, about the importance of early antenatal care initiation is a promising avenue for encouraging pregnant women to seek care earlier in pregnancy.

Health information-seeking behavior among Congolese refugees

Background

The purpose of this cross-sectional study was to determine the extent to which Congolese refugees seek health information, to identify and assess the resources used while exercising Health Information-Seeking Behavior (HISB), and to identify individual determinants that affect their HISB.

Methodology

Building Bridges program participants who resided in Texas between 2017–2020, reported country of origin as Democratic Republic of Congo, and responded to HISB questions were included in this study. Four HISB questions asked about frequency seeking health information, preferred source and perceived trustworthiness of source, and frequency worrying about their health. Associations between HISB and sociodemographic factors (age, gender, education years, years in US, proficiency speaking English, marital status) were tested using Pearson chi-square or Fisher’s exact tests (α≤0.05).

Results

Most participants (59%) reported seeking health information sometimes. Less than half (44%) of participants identified doctors as their preferred source of health information, Twenty-five percent relied on family, friends, and community leaders, and 23% used media sources. Doctors were identified as the most trustworthy source (71%), family and friends were the second highest trusted source (25%), whereas media sources were the least trusted (4%). Sociodemographic factors age (p = .02), gender (p < .01), and education years (p < .01) were the only significant predictors of preferred information sources. Conversely, those residing in US <5 years were more likely to seek health information more frequently (p = .01). The majority of participants did not worry about their health, and it was not significantly associated with source or frequency of seeking health information.

Conclusions

The high trust in doctors represents an opportunity for healthcare professionals to educate and address individual barriers contributing to refugees’ underutilization of preventive care services such as routine immunizations and preventive health screenings.

Implementation of the South African Triage Scale (SATS) in a New Ambulance System in Beira, Mozambique: A Retrospective Observational Study

In 2019, an urban ambulance system was deployed in the city of Beira, Mozambique to refer patients from peripheral health centres (HCs) to the only hospital of the city (Beira Central Hospital-HCB). Initially, the system worked following a first-in-first-out approach, thus leading to referrals not based on severity condition. With the aim of improving the process, the South African Triage Scale (SATS) has been subsequently introduced in three HCs. In this study, we assessed the impact of SATS implementation on the selection process and the accuracy of triage performed by nurses. We assessed 552 and 1608 referral charts from before and after SATS implementation, respectively, and we retrospectively calculated codes. We compared the expected referred patients' codes from the two phases, and nurse-assigned codes to the expected ones. The proportion of referred orange and red codes significantly increased (+12.2% and +12.9%) while the proportion of green and yellow codes decreased (-18.7% and -5.8%). The overall rates of accuracy, and under- and overtriage were 34.2%, 36.3%, and 29.5%, respectively. The implementation of SATS modified the pattern of referred patients and increased the number of severe cases receiving advanced medical care at HCB. While nurses' accuracy improved with the routine use of the protocol, the observed rates of incorrect triage suggest that further research is needed to identify factors affecting SATS application in this setting.

Factors Associated with Underutilization of Maternity Health Care Cascade in Mozambique: Analysis of the 2015 National Health Survey

Maternity health care services utilization determines maternal and neonate outcomes. Evidence about factors associated with composite non-utilization of four or more antenatal consultations and intrapartum health care services is needed in Mozambique. This study uses data from the 2015 nationwide Mozambique’s Malaria, Immunization and HIV Indicators Survey. At selected representative households, women (n = 2629) with child aged up to 3 years answered a standardized structured questionnaire. Adjusted binary logistic regression assessed associations between women-child pairs characteristics and non-utilization of maternity health care. Seventy five percent (95% confidence interval (CI) = 71.8–77.7%) of women missed a health care cascade step during their last pregnancy. Higher education (adjusted odds ratio (AOR) = 0.65; 95% CI = 0.46–0.91), lowest wealth (AOR = 2.1; 95% CI = 1.2–3.7), rural residency (AOR = 1.5; 95% CI = 1.1–2.2), living distant from health facility (AOR = 1.5; 95% CI = 1.1–1.9) and unknown HIV status (AOR = 1.9; 95% CI = 1.4–2.7) were factors associated with non-utilization of the maternity health care cascade. The study highlights that, by 2015, recommended maternity health care cascade utilization did not cover 7 out of 10 pregnant women in Mozambique. Unfavorable sociodemographic and economic factors increase the relative odds for women not being covered by the maternity health care cascade.

Factors Associated with Caesarean and Peripartum Complications at Southern Mozambique’s Rural Hospitals: A Cross-Sectional Analytical Study

Information about factors underlying peripartum complications is needed to inform health programs in Mozambique. This retrospective study covered the period from January 2013 to December 2018 and was performed at three rural-district hospitals in southern Mozambique, aiming at assessing factors associated with caesarean and peripartum complications. Data were extracted by clinical criteria-based audits on randomly select clients’ files. Logistical regression was used to identify factors associated with peripartum complications. Amongst 5068 audited files, women mean age was 25 years (Standard Deviation (SD) = 7), gestational age was 38 weeks (SD = 2), 25% had “high obstetric-risk” and 19% delivered by caesarean. Factors significantly associated with caesarean included being transferred [Adjusted Odds Ratio (aOR) =1.8; 95% Confidence Interval (95%CI) = 1.3–2.6], preeclampsia [aOR (95%CI) = 2.0 (1.2–3.3)], age [aOR (95%CI) = 0.96 (0.93–0.99)] and “high obstetric-risk” [aOR (95%CI) = 0.54 (0.37–0.78)]. Factors significantly associated with neonatal complication included mother being transferred [aOR (95%CI) = 2.1 (1.8–2.6)], “high obstetric-risk” [aOR (95%CI) = 1.6 (1.3–1.96)], preeclampsia [aOR (95%CI) = 1.5 (1.2–1.8), mother’s age [aOR (95%CI) = −2% (−3%, −0.1%)] and gestational age [aOR (95%CI) = −8% (−13%, −6%)] increment. This study identified amendable factors associated with peripartum complications in rural referral health settings. Strengthening hospitals’ performance assurance is critical to address the identified factors and improve peripartum outcomes for mothers-neonate dyads.

How Gender Influenced the Experience of Using a mHealth Intervention in Rural Mozambique: Secondary Qualitative Analysis of Community Health Worker Survey Data

Background

The mixed-gender community health worker (CHW) program in Mozambique is a window into the different experiences that male and female CHWs may face in their work. The objective of this study is to investigate how gender influenced the experiences of community health workers using the PIERS on the Move (POM) mHealth app in Mozambique.

Methods

This is a secondary analysis by gender of health care workers involved in the Mozambique Community Level Intervention for Pre-eclampsia (CLIP) cluster randomized trial (NCT01911494). A structured survey with 10 open-ended questions was used to elicit CHW experiences using the POM app. Data collection took place in 2017 after completion of the CLIP trial. This analysis examined emergent themes to consider how experiences may have been shaped by health worker gender.

Results

Of the 43 CHWs who used the POM app, there were 31 (72%) women and 12 (28%) men. Gender differences emerged in descriptions of how using POM increased their value and respect by pregnant women and community members. Fifty-eight percent of female CHWs (18/31) said that POM positively influenced their status in the community in comparison to 33% of their male counterparts (4/12). While the small sample sizes, particularly of male CHWs who used POM, preclude conclusions, these findings were supported by qualitative results. Female CHWs tended to elaborate more about community perceptions of their increased value and status as health care providers than male CHWs.

Conclusion

CHWs work within existing gender norms. While gender norms are perceived to support the comfort of women to speak to another woman about their maternal and child health issues, gender norms also work against female CHWs as their professionalism may be questioned more than for their male counterparts. CHW's narratives suggested that the mHealth intervention was valued beyond the technology itself because it also added symbolic clinical value and demonstrated a tangible investment in their professional capacities, which may have been especially appreciated by the female CHWs.

Health-Seeking Behaviors in Mozambique: A Mini-Study of Ethnonursing

In settings where traditional medicine is a crucial part of the healthcare system, providing culturally competent healthcare services is vital to improving patient satisfaction and health outcomes. Therefore, this study sought to gain insight into how cultural beliefs influence health-seeking behaviors (HSBs) among Mozambicans. Participant observation and in-depth interviews (IDIs) were undertaken using the ethnonursing method to investigate beliefs and views that Mozambicans (living in Pemba City) often take into account to meet their health needs. Data were analyzed in accordance with Leininger’s ethnonursing guidelines. Twenty-seven IDIs were carried out with 12 informants from the Makonde and Makuwa tribes. The choice of health service was influenced by perceptions of health and illness through a spiritual lens, belief in supernatural forces, dissatisfaction with and dislike of the public medical system on grounds of having received poor-quality treatment, perceived poor communication skills of health professionals, and trust in the indigenous medical system. This study confirmed the need for health professionals to carefully take cultural influences into consideration when providing care for their patients. We recommend an educational intervention that emphasizes communication skills training for healthcare workers to ensure successful physician/nurse–patient relationships.

Rural Transportation Infrastructure in Low- and Middle-Income Countries: A Review of Impacts, Implications, and Interventions

The rural transport infrastructure sector is a critical force for sustainable development that is interwoven with many other sectors. Rural transportation is an underlying driver of many of the Sustainable Development Goals (SDGs) and a crucial contributor to many socioeconomic benefits for rural people around the world. This review paper expands upon, enhances, and cross-references the perspectives outlined in previous rural infrastructure-focused review papers. Firstly, this work gives a thorough look into the progress of the rural transportation sector in recent years by focusing on the thematic relationships between infrastructure and other components of sustainable development, namely, economics and agriculture, policy and governance, health, gender, education, and climate change and the environment. Secondly, several strategies, approaches, and tools employed by governments and practitioners within the rural transport sector are analyzed and discussed for their contributions to the wellbeing of rural dwellers in low- and middle-income countries (LMICs). These include rural roads, bridges, maintenance, and non-infrastructural approaches that include concepts such as advanced technological innovations, intermediate modes of transport (IMTs), and transport services. This paper concludes that enhancement, improvement, and extension of rural transportation infrastructure brings significant benefits to rural dwellers. However, this paper also calls for additional integration of the sector and increased usage of systems approaches that view rural transport as an active part of many other sectors and a key leverage point within rural development as a whole. Further, this paper notes areas for future research and investigation, including increased investigation of the relationship between rural transportation infrastructure and education, improved data collection and management in support of improved policymaking, improved prioritization of interventions and institutionalization of maintenance, and expansion of pro-poor transportation strategies and interventions.

Determinants of accessing healthcare in Sub-Saharan Africa: a mixed-effect analysis of recent Demographic and Health Surveys from 36 countries

OBJECTIVE

This study aimed to assess the determinants of accessing healthcare among reproductive-age women in Sub-Saharan Africa (SSA).

DESIGN, SETTING AND ANALYSIS

Cross-sectional data were sourced from recent Demographic and Health Surveys in 36 SSA countries. We employed mixed-effect analysis to identify the determinants of accessing healthcare in SSA. OR and its 95% CI were reported for determinants associated with accessing healthcare.

OUTCOME

The outcome for this study was whether accessing healthcare was a 'big problem' or 'not a big problem'. Responses to these questions were categorised as a big problem and not a big problem.

PARTICIPANTS

A total weighted sample of 500 439 reproductive-age (15-49 years) women from each country's recent Demographic and Health Surveys from 2006 to 2018 were included in this study.

RESULTS

The pooled prevalence of healthcare access among reproductive-age women in SSA was 42.56% (95% CI 42.43% to 42.69%). The results of the mixed-effect analysis revealed that the determinants of accessing healthcare were urban residence (adjusted OR (AOR)=1.25, 95% CI 1.34 to 1.73), ability to read and write (AOR=1.15, 95% CI 1.22 to 1.28), primary education (AOR=1.08, 95% CI 1.07 to 1.12), secondary education and above (AOR=1.12, 95% CI 1.10 to 1.14), husband with primary education (AOR=1.06, 95% CI 1.07 to 1.1.12), husband with secondary education and above (AOR=1.22, 95% CI 1.18 to 1.27), middle wealth index (AOR=1.43, 95% CI 1.40 to 1.47), rich wealth index (AOR=2.19, 95% CI 2.13 to 2.24) and wanted pregnancy (AOR=1.27, 95% CI 1.19 to 1.29).

CONCLUSION

Healthcare access in SSA was found at 42.56%, which is very low even if Sustainable Development Goal 3.8 targeted universal health coverage for everyone so they can obtain the health services they need. The major determinants of healthcare access among reproductive-age women in SSA were urban residence, higher educational level, higher wealth index and wanted pregnancy. The findings of this study suggest and recommend strengthening and improving healthcare access for women who reside in the countryside, women with low level of education and women of low socioeconomic status.

Antenatal Care Research in East Africa During the Millennium Development Goals Initiative: A Scoping Review

INTRODUCTION

The global burden of maternal mortality remains high and inequitably distributed between countries. Antenatal care (ANC) was identified as critical component in achieving the Millennium Development Goal of improving maternal health. This scoping review aimed to summarize trends and critically explore research about ANC attendance for East African women conducted during the Millennium Development Goals initiative, with a specific focus on barriers to ANC access.

METHODS

Using a scoping review methodology, aggregator databases were searched for relevant articles. Articles were screened by independent reviewers using a priori inclusion criteria. Eligible articles were retained for data charting and analysis.

RESULTS

Following screening, 211 articles were analyzed. The number of relevant articles increased over time; utilized primarily quantitative methods; and involved authors with affiliations from various African countries. Many interrelated physical, social, and cultural factors influenced women's seeking, reaching, and receiving of quality ANC. The extent of studies identified suggest that ANC is a priority research area, yet key gaps in the literature exist. Limited qualitative research, and few articles examining ANC experiences of women from vulnerable groups (e.g. adolescents, women with a disability, and Indigenous women) were identified.

DISCUSSION

These context-specific findings are important considering the Sustainable Development Goals aim to nearly triple the maternal mortality reductions by 2030. In order to achieve this goal, interventions should focus on improving the quality of ANC care and patient-provider interactions. Furthermore, additional qualitative research examining vulnerable populations of women and exploring the inclusion of men in ANC would help inform interventions intended to improve ANC attendance in East Africa.

Community mobilization to strengthen support for appropriate and timely use of antenatal and postnatal care: A review of reviews

Background

Antenatal care (ANC) and postnatal care (PNC) are critical opportunities for women, babies and parents/families to receive quality care and support from health services. Community-based interventions may improve the accessibility, availability, and acceptance of this vital care. For example, community mobilization strategies have been used to involve and collaborate with women, families and communities to improve maternal and newborn health.

Objective

To synthesize existing reviews of evidence on community mobilization strategies that strengthen support for appropriate and timely use of ANC and PNC.

Methods

Six databases (MEDLINE, Embase, CINAHL, PsychINFO, Cochrane Library, PROSPERO) were searched for published reviews that describe community mobilization related strategies for ANC and/or PNC. Reviews were eligible for inclusion if they described any initiatives or strategies targeting the promotion of ANC and/or PNC uptake that included an element of community mobilization in a low- or middle-income country (LMIC), published after 2000. Included reviews were critically appraised according to the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Evidence Syntheses. This review of reviews was conducted following JBI guidelines for undertaking and reporting umbrella reviews.

Results

In total 23 papers, representing 22 reviews were included. While all 22 reviews contained some description of community mobilization and ANC/PNC, 13 presented more in-depth details on the community mobilization processes and relevant outcomes. Seventeen reviews focused on ANC, four considered both ANC and PNC, and only one focused on PNC. Overall, 16 reviews reported at least one positive association between community mobilization activities and ANC/PNC uptake, while five reviews presented primary studies with no statistically significant change in ANC uptake and one included a primary study with a decrease in use of antenatal facilities. The community mobilization activities described by the reviews ranged from informative, passive communication to more active, participatory approaches that included engaging individuals or consulting local leaders and community members to develop priorities and action plans.

Conclusions

While there is considerable momentum around incorporating community mobilization activities in maternal and newborn health programs, such as improving community support for the uptake of ANC and PNC, there is limited evidence on the processes used. Furthermore, the spectrum of terminology and variation in definitions should be harmonized to guide the implementation and evaluation efforts.

Experiences from the Field: A Qualitative Study Exploring Barriers to Maternal and Child Health Service Utilization in IDP Settings Somalia

Background

In Somalia, maternal and child health service utilization is unacceptably low. Little is known about factors contributing to low maternal and child health service utilization in Somalia, especially in internally displaced people (IDP) settings. This study aimed to understand barriers to the use of maternal and child health-care services among IDPs in Mogadishu.

Methods

A total of 17 in-depth interviews (IDIs), 7 focus group discussions (FGDs), and field observations were conducted on lactating/pregnant mothers, health-care providers, traditional birth attendants (TBA), and IDP camp leaders. The socio-ecological model (SEM) framework was employed for the categorization of barriers to healthcare utilization and further analysis was conducted to understand the major types and nature of barriers.

Results

Using the SEM, the following major barriers that hinder maternal and child health service utilization were identified. Low socio-economic, lack of decision making power of women, TBA trust, poor knowledge and awareness on pregnancy danger signs, fear of going to unfamiliar areas were identified barriers at individual level. Traditional beliefs, male dominance in decision making, and lack of family support were also identified barriers at interpersonal level. Security and armed conflict barriers and formidable distance to health facility were identified barrier at the community level. Lack of privacy in the facility, transportation challenges, poor functional services, negative experiences, closure of the health facility in some hours, and lack of proper referral pathways were identified barriers at organizational or policy level.

Conclusion

Overall, various factors across different levels of SEM were identified as barrier to the utilization of maternal and child health services. Hence, multi-component interventions that target these complex and multifaceted barriers are required to be implemented in order to improve maternal and child health services utilization among IDP in Mogadishu, Somalia.

Psychosocial factors and health practices in pregnancy: A cross-sectional study

AIM

The aim of this study was to investigate psychosocial, demographic and obstetric factors that affect health practices in pregnancy.

METHODS

This cross-sectional study was conducted with pregnant women selected by using random sampling in a public hospital in Turkey. The pregnant women (n = 383) completed the Health Practices Questionnaire in Pregnancy, the Center for Epidemiologic Studies Depression Scale, the Beck Anxiety Inventory and the Multidimensional Scale of Perceived Social Support. Multiple linear regression was used to examine predictors of participation in health practices. The variables were subjected to multiple linear regression analysis to estimate the effect of each independent variable (depression, anxiety, perceived social support, age, educational level, gestational week and parity) on the dependent variable (health practices).

RESULTS

Depression and anxiety were not significantly related to gestational health practices. The multiple linear regression model showed that inadequate social support, low education level, early gestational week and high parity were significant predictors of nonengagement in favourable health practices during pregnancy.

CONCLUSIONS

Pregnant women with inadequate social support and specific demographic and obstetric characteristics are less likely to participate in gestational health practices. This study suggests that more attention should be paid to these groups to improve the health practices of pregnant women.

Household Socioeconomic Status and Antenatal Care Utilization Among Women in the Reproductive-Age

The study examined the effect of household socioeconomic status and other socio-demographic characteristics on antenatal care (ANC) utilization among 819 women within the reproductive ages across eight rural communities in Delta State, Southern part of Nigeria. Characteristics of the women were described using simple proportion and frequency. The chi-square test was used to examine factors that were significantly associated with a minimum of four (≥4) and eight (≥8) antenatal care contacts, which were respectively in line with the focused ANC and WHO's new guideline. The multivariable logistic regression was used to examine the determinants of a minimum of four and eight ANC. Statistical analyses were set at 5%. The results showed that 31.4% (257/819) and 2.2% (18/819) of mothers, respectively, made ≥ 4 and ≥ 8 ANC contacts in the course of their last pregnancies. According to the results, the odds for reporting 4≥ and ≥ 8 ANC improved with both wealth and educational attainment. Distance to the health center and cost are barriers to maternal care utilization and they reduce the odds for undertaking ≥ 4 and ≥8 ANC contacts. Women on higher media exposure were more likely to undertake ≥ 4 and ≥8 ANC contacts, and those on the highest media exposure were more likely to undertake ≥8 ANC contacts. Financing maternal care through health insurance and free maternal care significantly improves the odds to undertake ≥ 4 and ≥ 8 ANC contacts. Intervention programs should be designed to improve access to maternal care services and should expand education opportunities for mothers, improve household socioeconomic conditions, and encourage enrolment in health insurance and free maternal care in the study area.

Role of male partners in the long-term well-being of women who have experienced severe pre-eclampsia and eclampsia in rural Tanzania: a qualitative study

Men can be essential sources of support in maternal health, even more so in case of severe acute maternal morbidity (SAMM), affecting 1-2% of childbearing women in low-resource settings. In a qualitative study using semi-structured interviews, we explored the perspectives of nine male partners of women who suffered from (pre-)eclampsia six to seven years earlier in rural Tanzania. Male partners considered their role to be pivotal regarding finances, decision-making in healthcare-seeking and family planning and provided physical and emotional support. After SAMM, households may be affected in the long run. Some men took over their female partner's household duties until up to two years after birth. Providing men with more information on complication readiness and birth preparedness would enable them to extend their role in maternal morbidity prevention.IMPACT STATEMENTWhat is already known on this subject? The essential role of male partners in maternal health in low- and middle-income countries is well-studied in relation to its impact on care-seeking behaviour. After childbirth, the long-term role of male partners has not yet been studied.What do the results of this study add? We demonstrated the important role of men during, but also after SAMM. Households may be affected years after women suffered from SAMM. For women with the most urgent support needs, this study suggest that at least some men feel responsible for their partner and have different pivotal roles.What are the implications of these findings for clinical practice and/or further research? Because of their motivation to support their female partner, strategies to reduce recurring complications in subsequent pregnancies should include targeting male partners, for example, by increasing birth preparedness and complication readiness. Further studies should confirm the results from our innovative but small-scale study, as well as investigate the long-term role of male partners after uncomplicated births. Other studies could investigate the separation of couples after SAMM, family planning decisions after SAMM and strategies for involving men and increasing complication readiness and birth preparedness.

Feasibility of task-sharing with community health workers for the identification, emergency management and referral of women with pre-eclampsia, in Mozambique

BACKGROUND

Maternal mortality is an important public health problem in low-income countries. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. There is limited evidence on the role of community health workers in the management of pregnancy complications. This study aimed to describe the feasibility of task-sharing the initial screening and initiation of obstetric emergency care for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and document healthcare facility preparedness to respond to referrals.

METHOD

The study took place in Maputo and Gaza Provinces in southern Mozambique and aimed to inform the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial. This was a mixed-methods study. The quantitative data was collected through self-administered questionnaires completed by community health workers and a health facility survey; this data was analysed using Stata v13. The qualitative data was collected through focus group discussions and in-depth interviews with various community groups, health care providers, and policymakers. All discussions were audio-recorded and transcribed verbatim prior to thematic analysis using QSR NVivo 10. Data collection was complemented by reviewing existing documents regarding maternal health and community health worker policies, guidelines, reports and manuals.

RESULTS

Community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they have not been trained to manage obstetric emergencies. Furthermore, barriers at health facilities were identified, including lack of equipment, shortage of supervisors, and irregular drug availability. All primary and the majority of secondary-level facilities (57%) do not provide blood transfusions or have surgical capacity, and thus such cases must be referred to the tertiary-level. Although most healthcare facilities (96%) had access to an ambulance for referrals, no transport was available from the community to the healthcare facility.

CONCLUSIONS

This study showed that task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia were deemed feasible and acceptable at the community-level, but an effort should be in place to address challenges at the health system level.

How prepared is Mozambique to treat COVID-19 patients? A new approach for estimating oxygen service availability, oxygen treatment capacity, and population access to oxygen-ready treatment facilities

BACKGROUND

This study aims to assess the COVID-19 response preparedness of the Mozambican health system by 1) determining the location of oxygen-ready public health facilities, 2) estimating the oxygen treatment capacity, and 3) determining the population coverage of oxygen-ready health facilities in Mozambique.

METHODS

This analysis utilizes information on the availability of oxygen sources and delivery apparatuses to determine if a health facility is ready to deliver oxygen therapy to patients in need, and estimates how many patients can be treated with continuous oxygen flow for a 7-day period based on the available oxygen equipment at health facilities. Using GIS mapping software, the study team modeled varying travel times to oxygen-ready facilities to estimate the proportion of the population with access to care.

RESULTS

0.4% of all health facilities in Mozambique are prepared to deliver oxygen therapy to patients, for a cumulative total of 283.9 to 406.0 patients-weeks given the existing national capacity, under varying assumptions including ability to divert oxygen from a single source to multiple patients. 35% of the population in Mozambique has adequate access within one-hour driving time of an oxygen-ready health facility. This varies widely by region; 89.1% of the population of Maputo City was captured by the one-hour driving time network, as compared ot 4.4% of the population of Niassa province.

CONCLUSIONS

The Mozambican health system faces the dual challenges of under-resourced health facilities and low geographic accessibility to healthcare as it prepares to confront the COVID-19 pandemic. This analysis also illustrates the disparity between provinces in preparedness to deliver oxygen therapy to patient, with Cabo Delgado and Nampula being particularly under-resourced.

Determinants, reasons for choice and willingness to recommend birthing facility among mothers in public and private health facilities in Ebonyi, Nigeria

Introduction

facility-based births remain low in Nigeria despite the enormous benefits on maternal and neonatal health. We compared the determinants, reasons for choice and willingness to recommend public and private birthing facilities among mothers in Ebonyi, Nigeria.

Methods

this was a cross-sectional survey among 620 women whose childbirth occurred in public (teaching) and private-for-profit mission hospitals in Ebonyi, Nigeria. Semi-structured, interviewer-administered questionnaires were used for data collection.

Results

the mean age of the respondents was 29.86±4.4. Most had post-secondary education (71.0%), more than 4 antenatal visits (83.4%) and vaginal births (77.7%). Respondents with high economic status [adjusted odds ratio (aOR) 2.88; Confidence Interval (CI) 1.98-4.18], post-secondary education (aOR 1.73; CI 1.13-2.64) and urban residence (aOR 3.51; CI 2.19-5.61) were more likely to utilize public birthing facilities. In the private hospital, religion (78.4%) was the commonest reason for utilization while poor quality of services (61.9%) was the major cause of dissatisfaction. In the public hospital, the main reason for patronage was insurance enrolment (73.2%) while negative provider attitude (66.7%) led to dissatisfaction. In both facilities, majority (92%) were willing to recommend their birth facility to others.

Conclusion

regardless of facility type, respondents were willing to recommend or reuse the health facility for subsequent obstetric care. Religion and insurance enrolment were the major reasons for choosing the private and public hospital respectively. Residence, educational and income status influenced birthing facility type used. We recommend improved quality of services in private hospitals and provision of insurance with improved provider attitude in public health facilities.

Implementation of a Community Transport Strategy to Reduce Delays in Seeking Obstetric Care in Rural Mozambique

Encouraging local transport programs and transport infrastructure in poorly-resourced communities can help improve community access and strengthen engagement with health systems. Mobilizing community resources and leadership to implement a community-based transport scheme in rural Mozambique to support referrals to health facilities can help improve maternal and child health outcomes.

Introduction:

Delays due to long distances to health facilities, poor road infrastructure, and lack of affordable transport options contribute to the burden of maternal deaths in Mozambique. This study aimed to assess the implementation and uptake of an innovative community-based transport program to improve access to emergency obstetric care in southern Mozambique.

Methods:

From April 2016 to February 2017, a community transport strategy was implemented as part of the Community Level Interventions for Pre-eclampsia Trial. The study aimed to reduce maternal and perinatal mortality and morbidity by 20% in intervention clusters in Maputo and Gaza Provinces, Mozambique, by involving community health workers in the identification and referral of pregnant and puerperal women at risk. Based on a community-based participatory needs assessment, the transport program was implemented with the trial. Demographics, conditions requiring transportation, means of transport used, route, and outcomes were collected during implementation. Data were entered into a REDCap database.

Results:

Fifty-seven neighborhoods contributed to the needs assessment; of those, 13 (23%) implemented the transport program. Neighborhoods were selected based on their expression of interest and ability to contribute financially to the program (US$0.33 per family per month). In each selected neighborhood, a community management committee was created, training in small-scale financial management was conducted, and monitoring tools were provided. Twenty people from 9 neighborhoods benefited from the transport program, 70% were pregnant and postpartum women.

Conclusion:

These results demonstrate that it was feasible to implement a community-based transport program with no external input of vehicles, fuel, personnel, and maintenance. However, high cost and a lack of acceptable transport options in some communities continue to impede access to obstetric health care services and the ability for timely follow-up. When strengthening capacities of community health workers to promptly assist and refer emergency cases, it is crucial to encourage local transport programs and transportation infrastructure among minimally resourced communities to support access and engagement with health systems.

Community-funded integrated care outreach clinics as a capacity building strategy to expand access to health care in remote areas of Uganda

Most Ugandans live in rural, medically underserved communities where geography and poverty lead to reduced access to healthcare. We present a novel low-cost approach for supplemental primary care financing through 1) pooling community wealth to cover overhead costs for outreach clinic activities and 2) issuing microfinance loans to motorcycle taxi entrepreneurs to overcome gaps in access to transportation. The intervention described here, which leverages community participation as a means to extend the reach of government health service delivery, was developed and implemented by Health Access Connect (HAC), a non-governmental organization based in Uganda. HAC began its work in August 2015 in the Lake Victoria region and now serves over 40 sites in Uganda across 5 districts, helping government health-care workers to provide over 1,300 patient services per month (and over 35,000 since the program's inception) with an average administrative cost of $6.24 per patient service in 2020. In this article, we demonstrate how integrated and appropriately resourced monthly outreach clinics, based on a microfinance-linked model of wealth pooling and government cooperation, can expand the capacity of government-provided healthcare to reach more patients living in remote communities. This scalable, sustainable, and flexible model is responsive to shifting needs of patients and health systems and presents an alternative approach to healthcare financing in low-resource settings. More rigorous evaluation of health outcomes stemming from such community-based models of service delivery is warranted.

A qualitative exploration of barriers to health-facility-based delivery in Bomachoge-Borabu and Kaloleni, Kenya

OBJECTIVE

To explore barriers to utilization of health-facility-based delivery in Kenya, use of which is associated with reduced maternal mortality.

METHODS

In April 2017, a qualitative study utilizing key informant interviews (KIIs) and focus group discussions (FGDs) was carried out in Bomachoge-Borabu and Kaloleni, Kenya. Twenty-four KIIs were performed including health service providers, community health workers, religious leaders, local government representatives, Ministry of Health representatives, and representatives of women's organizations. Sixteen FGDs were held separately with adolescent females, adult females, adult males, and Community Health Committee members. Data were transcribed, coded, and categorized thematically to illustrate supply-side and demand-side barriers to use of health-facility-based delivery services.

RESULTS

Supply-side barriers included staff shortages, inadequate supplies and space, poor interpersonal relations, few trained staff, long distance to services, poor transport infrastructure, and limited service hours. Demand-side barriers included financial constraints, limited spousal support, observance of birthing traditions, limited knowledge on importance of health-facility-based delivery, and fear of health-facility procedures.

CONCLUSIONS

Diverse barriers continue to influence use of health-facility-based delivery services in Kenya. Practical, integrated interventions are urgently needed to reduce barriers noted, to further reduce the maternal mortality rate.

Barriers to accessing healthcare among women in Ghana: a multilevel modelling

BACKGROUND

Women's health remains a global public health concern, as enshrined in the Sustainable Development Goals. This study, therefore, sought to assess the individual and contextual factors associated with barriers to accessing healthcare among women in Ghana.

METHODS

The study was conducted among 9370 women aged 15-49, using data from the 2014 Ghana Demographic and Health Survey. Barrier to healthcare, derived from four questions- whether a woman faced problems in getting money, distance, companionship, and permission to see a doctor-was the outcome variable. Descriptive and multilevel logistic regression analyses were carried out. The fixed effect results of the multilevel logistic regression analyses were reported using adjusted odds ratios at a 95% confidence interval.

RESULTS

More than half (51%) of the women reported to have at least one form of barrier to accessing healthcare. Women aged 45-49 (AOR = 0.65, CI: 0.49-0.86), married women (AOR = 0.71, CI:0.58-0.87), those with a higher level of education (AOR = 0.51, CI: 0.37-0.69), those engaged in clerical or sales occupation (AOR = 0.855, CI: 0.74-0.99), and those who were covered by health insurance (AOR = 0.59, CI: 0.53-0.66) had lower odds of facing barriers in accessing healthcare. Similarly, those who listened to radio at least once in a week (AOR =0.77, CI: 0.66-0.90), those who watched television at least once a week (AOR = 0.75, CI: 0.64-0.87), and women in the richest wealth quintile (AOR = 0.47, CI: 0.35-0.63) had lower odds of facing barriers in accessing healthcare. However, women who were widowed (AOR = 1.47, CI: 1.03-2.10), those in the Volta Region (AOR 2.20, CI: I.38-3.53), and those in the Upper West Region (AOR =2.22, CI: 1.32-3.74) had the highest odds of facing barriers to healthcare accessibility.

CONCLUSION

This study shows that individual and contextual factors are significant in predicting barriers in healthcare access in Ghana. The factors identified include age, marital status, employment, health insurance coverage, frequency of listening to radio, frequency of watching television, wealth status, and region of residence. These findings highlight the need to pay critical attention to these factors in order to achieve the Sustainable Development Goals 3.1, 3.7, and 3.8. It is equally important to strengthen existing strategies to mitigate barriers to accessing healthcare among women in Ghana.

Individual and contextual factors associated with barriers to accessing healthcare among women in Papua New Guinea: insights from a nationwide demographic and health survey

BACKGROUND

This study sought to assess the individual and contextual factors associated with barriers to accessing healthcare among women in Papua New Guinea.

METHODS

The study was conducted among 14 653 women aged 15-49 y using data from the 2016-2018 Papua New Guinea Demographic and Health Survey. The outcome variable was barriers to accessing healthcare. Descriptive and multilevel logistic regression analyses were conducted. Statistical significance was declared at P < 0.05.

RESULTS

Women aged 15-19 y were more likely to experience at least one barrier compared with those aged 40-49 y (adjusted OR [AOR]=1.48; 95% CI 1.18 to 1.86). Women with secondary/higher education (AOR=0.68; 95% CI 0.57 to 0.81), women in the richest wealth quintile (AOR=0.36; 95% CI 0.28 to 0.46) and those in the least disadvantaged socioeconomic status (AOR=0.46; 95% CI 0.33 to 0.64) had lower odds of having challenges with at least one barrier to healthcare. However, living in rural areas increased the odds of facing at least one barrier to healthcare (AOR=1.87; 95% CI 1.27 to 2.77).

CONCLUSIONS

This study has demonstrated that both individual and contextual factors are associated with barriers to healthcare accessibility among women in Papua New Guinea. To enhance the achievement of the Sustainable Development Goals 3.1, 3.7 and 3.8, it is critical to deem these factors necessary and reinforce prevailing policies to tackle barriers to accessing healthcare among women in Papua New Guinea.

Beyond severe acute maternal morbidity: a mixed-methods study on the long-term consequences of (severe pre-)eclampsia in rural Tanzania

OBJECTIVES

To explore the long-term (perceived) consequences of (severe pre-)eclampsia in rural Tanzania.

METHODS

Women were traced for this mixed-methods study 6-7 years after the diagnosis of (severe pre-)eclampsia. Demographic and obstetric characteristics were noted, and blood pressure was recorded. Questionnaires were used to assess physical and mental health. The qualitative part consisted of semi-structured interviews (SSI). A reference group consisted of women without hypertensive disorders of pregnancy.

RESULTS

Of 74 patients, 25 (34%) were available for follow-up, and 24 were included. Five (20%) had suffered from (pre-)eclampsia twice. Hypertension was more common after (pre-)eclampsia than in the reference group (29% vs. 13%). Thirteen women (56%) had feelings of anxiety and depression, compared to 30% in the reference group. In SSIs, experiences during the index pregnancy were explored, as well as body functions, reproductive life course and limitations in daily functioning, which were shown to be long-lasting.

CONCLUSIONS

Women who suffered from (severe pre-)eclampsia may experience long-term sequelae, including hypertension, depression and anxiety. Women lack information about their condition, and some are worried to conceive again. To address their specific needs, a strategy along the continuum of care is needed for women following a complicated pregnancy, starting with a late postnatal care visit 6 weeks after giving birth.

Mixed effects analysis of factors associated with barriers to accessing healthcare among women in sub-Saharan Africa: Insights from demographic and health surveys

Background

Access to healthcare is one of the key global concerns as treasured in the Sustainable Development Goals. This study, therefore, sought to assess the individual and contextual factors associated with barriers to accessing healthcare among women in sub-Saharan Africa (SSA).

Materials and methods

Data for this study were obtained from the latest Demographic and Health Surveys (DHS) conducted between January 2010 and December 2018 across 24 countries in SSA. The sample comprised 307,611 women aged 15–49. Data were analysed with STATA version 14.2 using both descriptive and multilevel logistic regression modelling. Statistical significance was set at p<0.05.

Results

It was found that 61.5% of women in SSA face barriers in accessing healthcare. The predominant barriers were getting money needed for treatment (50.1%) and distance to health facility (37.3%). Women aged 35–39 (AOR = 0.945, CI: 0.911–0.980), married women (AOR = 0.694, CI: 0.658–0.732), richest women (AOR = 0.457, CI:0.443–0.472), and those who read newspaper or magazine at least once a week (AOR = 0.893, CI:0.811–0.983) had lower odds of facing barriers in accessing healthcare. However, those with no formal education (AOR = 1.803, CI:1.718–1.891), those in manual occupations (AOR = 1.551, CI: 1.424–1.689), those with parity 4 or more (AOR = 1.211, CI: 1.169–1.255), those who were not covered by health insurance (AOR = 1.284, CI: 1.248–1.322), and those in rural areas (AOR = 1.235, CI:1.209–1.26) had higher odds of facing barriers to healthcare access.

Conclusion

Both individual and contextual factors are associated with barriers to healthcare accessibility in SSA. Particularly, age, marital status, employment, parity, health insurance coverage, exposure to mass media, wealth status and place of residence are associated with barriers to healthcare accessibility. These factors ought to be considered at the various countries in SSA to strengthen existing strategies and develop new interventions to help mitigate the barriers. Some of the SSA African countries can adopt successful programs in other parts of SSA to suit their context such as the National Health Insurance Scheme (NHIS) and the Community-based Health Planning and Services concepts in Ghana.

Patterns and Predictors of Insufficient Antenatal Care Utilization in Nigeria over a Decade: A Pooled Data Analysis Using Demographic and Health Surveys

This study investigated the patterns of antenatal care (ANC) utilization and insufficient use of ANC as well as its association with some proximate socio-demographic factors. This was a cross-sectional study using pooled data Nigeria Demographic and Health Surveys from years 2008, 2013 and 2018. Participants were 52,654 women of reproductive age who reported at least one birth in the five years preceding the surveys. The outcome variables were late attendance, first contact after first trimester and less than four antenatal visits using multivariable logistic regression analysis. The overall prevalence of late timing was 74.8% and that of insufficient ANC visits was 46.7%. In the multivariable regression analysis; type of residency, geo-political region, educational level, household size, use of contraceptives, distance to health service, exposure to the media and total number of children were found to be significantly associated with both late and insufficient ANC attendance. About half of the pregnant women failed to meet the recommendation of four ANC visits. Investing on programs to improve women's socio-economic status, addressing the inequities between urban and rural areas of Nigeria in regard to service utilization, and controlling higher fertility rates may facilitate the promotion of ANC service utilization in Nigeria.

When it rains, it pours: detecting seasonal patterns in utilization of maternal healthcare in Mozambique using routine data

BACKGROUND

Climatic conditions and seasonal trends can affect population health, but typically, we consider the effect of climate on the epidemiology of communicable diseases. However, climate can also have an effect on access to care, particularly in remote rural areas of low- and middle-income countries. In this study, we investigate associations between the rainy season and the utilization of maternal health services in Mozambique.

METHODS

We examined patterns in the number of women receiving antenatal care (ANC) and delivering at a health facility for 2012-2019, using data from Mozambique's Health Management Information Systems. We investigated the association between seasonality (rainfall) and maternal health service utilization (ANC and institutional delivery) at national and provincial level. We fit a negative binomial regression model for institutional delivery and used it to estimate the yearly reduction in institutional deliveries due to the rainy season, with other factors held constant. We used the Lives Saved Tool (LiST) to model increases in mortality due to this estimated decrease in institutional delivery associated with the rainy season.

RESULTS

In our national analysis, the rate of ANC visits was 1% lower during the rainy season, adjusting for year and province (IRR = 0.99, 95% CI: 0.96-1.03). The rate of institutional deliveries was 6% lower during the rainy season than the dry season, after adjusting for time and province (IRR = 0.94, 95% CI: 0.92-0.96). In provincial analyses, all provinces except for Maputo-Cidade, Maputo-Province, Nampula, and Niassa showed a statistically significantly lower rate of institutional deliveries in the rainy season. None were statistically significantly lower for ANC. We estimate that, due to reductions in institutional delivery attributable only to the rainy season, there were 74 additional maternal deaths and 726 additional deaths of children under the age of 1 month in 2021, that would not have died if the mothers had instead delivered at a facility.

CONCLUSION

Fewer women deliver at a health facility during the rainy season in Mozambique than during the dry season. Barriers to receiving care during pregnancy and childbirth must be addressed using a multisectoral approach, considering the impact of geographical inequities.

A cross-sectional study of the role of men and the knowledge of danger signs during pregnancy in southern Mozambique

Background

The role of the male partner and wider family in maternal health, especially in case of emergencies, has been receiving increasing attention over the last decade. Qualitative research has highlighted that women depend on others to access high quality maternity care. Currently little is known about these factors in relation to maternal health in Mozambique.

Methods

A cross sectional household survey was conducted with men and women in southern Mozambique about decision making, financial support and knowledge of danger signs. A multivariable logistic model was used to identify factors associated with knowledge of danger signs and Cohen’s kappa for agreement among couples.

Results

A total of 775 men and women from Marracuene and Manhica districts were interviewed. Maternal health care decisions were frequently made jointly by the couple (32–49%) and financial support was mainly provided by the man (46–80%). Parental and parent-in-law involvement in decision making and financial support was minimal (0–3%). The average number of danger signs respondents knew was 2.05 and no significant difference (p = 0.294) was found between men and women. Communication with the partner was a significant predictor for higher knowledge of danger signs for both men (p = 0.01) and women (p = 0.03). There was very low agreement within couples regarding decision making (p = 0.04), financial support (p = 0.01) and presence at antenatal care consultations (p = 0.001). Results suggest women and men have a high willingness for more male participation in antenatal care, although their understanding of what constitutes this participation is not clear.

Conclusion

The study findings highlight the important role men play in decision making and financial support for maternal health care issues. Strengthening male involvement in antenatal care services, by investing in counselling and receiving couples, could help accelerate gains in maternal health in Mozambique. Maternal health care studies should collect more data from men directly as men and women often report different views and behavior regarding maternal health care issues and male involvement.

Decomposition and Spatio-temporal analysis of health care access challenges among reproductive age women in Ethiopia, 2005-2016

Background

The high maternal mortality, home delivery, unwanted pregnancies, incidence of unsafe abortion, and unmeet family planning needs are maternal health gaps attributed to health care access barriers and responsible for the observed health care disparities. Over the last decades remarkable achievements have made in relation to maternal health problems and the reduction of health care access barriers. Thus, this study aimed to assess the decomposition and spatial-temporal analysis of health care access challenges among reproductive-age women in Ethiopia.

Methods

Secondary data analysis was conducted based on the three consecutive Ethiopian Demographic and Health Surveys (2005–2016 EDHSs). A total weighted sample of 46,235 reproductive-age women was included in this study. A logit based multivariate decomposition analysis was employed for identifying factors contributing to the overall decrease in health care access challenges over time. For the spatial analysis, ArcGIS version 10.6 and SaTScan™ version 9.6 were used to explore hotspot areas of health care access challenges in Ethiopia over time. Variables with p-value < 5% in the multivariable Logit based multivariate decomposition analysis were considered as significantly contributed predictors for the decrease in health care access challenges over time.

Result

The mean age of the women was 27.8(±9.4) years in 2005, 27.7(±9.2) years in 2011, and 27.9 (±9.1) years in 2016. Health care access challenges have been significantly decreased from 96% in 2005 to 70% in 2016 with the Annual Rate of Reduction (ARR) of 2.7%. In the decomposition analysis, about 85.2% of the overall decrease in health care access challenge was due to the difference in coefficient and 14.8% were due to differences in the composition of the women (endowment) across the surveys. Socio-demographic characteristics (age, residence, level of education, female household head, better wealth and media exposure) and service utilization history before the survey (facility delivery and had ANC follow up) contribute to the observed decrease over time. The spatial analysis revealed that health care access challenges were significantly varied across the country over time. The SaTScan analysis identified significant hotspot areas of health care access challenges in the southern, eastern, and western parts of Ethiopia consistently over the surveys.

Conclusion

Perceived health care access challenges have shown a remarkable decrease over time but there was variation in barriers to health care access across Ethiopia. Media exposure improved mothers’ health care access in Ethiopia. Public health programs targeting rural, uneducated, unemployed, and women whose husband had no education would be helpful to alleviate health care access problems in Ethiopia. Besides, improving mother’s media exposure plays a significant role to improve mothers’ health care access. Health care access challenges have significantly varied across the country. This suggests that further public health interventions are important for further reduction of health care access barriers through the uplifting socio-demographic and economic status of the population.

Factors associated with the perceived barriers of health care access among reproductive-age women in Ethiopia: a secondary data analysis of 2016 Ethiopian demographic and health survey

Background

Health care access is the timely use of personal health services to achieve the best health outcomes. Problems in accessing health care among reproductive-age may lead to various adverse health outcomes like death and disabilities. Therefore, this study aimed to identify factors associated with the perceived barriers of healthcare access among reproductive-age women in Ethiopia.

Method

This study was based on secondary data sources from the 2016 Ethiopia Demography and Health Survey. The individual women record (IR) file was used to extract about 15, 683 women for the final analysis from the largest dataset. A composite variable of health care access was created from four questions used to rate health care access problems among women of reproductive age. To identify factors associated with the perceived barriers of health care access among reproductive-age women, generalized estimating equation (GEE) model was fitted. Crude and adjusted odds ratio (AOR) with a 95% confidence interval (CI) computed to assess the strength of association between independent and outcome variables.

Results

This study revealed that the magnitude of perceived barriers of healthcare access among reproductive-age women was 69.9% with 95%CI (69.3 to 70.7) to at least one or more of the four reasons. Rural resident (AOR = 2.13, 95%CI: 1.79 to 2.53), age 35–49 years (AOR = 1.24, 95%CI: 1.09 to 1.40), divorced/separated (AOR = 1.34, 95%CI: 1.17 to 1.54), had no health insurance coverage (AOR = 1.19, 95%CI: 1.01 to 1.45), poorer (AOR = 2.09,95%CI: 1.86 to 2.35) and middle wealth (AOR = 1.57,95%CI:1.38 to 1.79), no education (AOR = 2.30, 95%CI:1.95 to 2.72), primary education (AOR = 1.84, 95%CI: 1.58 to 2.15) and secondary education (AOR = 1.31, 95%CI: 1.13 to 1.51) were factors associated with the perceived barriers of health care access.

Conclusion

A significant proportion of women of reproductive age faced barriers to healthcare access, of which money and distance were the most frequently perceived barriers. Divorced/separated marital status, old age, rural dwelling, no health insurance coverage, low economic situation, and level of education were factors associated with perceived barriers. These findings suggest further strengthening and improving health care access to those women with low socio-economic status for the realization of universal health coverage.

Community-Based Improvements to Increase Identification of Pregnant Women and Promote Linkages to Antenatal and HIV Care in Mozambique

A Community Health System Strengthening model, which mobilizes communities by applying quality improvement, was used in 39 communities around 3 health centers in Gaza Province, Mozambique, to increase identification of pregnant women and support them to attend antenatal care (ANC). This article describes the process and results. Community group representatives formed a community improvement team to spread messages about the importance of ANC, identify pregnant women, link them to the facility, and follow up. Between March 2014 and February 2015, teams identified 2020 pregnant women. Antenatal care attendance increased at all 3 centers. One health center did an additional chart review and found that postintervention, women were enrolling in care earlier in pregnancy. There were no changes in HIV testing or treatment initiation for HIV-positive women. Community-led improvement initiatives play an important role in connecting pregnant women with services to receive testing and treatment to promote optimal health and prevent HIV transmission.

Improving geographical accessibility modeling for operational use by local health actors

BACKGROUND

Geographical accessibility to health facilities remains one of the main barriers to access care in rural areas of the developing world. Although methods and tools exist to model geographic accessibility, the lack of basic geographic information prevents their widespread use at the local level for targeted program implementation. The aim of this study was to develop very precise, context-specific estimates of geographic accessibility to care in a rural district of Madagascar to help with the design and implementation of interventions that improve access for remote populations.

METHODS

We used a participatory approach to map all the paths, residential areas, buildings and rice fields on OpenStreetMap (OSM). We estimated shortest routes from every household in the District to the nearest primary health care center (PHC) and community health site (CHS) with the Open Source Routing Machine (OSMR) tool. Then, we used remote sensing methods to obtain a high resolution land cover map, a digital elevation model and rainfall data to model travel speed. Travel speed models were calibrated with field data obtained by GPS tracking in a sample of 168 walking routes. Model results were used to predict travel time to seek care at PHCs and CHSs for all the shortest routes estimated earlier. Finally, we integrated geographical accessibility results into an e-health platform developed with R Shiny.

RESULTS

We mapped over 100,000 buildings, 23,000 km of footpaths, and 4925 residential areas throughout Ifanadiana district; these data are freely available on OSM. We found that over three quarters of the population lived more than one hour away from a PHC, and 10-15% lived more than 1 h away from a CHS. Moreover, we identified areas in the North and East of the district where the nearest PHC was further than 5 h away, and vulnerable populations across the district with poor geographical access (> 1 h) to both PHCs and CHSs.

CONCLUSION

Our study demonstrates how to improve geographical accessibility modeling so that results can be context-specific and operationally actionable by local health actors. The importance of such approaches is paramount for achieving universal health coverage (UHC) in rural areas throughout the world.

Community-level interventions for pre-eclampsia (CLIP) in Mozambique: A cluster randomised controlled trial

OBJECTIVES

Pregnancy hypertension is the third leading cause of maternal mortality in Mozambique and contributes significantly to fetal and neonatal mortality. The objective of this trial was to assess whether task-sharing care might reduce adverse pregnancy outcomes related to delays in triage, transport, and treatment.

STUDY DESIGN

The Mozambique Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised controlled trial (NCT01911494) recruited pregnant women in 12 administrative posts (clusters) in Maputo and Gaza Provinces. The CLIP intervention (6 clusters) consisted of community engagement, community health worker-provided mobile health-guided clinical assessment, initial treatment, and referral to facility either urgently (<4hrs) or non-urgently (<24hrs), dependent on algorithm-defined risk. Treatment effect was estimated by multi-level logistic regression modelling, adjusted for prognostically-significant baseline variables. Predefined secondary analyses included safety and evaluation of the intensity of CLIP contacts.

MAIN OUTCOME MEASURES

20% reduction in composite of maternal, fetal, and newborn mortality and major morbidity.

RESULTS

15,013 women (15,123 pregnancies) were recruited in intervention (N = 7930; 2·0% loss to follow-up (LTFU)) and control (N = 7190; 2·8% LTFU) clusters. The primary outcome did not differ between intervention and control clusters (adjusted odds ratio (aOR) 1·31, 95% confidence interval (CI) [0·70, 2·48]; p = 0·40). Compared with intervention arm women without CLIP contacts, those with ≥8 contacts experienced fewer primary outcomes (aOR 0·79 (95% CI 0·63, 0·99); p = 0·041), primarily due to improved maternal outcomes (aOR 0·72 (95% CI 0·53, 0·97); p = 0·033).

INTERPRETATION

As generally implemented, the CLIP intervention did not improve pregnancy outcomes; community implementation of the WHO eight contact model may be beneficial.

FUNDING

The University of British Columbia (PRE-EMPT), a grantee of the Bill & Melinda Gates Foundation (OPP1017337).

Barriers to Accessing Maternal Care in Low Income Countries in Africa: A Systematic Review

The new Sustainable Development Goals (SDGs) to 2030 aim to reduce maternal mortality and provide equitable access to maternal healthcare. Compromised access to maternal health facilities in low-income countries, and specifically in Africa, contribute to the increased prevalence of maternal mortality. We conducted a systematic review to investigate access barriers to maternal health in low-income countries in Africa since 2015, from the perspective of both community members and health providers. The findings show that the most important barriers to maternal health are transportation barriers to health facilities, economic factors, and cultural beliefs, in addition to lack of family support and poor quality of care. Further research is required to guide policymakers towards firm multi-sectoral action to ensure appropriate and equitable access to maternal health in line with the SDGs to 2030.

How do pregnant women and new mothers navigate and respond to challenges in accessing health care? Perspectives from rural South Africa

Women in low- and middle-income countries and in contexts characterized by inequality face various interpersonal and structural barriers when accessing formal maternal and child health (MCH) services. These barriers persist even in contexts where programs to increase access to services, such as community health worker (CHW) interventions, have been implemented. However, while barriers to accessing care have been extensively documented, less is known about the diverse ways that women respond to, and navigate, these situations. This study explores strategies pregnant women and new mothers use to navigate and respond to health care barriers in a rural district in the Eastern Cape, South Africa. Twenty-six pregnant or recently delivered clients of the Enable Mentor Mother program were interviewed about their experiences of accessing formal MCH services. Interviews were conducted between February-March 2018 by an experienced isiXhosa-speaking research assistant, translated and transcribed into English, with transcripts coded and organized by themes using ATLAS.ti software. Facing resource shortages, inconsistent communication, and long travel times to clinics, participants employed diverse, innovative strategies to navigate interpersonal and structural barriers to care. While some participants chose to respond to barriers more passively-citing endurance and acceptance as practices of health system engagement-those participants who focused more on active responses tended to leverage their education, existing relationships, and available community resources to overcome barriers. Nevertheless, most participants described feelings of frustration and dejection. While CHW interventions may alleviate some of the burdens facing fragile health care systems in these contexts, these programs still rely on an underlying infrastructure of care that primary health care clinics and hospitals should be providing. Future programming should work in tandem with formal health systems and should support staff to improve quality of care provided to pregnant women, new mothers, and their infants to prioritize their health at a time of vulnerability.

Adolescent motherhood in Mozambique. Consequences for pregnant women and newborns

Introduction

In sub-Saharan Mozambique, high adolescent fertility rates are a significant public health problem. Understanding the consequences of teenage pregnancies facilitates effective strategies for improving the quality of care of both mother and the newborn.

Aims

To identify the factors associated with adolescent motherhood in Tete (Mozambique).

Methods

This was a cross-sectional study including 821 pregnant women (255 teenagers) admitted to the general maternity ward of the Provincial Hospital between March and October 2016. The survey included clinical data of the mother and newborn.

Results

The overall prevalence of adolescent deliveries was 31.8% (95% CI 27.9% - 34.2%). Multivariate analysis showed that independent factors associated with teenage motherhood were: number of pregnancies (OR 0.066; 95% CI 0.040–0.110), pregnancy follow-up (OR 0.29; CI 0.173–0.488) and previous abortions (OR 4.419; 95% CI 1.931–10.112). When the age of the mother was analysed as a continuous variable, positively associated factors were body mass index, arterial hypertension, HIV infection, previous abortions, pregnancy follow-up, and the weight of the newborn. Negatively associated factors were episiotomy and respiratory distress in the newborn.

Conclusion

Teenage motherhood is a serious public health problem in Mozambique. Intensive sexual and reproductive health planning for adolescents is needed.

The contribution of qualitative research within the PRECISE study in sub-Saharan Africa

The PRECISE Network is a cohort study established to investigate hypertension, fetal growth restriction and stillbirth (described as "placental disorders") in Kenya, Mozambique and The Gambia. Several pregnancy or birth cohorts have been set up in low- and middle-income countries, focussed on maternal and child health. Qualitative research methods are sometimes used alongside quantitative data collection from these cohorts. Researchers affiliated with PRECISE are also planning to use qualitative methods, from the perspective of multiple subject areas. This paper provides an overview of the different ways in which qualitative research methods can contribute to achieving PRECISE's objectives, and discusses the combination of qualitative methods with quantitative cohort studies more generally.We present planned qualitative work in six subject areas (health systems, health geography, mental health, community engagement, the implementation of the TraCer tool, and respectful maternity care). Based on these plans, with reference to other cohort studies on maternal and child health, and in the context of the methodological literature on mixed methods approaches, we find that qualitative work may have several different functions in relation to cohort studies, including informing the quantitative data collection or interpretation. Researchers may also conduct qualitative work in pursuit of a complementary research agenda. The degree to which integration between qualitative and quantitative methods will be sought and achieved within PRECISE remains to be seen. Overall, we conclude that the synergies resulting from the combination of cohort studies with qualitative research are an asset to the field of maternal and child health.

The PRECISE (PREgnancy Care Integrating translational Science, Everywhere) Network's first protocol: deep phenotyping in three sub-Saharan African countries

BACKGROUND

The PRECISE (PREgnancy Care Integrating translational Science, Everywhere) Network is a new and broadly-based group of research scientists and health advocates based in the UK, Africa and North America.

METHODS

This paper describes the protocol that underpins the clinical research activity of the Network, so that the investigators, and broader global health community, can have access to 'deep phenotyping' (social determinants of health, demographic and clinical parameters, placental biology and agnostic discovery biology) of women as they advance through pregnancy to the end of the puerperium, whether those pregnancies have normal outcomes or are complicated by one/more of the placental disorders of pregnancy (pregnancy hypertension, fetal growth restriction and stillbirth). Our clinical sites are in The Gambia (Farafenni), Kenya (Kilifi County), and Mozambique (Maputo Province). In each country, 50 non-pregnant women of reproductive age will be recruited each month for 1 year, to provide a final national sample size of 600; these women will provide culturally-, ethnically-, seasonally- and spatially-relevant control data with which to compare women with normal and complicated pregnancies. Between the three countries we will recruit ≈10,000 unselected pregnant women over 2 years. An estimated 1500 women will experience one/more placental complications over the same epoch. Importantly, as we will have accurate gestational age dating using the TraCer device, we will be able to discriminate between fetal growth restriction and preterm birth. Recruitment and follow-up will be primarily facility-based and will include women booking for antenatal care, subsequent visits in the third trimester, at time-of-disease, when relevant, during/immediately after birth and 6 weeks after birth.

CONCLUSIONS

To accelerate progress towards the women's and children's health-relevant Sustainable Development Goals, we need to understand how a variety of social, chronic disease, biomarker and pregnancy-specific determinants health interact to result in either a resilient or a compromised pregnancy for either mother or fetus/newborn, or both. This protocol has been designed to create such a depth of understanding. We are seeking funding to maintain the cohort to better understand the implications of pregnancy complications for both maternal and child health.

Misoprostol for the prevention of post-partum haemorrhage in Mozambique: an analysis of the interface between human rights, maternal health and development

BACKGROUND

Mozambique has high maternal mortality which is compounded by limited human resources for health, weak access to health services, and poor development indicators. In 2011, the Mozambique Ministry of Health (MoH) approved the distribution of misoprostol for the prevention of post-partum haemorrhage (PPH) at home births where oxytocin is not available. Misoprostol can be administered by a traditional birth attendant or self-administered. The objective of this paper is to examine, through applying a human rights lens, the broader contextual, policy and institutional issues that have influenced and impacted the early implementation of misoprostol for the prevention of PPH. We explore the utility of rights-based framework to inform this particular program, with implications for sexual and reproductive health programs more broadly.

METHODS

A human rights, health and development framework was used to analyse the early expansion phase of the scale-up of Mozambique's misoprostol program in two provinces. A policy document review was undertaken to contextualize the human rights, health and development setting in Mozambique. Qualitative primary data from a program evaluation of misoprostol for the prevention of PPH was then analysed using a human rights lens; these results are presented alongside three examples where rights are constrained.

RESULTS

Structural and institutional challenges exacerbated gaps in the misoprostol program, and sexual and reproductive health more generally. While enshrined in the constitution and within health policy documents, human rights were not fully met and many individuals in the study were unaware of their rights. Lack of information about the purpose of misoprostol and how to access the medication contributed to power imbalances between the state, health care workers and beneficiaries. The accessibility of misoprostol was further limited due to dynamics of power and control.

CONCLUSIONS

Applying a rights-based approach to the Mozambican misoprostol program is helpful in contextualising and informing the practical changes needed to improve access to misoprostol as an essential medicine, and in turn, preventing PPH. This study adds to the evidence of the interconnection between human rights, health and development and the importance of integrating the concepts to ensure women's rights are prioritized within health service delivery.

Why do women deliver where they had not planned to go? A qualitative study from peri-urban Nairobi Kenya

Background

In urban Kenya, couples face a wide variety of choices for delivery options; however, many women end up delivering in different facilities from those they had intended while pregnant. One potential consequence of this is delivering in facilities that do not meet minimum quality standards and lack the capacity to provide treatment for obstetric and neonatal complications.

Methods

This study investigated why women in peri-urban Nairobi, Kenya deliver in facilities they had not intended to use. We used 60 in-depth audio-recorded interviews in which mothers shared their experiences 2–6 months after delivery. Descriptive statistics were used to summarize socio-demographic characteristics of participants. Qualitative data were analyzed in three steps i) exploration and generation of initial codes; ii) searching for themes by gathering coded data that addressed specific themes; and iii) defining and naming identified themes. Verbatim excerpts from participants were provided to illustrate study findings. The Health Belief Model was used to shed light on individual-level drivers of delivery location choice.

Results

Findings show a confluence of factors that predispose mothers to delivering in unintended facilities. At the individual level, precipitate labor, financial limitations, onset of pain, complications, changes in birth plans, undisclosed birth plans, travel during pregnancy, fear of health facility providers, misconception of onset of labor, wrong estimate of delivery date, and onset of labor at night, contributed to delivery at unplanned locations. On the supply side, the sudden referral to other facilities, poor services, wrong projection of delivery date, and long distance to chosen delivery facility, were factors in changes in delivery location. Lack of transport discouraged delivery at a chosen health facility. Social influences included others’ perspectives on delivery location and lack of aides/escorts.

Conclusions

Results from this study suggest that manifold factors contribute to the occurrence of women delivering in facilities that they had not intended during pregnancy. Future studies should consider whether these changes in delivery location late in pregnancy contribute to late facility arrival and the use of lower quality facilities. Deliberate counseling during antenatal care regarding birth plans is likely to encourage timely arrival at facilities consistent with women’s preferences.

Referral linkage among public health facilities in Ethiopia: A qualitative explanatory study of facilitators and barriers for emergency obstetric referral in Addis Ababa city administration

BACKGROUND

In developing countries including Ethiopia, maternal mortality ratio remains unacceptably high. During pregnancy and childbirth, a woman may acquire one or more of obstetric complications including hemorrhage, sepsis, hypertension and obstructed labor. Early diagnosed and referral of women who experienced obstetric complications to a specialty center can save the life of women and babies. However, several factors might affect the referral procedures of these women. Therefore, this study was aimed at assessing the facilitators and barriers of obstetric referral in selected public health facilities of Addis Ababa city administration, Ethiopia.

METHODS

A qualitative study design was employed to obtain the narratives of 12 healthcare workers and three recently referred mothers. The study included a regional health bureau, a lead hospital and a health center. Thematic analysis was employed to present to present the findings of the study and open code software was used to code and generate the themes.

RESULTS

This study revealed several barriers and some facilitators of obstetric referral. Early identification of complications, exercising teamwork, availability of referral protocol, availability of ambulance and effective communication system were the major reported factors which enhanced obstetric referral. Several themes including poor perception of clients, poor supportive supervision, lack of staff motivation and shortage of beds and medical equipment, lack of competence among the staffs and shortage of ambulance at health center were emerged as barriers of obstetric referral.

CONCLUSIONS

This study revealed several barriers of obstetric referral in the Addis Ababa city administration although a number of facilitators of obstetric referral exist. All of the reported barriers are related to the existing health system that need a collective action of all the actors to eliminate the barriers while enhancing the facilitators of obstetric referral.