Continuum of care for maternal health in Uganda: A national cross-sectional study

How interventions to maintain services during the COVID-19 pandemic strengthened systems for delivery of maternal and child health services: a case-study of Wakiso District, Uganda

BACKGROUND

Health systems are resilient if they absorb, adapt, and transform in response to shocks. Although absorptive and adaptive capacities have been demonstrated during the COVID-19 response, little has been documented about their transformability and strengthened service delivery systems. We aimed to describe improvements in maternal and child health service delivery as a result of investments during the COVID-19 response.

METHODS

This was a descriptive case study conducted in Wakiso District in central Uganda. It included 21 nurses and midwives as key informants and 32 mothers in three focus group discussions. Data were collected using an interview guide following the Systems Engineering Initiative for Patient Safety theoretical framework for service delivery.

RESULTS

Maternal and child health service delivery during the pandemic involved service provision without changes, service delivery with temporary changes and outcomes, and service delivery that resulted into sustained changes and outcomes. Temporary changes included patient schedule adjustments, community service delivery and negative outcomes such as increased workload and stigma against health workers. Sustained changes that strengthened service delivery included new infrastructure and supplies such as ambulances and equipment, new roles involving infection prevention and control, increased role of community health workers and outcomes such as improved workplace safety and teamwork.

CONCLUSIONS

In spite of the negative impact the COVID-19 pandemic had on health systems, it created the impetus to invest in system improvements. Investments such as new facility infrastructure and emergency medical services were leveraged to improve maternal and child health services delivery. The inter-departmental collaboration during the response to the COVID-19 pandemic resulted into an improved intra-hospital environment for other service delivery. However, there is a need to evaluate lessons beyond health facilities and whether these learnings are deliberately integrated into service delivery. Future responses should also address the psychological and physical impacts suffered by health workers to maintain service delivery.

The epidemiology and risk factors for postnatal complications among postpartum women and newborns in southwestern Uganda: A prospective cohort study

Sub-Saharan Africa accounts for two-thirds of the global burden of maternal and newborn deaths. Adverse outcomes among postpartum women and newborns occurring in the first six weeks of life are often related, though data co-examining patients are limited. This study is an exploratory analysis describing the epidemiology of postnatal complications among postpartum women and newborns following facility birth and discharge in Mbarara, Uganda. This single-site prospective cohort observational study enrolled postpartum women following facility-based delivery. To capture health information about both the postpartum women and newborns, data was collected and categorized according to domains within the continuum of care including (1) social and demographic, (2) pregnancy history and antenatal care, (3) delivery, (4) maternal discharge, and (5) newborn discharge. The primary outcomes were readmission and mortality within the six-week postnatal period as defined by the WHO. Multivariable logistic regression was used to identify risk factors. Among 2930 discharged dyads, 2.8% and 9.0% of women and newborns received three or more postnatal visits respectively. Readmission and deaths occurred among 108(3.6%) and 25(0.8%) newborns and in 80(2.7%) and 0(0%) women, respectively. Readmissions were related to sepsis/infection in 70(88%) women and 68(63%) newborns. Adjusted analysis found that caesarean delivery (OR:2.91; 95%CI:1.5-6.04), longer travel time to the facility (OR:1.54; 95%CI:1.24-1.91) and higher maternal heart rate at discharge (OR:1.02; 95%CI:1.00-1.01) were significantly associated with maternal readmission. Discharge taken on all patients including maternal haemoglobin (per g/dL) (OR:0.90; 95%CI:0.82-0.99), maternal symptoms (OR:1.76; 95%CI:1.02-2.91), newborn temperature (OR:1.66; 95%CI:1.28-2.13) and newborn heart rate at (OR:1.94; 95%CI:1.19-3.09) were risk factors among newborns. Readmission and death following delivery and discharge from healthcare facilities is still a problem in settings with low rates of postnatal care visits for both women and newborns. Strategies to identify vulnerable dyads and provide better access to follow-up care, are urgently required.

The continuum of care for maternal health in Africa: A systematic review and meta-analysis

BACKGROUND

The continuum of care for maternal health (COCM) is a critical strategy for addressing preventable causes of maternal and perinatal mortality. Despite notable progress in reducing maternal and infant deaths globally, the problem persists, particularly in low-resource settings. Additionally, significant disparities in the provision of continuous care exist both between continents and within countries on the same continent. This study aimed to assess the pooled prevalence of completion across the maternity care continuum in Africa and investigate the associated factors.

METHODS

Relevant articles were accessed through the EMBASE, CINAHL, Cochrane Library, PubMed, HINARI, and Google Scholar databases. Funnel plots and Egger's test were employed to assess publication bias, while the I-squared test was used to evaluate study heterogeneity. The inclusion criteria were limited to observational studies conducted exclusively in Africa. The quality of these studies was assessed using the JBI checklist. Data extraction from the included studies was performed using Microsoft Excel and then analysed using Stata 16 software.

RESULTS

A total of 23 studies involving 74,880 mothers met the inclusion criteria. The overall prevalence of women who successfully completed the COCM was 20.9% [95% CI: 16.9-25.0]. Our analysis revealed several factors associated with this outcome, including urban residency [OR: 2.3; 95% CI: 1.6-3.2], the highest wealth index level [OR: 2.1; 95% CI: 1.4-3.0], primiparous status [OR: 1.3; 95% CI: 2.2-5.1], planned pregnancy [OR: 3.0; 95% CI: 2.3-3.7], and exposure to mass media [OR: 2.7; 95% CI: 1.9-3.8].

CONCLUSION

The study revealed that only 20.9% of women fully completed the COCM. It also identified several factors associated with completion of the COCM, such as residing in urban areas, possessing a higher wealth index, being a first-time mother, experiencing a planned pregnancy, and having access to mass media. Based on the study's findings, it is recommended that targeted interventions be implemented in rural areas, financial assistance be provided to women with lower wealth index levels, educational campaigns be conducted through mass media, early antenatal care be promoted, and family planning services be strengthened.

REVIEW REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42020205736).

Completion and predictors of maternity continuum of care among women in the post-partum period in Gedeb district, southern Ethiopia: A community based cross-sectional study

INTRODUCTION

Maternal and neonatal complications related to pregnancy and childbirth pose a significant risk of morbidity and mortality to both the mother and the child. Despite its benefits in reducing maternal and neonatal mortality and morbidity associated with pregnancy and childbirth, the majority of Ethiopian mothers were dropped from the maternal continuum of care. Furthermore, there is a dearth of data regarding the status of the maternal continuum of care and its underlying factors in southern Ethiopia.

OBJECTIVE

This study aimed to assess the completion of the maternity continuum of care and its predictors among postpartum women who had given birth in the previous six months in the Gedeb district of Gedio Zone, southern Ethiopia.

METHODS

A community-based cross-sectional survey was conducted among 625 postpartum women selected by simple random sampling from June 1 to 30, 2022. The data was collected through face-to-face interviews using pretested, structured questionnaires. The association between the explanatory variables and the maternity continuum of care was examined using bivariate and multivariable logistic regression models. The adjusted odds ratio (AOR) with a 95% confidence interval was employed to measure the strength of association and the level of significance was set at p<0.05.

RESULTS

In this study, only 32.00% (95% CI: 28.45, 35.77) of the women completed the maternal continuum of care. Attending primary education (AOR = 2.09; 95% CI: 1.23, 3.55), secondary and above education (AOR = 1.97; 95% CI: 1.01, 3.87), receiving counseling during ANC (AOR = 1.89; 95% CI: 1.22, 2.92), being well prepared for birth and complications readiness (AOR = 4.13; 95% CI: 2.23, 7.62), and having good knowledge of pregnancy danger signs (AOR = 4.13; 95% CI: 2.60, 6.55) were all significantly associated with completing the maternity continuum of care.

CONCLUSION

Nearly one-third of the women completed the maternity continuum of care. Enhancing women's knowledge, offering counseling during prenatal visits, ensuring women's awareness of pregnancy danger signs, and implementing health promotion programs targeted at enhancing birth preparedness and complications readiness for all are crucial.

Multilevel analysis of dropout from maternal continuum of care and its associated factors: Evidence from 2022 Tanzania Demographic and Health Survey

BACKGROUND

The maternal continuum of care (CoC) is a cost-effective approach to mitigate preventable maternal and neonatal deaths. Women in developing countries, including Tanzania, face an increased vulnerability to significant dropout rates from maternal CoC, and addressing dropout from the continuum remains a persistent public health challenge.

METHOD

This study used the 2022 Tanzania Demographic and Health Survey (TDHS). A total weighted sample of 5,172 women who gave birth in the past 5 years and had first antenatal care (ANC) were included in this study. Multilevel binary logistic regression analyses were used to examine factors associated with dropout from the 3 components of maternal CoC (i.e., ANC, institutional delivery, and postnatal care (PNC)).

RESULTS

The vast majority, 83.86% (95% confidence interval (CI): 82.83%, 84.83%), of women reported dropout from the maternal CoC. The odds of dropout from the CoC was 36% (AOR = 0.64, (95% CI: 0.41, 0.98)) lower among married women compared to their divorced counterparts. Women who belonged to the richer wealth index reported a 39% (AOR = 0.61, (95% CI: 0.39, 0.95)) reduction in the odds of dropout, while those belonged to the richest wealth index demonstrated a 49% (AOR = 0.51, (95% CI: 0.31, 0.82)) reduction. The odds of dropout from CoC was 37% (AOR = 0.63, (95% CI: 0.45,0.87)) lower among women who reported the use of internet in the past 12 months compared to those who had no prior exposure to the internet. Geographical location emerged as a significant factor, with women residing in the Northern region and Southern Highland Zone, respectively, experiencing a 44% (AOR = 0.56, 95% CI: 0.35-0.89) and 58% (AOR = 0.42, 95% CI: 0.26-0.68) lower odds of dropout compared to their counterparts in the central zone.

CONCLUSION

The dropout rate from the maternity CoC in Tanzania was high. The findings contribute to our understanding of the complex dynamics surrounding maternity care continuity and underscore the need for targeted interventions, considering factors such as marital status, socioeconomic status, internet usage, and geographical location.

Delivery of a post-natal neonatal jaundice education intervention improves knowledge among mothers at Jinja Regional Referral Hospital in Uganda

BACKGROUND

Neonatal jaundice (NNJ) is a major contributor to childhood morbidity and mortality. As many infants are discharged by 24 hours of age, mothers are key in detecting severe forms of jaundice. Mothers with limited knowledge of NNJ have a hard time identifying these infants who could go on to have the worst outcomes. This study aimed to determine the effect of a jaundice education package delivered to mothers prior to hospital discharge on maternal knowledge after discharge.

METHODS

This was a before and after interventional study involving an education package delivered through a video message and informational voucher. At 10-14 days after discharge, participants were followed up via telephone to assess their post-intervention knowledge. A paired t-test was used to determine the effectiveness of the intervention on knowledge improvement. Linear regression was used to determine predictors of baseline knowledge and of change in knowledge score.

RESULTS

Of the 250 mothers recruited, 188 were fit for analysis. The mean knowledge score was 10.02 before and 14.61 after the intervention, a significant difference (p<0.001). Factors determining higher baseline knowledge included attendance of 4 or more antenatal visits (p < 0.001), having heard about NNJ previously (p < 0.001), having experienced an antepartum illness (p = 0.019) and higher maternal age (p = 0.015). Participants with poor baseline knowledge (β = 7.523) and moderate baseline knowledge (β = 3.114) had much more to gain from the intervention relative to those with high baseline knowledge (p < 0.001).

CONCLUSION

Maternal knowledge of jaundice can be increased using a simple educational intervention, especially in settings where the burden of detection often falls on the mother. Further study is needed to determine the impact of this intervention on care seeking and infant outcomes.

Individual and community-level factors associated with women's utilization of postnatal care services in Uganda, 2016: a multilevel and spatial analysis

BACKGROUND

Over time, Uganda has experienced high levels of maternal mortality (435 deaths per 100,000 live births in 2006 to 336 deaths per 100,000 live births in 2016). The persistence of high levels of maternal mortality jeopardizes the achievement of Sustainable Development Goal (SDG) 3.1, which calls for reducing maternal mortality to 70 deaths per 100,000 live births by 2030. Conversely, the utilization of postnatal care (PNC) services in Uganda remained very low and has varied across regions. This study examined the individual and community-level factors influencing women's utilization of postnatal care services in Uganda.

METHODS

Secondary data from the 2016 Uganda Demographic and Health Survey (UDHS) were used in this study. The study population consisted of women aged 15 to 49 who reported giving birth in the five years preceding the 2016 UDHS survey. The factors associated with postnatal care services were identified using multilevel binary logistic regression and spatial analysis.

RESULTS

The result shows that the prevalence of postnatal care service utilization in Uganda was low (58.3%) compared to the World Health Organization (WHO) target of 100%. The univariate analysis shows that 13.7% of women were adolescents, 79% were of higher parity, and 70.4% had primary/no formal education, of which 76.6% resided in rural areas. On the other hand, the multilevel analysis results showed that women aged 20-29 years and 30-39 years were also found to be more likely to use PNC services (AOR = 1.2, 95% CI: 1.01-1.47). Women who received quality ANC (AOR = 2.1, 95% CI: 1.78-2.36) were more likely to use postnatal care services than their counterparts. At the community level, women who lived in media-saturated communities were more likely to use postnatal care services (AOR = 1.3, 95% CI: 1.01-1.65). The spatial analysis found that the Central, Eastern, and Northern regions were the areas of hotspots in the utilization of postnatal care services.

CONCLUSION

This study found that age, parity, level of education, place of residence, employment status, quality of the content of antenatal care, and community media saturation were the predictors of postnatal care service utilization. The spatial analysis showed that the spatial distributions of postnatal care service utilization were significantly varied across Uganda. The government must expand access to various forms of media throughout the country to increase PNC utilization.

Contextualizing the standard maternal continuum of care in Pakistan: an application of revised recommendation of the World Health Organization

Objective

This study utilizes recent nationally representative data to contextualize the standard maternal continuum of care (SMCoC) in Pakistan. The revised SMCoC framework encompasses at least eight antenatal care visits, skilled birth attendants during delivery, and postnatal care within 48 h of childbirth.

Methods

The study used a sample of 3,887 ever-married women aged 15-49 from the latest Pakistan Demographic and Health Survey (PDHS) conducted in 2017-18. Several statistical methods were employed: descriptive statistics, bivariate, multilevel logistic regression models, and Fairlie decomposition analysis.

Results

Only 12% of women had accessed full SMCoC services in Pakistan. Education and the wealth quintile emerged as pivotal factors influencing the utilization of SMCoC. The likelihood of full SMCC utilization was more likely among higher educated women (OR: 3.37; 95% CI: 2.16-5.25) and those belonging to the wealthiest household wealth quintile (OR: 4.95; 95% CI: 2.33-5.51). Media exposure, autonomy, healthcare accessibility, residence, and region were also identified as significant predictors of SMCoC utilization among women.

Conclusion

In conclusion, while most women did not utilize full SMCoC services in Pakistan, the pattern is substantially varied by background characteristics. Education, wealth quintile, mass media exposure, and autonomy were significant factors, along with geographical aspects such as healthcare accessibility and region. The study underscores the need for a multifaceted approach to ensure equitable access to full SMCoC services for women in Pakistan, addressing individual, socioeconomic, and geographical factors.

Prognostic algorithms for post-discharge readmission and mortality among mother-infant dyads: an observational study protocol

Introduction

In low-income country settings, the first six weeks after birth remain a critical period of vulnerability for both mother and newborn. Despite recommendations for routine follow-up after delivery and facility discharge, few mothers and newborns receive guideline recommended care during this period. Prediction modelling of post-delivery outcomes has the potential to improve outcomes for both mother and newborn by identifying high-risk dyads, improving risk communication, and informing a patient-centered approach to postnatal care interventions. This study aims to derive post-discharge risk prediction algorithms that identify mother-newborn dyads who are at risk of re-admission or death in the first six weeks after delivery at a health facility.

Methods

This prospective observational study will enroll 7,000 mother-newborn dyads from two regional referral hospitals in southwestern and eastern Uganda. Women and adolescent girls aged 12 and above delivering singletons and twins at the study hospitals will be eligible to participate. Candidate predictor variables will be collected prospectively by research nurses. Outcomes will be captured six weeks following delivery through a follow-up phone call, or an in-person visit if not reachable by phone. Two separate sets of prediction models will be built, one set of models for newborn outcomes and one set for maternal outcomes. Derivation of models will be based on optimization of the area under the receiver operator curve (AUROC) and specificity using an elastic net regression modelling approach. Internal validation will be conducted using 10-fold cross-validation. Our focus will be on the development of parsimonious models (5-10 predictor variables) with high sensitivity (>80%). AUROC, sensitivity, and specificity will be reported for each model, along with positive and negative predictive values.

Discussion

The current recommendations for routine postnatal care are largely absent of benefit to most mothers and newborns due to poor adherence. Data-driven improvements to postnatal care can facilitate a more patient-centered approach to such care. Increasing digitization of facility care across low-income settings can further facilitate the integration of prediction algorithms as decision support tools for routine care, leading to improved quality and efficiency. Such strategies are urgently required to improve newborn and maternal postnatal outcomes.

Clinical trial registration

https://clinicaltrials.gov/, identifier (NCT05730387).

Gender inequities in women's access to maternal health care utilisation in Zambia: a qualitative analysis

BACKGROUND

The role of gender inequities in women's ability to access maternal health care has mainly been analysed from either women's or men's perspective only. In this article, we explore the role of gender inequities in maternal health care utilisation from both men's and women's perspectives.

METHODS

Thirty-six interviews were conducted with reproductive age women (n = 24), and men whose wives/partners gave birth within the last three years prior to our study in Zambia (n = 12). Our study sought to improve understanding of the normative environment in which women and men make decisions on maternal health care utilisation in Zambia.

RESULTS

We found that men and women had different expectations regarding their gender roles in maternal health care utilisation, which created inequities reinforced by societal norms and traditions. Men make most household decisions including those related to reproductive health and they often have the major say in access to maternal health services despite not having holistic maternal health information which creates challenges in maternal health care utilisation.

CONCLUSION

The study highlights the need for maternal health care utilisation decisions to be made by both men and women and that men should be fully involved in maternal health care from pregnancy until after child birth. Further, there is urgent need for concerted and sustained efforts to change traditional norms that reinforce these inequities and affect maternal health care utilisation if Zambia is to meet Sustainable Development Goal-3.1.

First trimester antenatal care contact in Africa: a systematic review and meta-analysis of prevalence and contributing factors

BACKGROUND

Early detection, prevention, and management of diseases associated with pregnancy and pregnancy-related conditions depend on the beginning of antenatal care contact in the first trimester. Across Africa, regional and national differences are observed in the proportion of first-trimester ANC contact and the factors contributing to it. To create a suitable intervention plan, it is crucial to overcome these differences through single standard and uniform guidelines. This can be achieved through meta-analysis and systematic reviews. Therefore, this systematic review aimed to assess the pooled prevalence of first trimester ANC contact and the factors contributing to it in Africa.

METHODS

Observational studies conducted in Africa were retrieved from PubMed, Google Scholar, EMASE, CINHAL, Cochrane Library, Hinari databases and Mednar using combinations of search terms with Boolean operators. The JBI 2020 Critical Appraisal Checklist was used to assess the methodological quality of the studies. To assess publication bias, a funnel plot and Egger's test were used to and I-squared was used to check the heterogeneity of the included studies. Data were extracted using Microsoft Excel and exported to Stata 16 software for analysis.

RESULTS

A total of 86 articles with 224,317 study participants from 19 African countries were included. The overall pooled prevalence of first-trimester ANC contact was 37.15% (95% CI: 33.3-41.0; I2 = 99.8%). The following factors were found to be significantly associated with first-trimester ANC contact: urban residence (OR = 2.2; 95% CI: 1.5-3.1; I2 = 98.5%); women under the age of 25 (OR = 1.5; 95% CI: 1.2-1.9; I2 = 94.1%);, educational status (OR = 1.8; 95% CI: 1.4-2.2; I2 = 96.1%), primiparity (OR: 1.7; 95% CI: 1.2-2.4: I2 = 97.4%), having planned pregnancies (OR: 2.1; 95% CI: 1.5-2.7; I2 = 95.5%) and employed women (OR = 1.7; 95% CI: 1.7-2.1; I2 = 94.4%).

CONCLUSION

Because so few women in Africa initiate first-trimester ANC contact, it is clear that increasing maternal healthcare service uptake is still a challenge and will require significant effort to scale up the services. When working to improve maternal health in Africa, each nation's government and nongovernmental organizations should prioritize raising women's educational levels and providing pertinent information to rural women, focusing on reducing unintended pregnancies, women who live far from health facilities, women with low socioeconomic statuses, multiparous women and older women.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic reviews (ID: CRD42023401711).

A secondary analysis of the factors associated with women´s adequate utilization of antenatal care services during their last pregnancy in Uganda

BACKGROUND

Adequate antenatal care services (ANC) use is critical to identifying and reducing pregnancy risks. Despite the importance placed on adequate antenatal care service utilization, women in Uganda continue to underutilize antenatal care services. The primary goal of this study is to identify the factors associated with women's adequate utilization of antenatal care services in Uganda.

METHODS

Secondary data from the 2016 Uganda Demographic and Health Survey were used in this study. The study sample consists of 9,416 women aged 15 to 49 who reported giving birth in the five years preceding the survey. The adequate use of antenatal care services is the dependent variable. A woman who used antenatal care services at least four times is considered to have adequately used antenatal care services. We used univariate, bivariate, and multilevel logistic regression modelling to identify the factors associated with adequate utilization of antenatal care services. STATA version 14.2 was used to analyze the data.

RESULTS

The prevalence of adequate utilization of antenatal care services in Uganda was found to be 61.4%. Women with secondary or higher education were 32.0% (AOR = 1.32, 95% CI;1.07-1.63), employed women were 26.0% (AOR = 1.26, 95% CI;1.10-1.44), women who received high-quality antenatal care content were 78.0% (AOR = 1.78, 95% CI;1.58-2.02), and women who belong to the rich category of the wealth index bracket were 27.0% (AOR = 1.27, 95% CI;1.09-1.49), more likely to use antenatal care services adequately. Finally, the study discovered that women from less diverse ethnic communities were 15.0% (AOR, 0.85, 95%CI; 0.73-0.99) less likely to use antenatal care services adequately.

CONCLUSION

Women's adequate utilization of antenatal care was influenced by both community and individual-level characteristics. Policymakers must use a multi-sectoral approach to develop policies that address both individual and community-level characteristics.

Postpartum family planning uptake in Uganda: findings from the lot quality assurance sampling survey

BACKGROUND

The initiation and use of family planning (FP) services within the first 12 months following childbirth, postpartum family planning (PPFP), promotes safe motherhood by reducing unintended pregnancies and ensuring appropriate pregnancy spacing. However, there is a paucity of information on PPFP uptake from community surveys. This study aimed to quantify the reported use of PPFP and identify predictors and barriers to PPFP uptake from a large community survey.

METHODS

We analysed data collected from the 2021 Lot Quality Assurance Sampling (LQAS) survey, a cross-sectional community and household survey that covered 68 districts in Uganda. The survey uses small sample sizes to designate health or administrative geographical areas which are assessed to determine whether they achieved the pre-determined target for defined indicators of interest. We abstracted and analysed data collected from mothers of children aged 12 months or younger on reproductive health and FP. PPFP use was defined as the reported use of modern FP by the mother or their partner. Associations were measured using Pearson's chi-square test at 5% significance. Multivariate logistic regression was performed for variables that were significantly associated with PPFP use to identify the predictors of PPFP.

RESULTS

Overall, 8103 mothers of children aged less than 12 years were included in the analysis; the majority of mothers, 55.8% (4521/8103) were above 24 years while 11.7% (950/8103) were 19 years and under. 98% (7942/8103) of the mothers attended at least one antenatal care (ANC) visit and 86.3% (6997/8103) delivered at a health facility. Only 10% (814/8103) of mothers who participated in the survey reported PPFP use at the time of the survey. Reporting of PPFP use was 5 times higher among mothers of children aged 7-12 months (AOR 4.9; 95%CI 4.1-5.8), 50% higher among mothers with secondary education (AOR 1.5; 95%CI 1.0-2.3), 80% higher among breastfeeding mothers (AOR 1.8; 95%CI 1.3-2.4) and 30% lower among those that didn't receive a health worker visit within 3 months preceding the survey (AOR 0.7; 95% CI 0.5-0.8). Among 4.6% (372/8103) who stated a reason for non-use of PPFP, the most cited reasons for not using were breastfeeding 43% (161/372), fear of side effects 26.9% (100/372), respondent/partner opposition 17.6% (48/372) and infrequent sex 12.1% (48/372).

CONCLUSION

The analysis showed a low proportion of PPFP uptake among mothers of children under 12 years. Possible barriers included child age, education, a health worker visit, and side effects and perceived benefits of possibly improperly implementing lactation amenorrhea method. Integration of social, community and health services could provide a more holistic approach to improving PPFP uptake.

Midwives' perceptions towards the ministry of health guidelines for the provision of immediate postpartum care in rural health facilities in Uganda

BACKGROUND

Guidelines for clinical practice have been part of the Ministry of health's efforts to improve the quality of care for over two decades. Their benefits have been documented in Uganda. However, having practice guidelines may not always result in their use in care provision. We explored the midwives' perceptions towards the ministry of health guidelines for providing immediate postpartum care.

METHODS

An exploratory descriptive qualitative study was conducted in three districts in Uganda from September 2020 to January 2021. In-depth interviews with 50 midwives from 35 health centers and 2 hospitals in Mpigi, Butambala, and Gomba districts were done. Thematic analysis of data was done.

RESULTS

Three themes emerged; awareness and use of the guidelines, perceived drivers, and perceived barriers to the provision of immediate postpartum care. The subthemes for theme I included; awareness of the guidelines, variations in the postpartum care practices, variations in preparedness to manage women with complications, and varied access to continuing midwifery education. Fear of complications and litigation were the perceived drivers of guideline use. On the other hand, lack of knowledge, busy maternity units, organization of the care, and the midwives' perceptions about their clients were the barriers to guideline use. Midwives felt that new guidelines and policies regarding immediate postpartum care should be disseminated widely.

CONCLUSION

The midwives felt that the guidelines were good for the prevention of postpartum complications but their knowledge of the guidelines for the provision of immediate postpartum care was suboptimal. They desired on-job training and mentorship to help them bridge the knowledge gaps. Variations in patient assessment, monitoring, and pre-discharge care were acknowledged and said to be due to a poor reading culture and health facility factors like patient-midwife ratios, unit setup, and prioritization of labor.

Status of information, education, and communication as perceived by clients receiving antenatal care at Chiradzulu District Hospital in Malawi

BACKGROUND

Information, education, and communication is a strategy to spread awareness through communication channels to a target audience to achieve a desired positive result. Women are supposed to receive information, education, and communication at each contact with the health worker during antenatal care. In Malawi, information, education, and communication for antenatal care is inadequate despite high antenatal care coverage. Most women do not receive it as stipulated. This could be one of the reasons that maternal and neonatal mortality is high. The provision of information, education, and communication is supposed to help in reducing maternal mortality because it is intended to develop positive attitudes towards health behaviours to support pregnant women accessing health services when required. This study, therefore, assessed the status of information, education, and communication as perceived by clients receiving antenatal care at Chiradzulu District Hospital in Malawi.

METHODS

A descriptive study design with a sample of 384 pregnant women attending antenatal care was used. The sample size for the study was calculated using Lemeshow, Hosmer, Klar and Rwanga's formula. Systematic random sampling method was used to select the study participants. Data were analysed using a statistical package for social sciences software version 20.0.

RESULTS

Findings revealed that information, education, and communication provided during antenatal care were inadequate. Most information was offered. However, no topic was rated adequate by 80% of the respondents according to the Likert Scale that was used. The majority of the respondents (71.4%, n = 274) (95% CI 66.5. 75.8) preferred to receive information, education, and communication from midwives who are in the category of skilled attendants. Results further showed that more than half of the respondents participated passively and spent little time receiving information, education, and communication.

CONCLUSION

The findings signify that information, education, and communication provided to women receiving antenatal care at Chiradzulu District Hospital had some gaps. It was inadequate and some topics were not taught. The target audience participated passively. It is recommended that midwives should provide the information, education, and communication and must have adequate contact time with the women. This is so because they are believed to be trusted sources of information.

Spatial variation and inequities in antenatal care coverage in Kenya, Uganda and mainland Tanzania using model-based geostatistics: a socioeconomic and geographical accessibility lens

BACKGROUND

Pregnant women in sub-Saharan Africa (SSA) experience the highest levels of maternal mortality and stillbirths due to predominantly avoidable causes. Antenatal care (ANC) can prevent, detect, alleviate, or manage these causes. While eight ANC contacts are now recommended, coverage of the previous minimum of four visits (ANC4+) remains low and inequitable in SSA.

METHODS

We modelled ANC4+ coverage and likelihood of attaining district-level target coverage of 70% across three equity stratifiers (household wealth, maternal education, and travel time to the nearest health facility) based on data from malaria indicator surveys in Kenya (2020), Uganda (2018/19) and Tanzania (2017). Geostatistical models were fitted to predict ANC4+ coverage and compute exceedance probability for target coverage. The number of pregnant women without ANC4+ were computed. Prediction was at 3 km spatial resolution and aggregated at national and district -level for sub-national planning.

RESULTS

About six in ten women reported ANC4+ visits, meaning that approximately 3 million women in the three countries had <ANC4+ visits. The majority of the 366 districts in the three countries had ANC4+ coverage of 50-70%. In Kenya, 13% of districts had < 70% coverage, compared to 10% and 27% of the districts in Uganda and mainland Tanzania, respectively. Only one district in Kenya and ten districts in mainland Tanzania were likely met the target coverage. Six percent, 38%, and 50% of the districts had at most 5000 women with <ANC4+ visits in Kenya, Uganda, and mainland Tanzania, respectively, while districts with > 20,000 women having <ANC4+ visits were 38%, 1% and 1%, respectively. In many districts, ANC4+ coverage and likelihood of attaining the target coverage was lower among the poor, uneducated and those geographically marginalized from healthcare.

CONCLUSIONS

These findings will be invaluable to policymakers for annual appropriations of resources as part of efforts to reduce maternal deaths and stillbirths.

Continuum of care for maternal, newborn, and child health in 17 sub-Saharan African countries

BACKGROUND

Given the intricate relationship between mothers and their children with the continuum of care, it is quintessential for their healthcare and interventions to be enhanced through a continuum of care approach. We examined the factors associated with the continuum of care for maternal, newborn, and child health in sub-Saharan Africa.

METHODS

Data for the study were pooled from the Demographic and Health Surveys of 17 countries in sub-Saharan Africa. We extracted the data from the women's files in all 17 countries. We included 15,359 married and cohabiting women with the most recent children aged 12-23 months at the time of the survey in the study. Multivariable multilevel logistic regression analysis was performed to examine the factors associated with continuum of care. Results were presented as adjusted odds ratios (aORs) with their 95% confidence interval.

RESULTS

Women whose partners had secondary or higher level of education [aOR = 1.52; 95%CI = 1.07, 2.16], those with health insurance [aOR = 1.64; 95%CI = 1.18, 2.30], those who decide alone on their healthcare [aOR = 1.38; 95%CI = 1.01, 1.89], those with joint healthcare decision [aOR = 1.33; 95%CI = 1.02, 1.74], those exposed to radio [aOR = 1.38; 95%CI = 1.06, 1.79], those who started antenatal care early [aOR = 1.88; 95%CI = 1.50, 2.36] and those in southern Africa [aOR = 7.02; 95%CI = 3.23, 15.27] had higher odds of completing the continuum of care.

CONCLUSION

We found that only 3.4% of women across the 17 sub-Saharan African countries included in this study completed all of the 11 maternal, newborn, and child health care interventions along the continuum of care. The factors that are associated with the maternal, newborn, and child health continuum of care include women's autonomy in decision-making, partners' level of education, health insurance coverage, early initiation of antenatal care, exposure to radio, and residing in Southern Africa. Problem with the distance to the facility lowered women's odds of completing the continuum of care. Governments and departments of health services across sub-Saharan African countries must leverage the radio to disseminate critical messages about the need to complete the continuum of care. Much commitment must be made toward advancing the autonomy of women. Health insurance coverage would have to be extended to reach all women to facilitate the completion of the continuum of care.

The interaction between antenatal care and abnormal temperature during delivery and its relationship with postpartum care: a prospective study of 1,538 women in semi-rural Uganda

BACKGROUND

Postnatal care (PNC) is an important tool for reducing maternal and neonatal morbidity and mortality. However, what predicts receipt and maintenance in PNC, particularly events during pregnancy and the peripartum period, is not well understood. We hypothesized that fever or hypothermia during delivery would engender greater health consciousness among those attending antenatal care, leading to greater PNC engagement after hospital discharge and our objective was to evaluate this relationship.

METHODS

Women were prospectively enrolled immediately postpartum at Mbarara Regional Referral Hospital (MRRH). We collected postpartum vital signs and surveyed women by telephone about PNC receipt, fever, and infection at two and six weeks postpartum. Our outcome of interest was receipt of PNC post-discharge, defined as whether a participant visited a health facility and/or was hospitalized in the postpartum period. Our explanatory variables were whether a participant was ever febrile (> 38.0˚C) or hypothermic (< 36.0˚C) during delivery stay and whether a participant attended at least 4 antenatal care (ANC) visits. We used logistic regressions to estimate the association between ANC and fever/hypothermia with PNC, including an interaction term between ANC and fever/hypothermia to determine whether there was a modifying relationship between variables on PNC. Regression models were adjusted for age, marital status, parity, HIV serostatus, Mbarara residency, and whether the participant was referred to MRRH, RESULTS: Of the 1,541 women, 86 (5.6%) reported visiting a health facility and/or hospitalization and 186 (12.0%) had an abnormal temperature recorded during delivery stay. Of those who reported at least one visit, 59/86 (68.6%) delivered by cesarean, 37/86 (43.0%) reported post-discharge fever, and 44/86 (51.2%) reported post-discharge infection. Neither ANC attendance, abnormal temperature after delivery, nor their interaction term, were significantly associated with post-discharge PNC. The included covariates were not significantly associated with the outcome.

CONCLUSIONS

While the overall proportion of women reporting post-discharge PNC was low, those who reported visiting a health facility and/or hospitalization had high proportions of post-discharge fever, post-discharge infection, and cesarean delivery, which suggests that these visits may have been related to problem-focused care. No significant associations between ANC and PNC were observed in this cohort. Further research assessing ANC quality and PNC visit focus is needed to ensure ANC and PNC are optimized to reduce morbidity and mortality.

Evaluating continuum of maternal and newborn healthcare in Rwanda: evidence from the 2019-2020 Rwanda demographic health survey

BACKGROUND

Access to a complete continuum of maternal and child health care has been recommended globally for better pregnancy outcomes. Hence this study determined the level (pooled prevalence) and predictors of successfully completing continuum of care (CoC) in Rwanda.

METHODS

We analyzed weighted secondary data from the 2019-2020 Rwanda Demographic and Health Survey (RDHS) that included 6,302 women aged 15 to 49 years who were selected using multistage stratified sampling. We analyzed complete continuum of care as a composite variable of three maternal care services: at least four ANC contacts, SBA, maternal and neonatal post-natal care. We used the SPSS version 25 complex samples package to conduct multivariable logistic regression.

RESULTS

Of the 6,302 women, 2,131 (33.8%) (95% CI: 32.8-35.1) had complete continuum of care. The odds of having complete continuum of care were higher among women who had exposure to newspapers (adjusted odds ratio (AOR): 1.30, 95% CI: 1.11-1.52), those belonging to the eastern region (AOR): 1.24, 95% CI: 1.01-1.52), southern region (AOR): 1.26, 95% CI: 1.04-1.53), those with health insurance (AOR): 1.55, 95% CI: 1.30-1.85), those who had been visited by a field health worker (AOR: 1.31, 95% CI: 1.15-1.49), those with no big problems with distance to health facility (AOR): 1.25, 95% CI: 1.07-1.46), those who were married (AOR): 1.35, 95% CI: 1.11-1.64), those with tertiary level of education (AOR): 1.61, 95% CI: 1.05-2.49), those belonging to richer households (AOR): 1.33, 95% CI: 1.07-1.65) and those whose parity was less than 2 (AOR): 1.52, 95% CI: 1.18-1.95).

CONCLUSION

We have identified modifiable factors (exposure to mass media, having been visited by a field health worker, having health insurance, having no big problems with distance to the nearest health facility, belonging to richer households, being married and educated), that can be targeted to improve utilization of the entire continuum of care. Promoting maternity services through mass media, strengthening the community health programmes, increasing access to health insurance and promoting girl child education to tertiary level may improve the level of utilization of maternity services.

Continuum of maternal and newborn health in Sierra Leone: a 2019 national survey

Introduction

Globally, Sierra Leone has some of the worst maternal and child health indicators. The situation is worsened by a dearth of evidence about the level of continuum of care, an evidence-based intervention aimed at reducing maternal and perinatal morbidity and mortality. Hence this study aimed to assess the level of and factors associated with continuum of maternal and newborn care in Sierra Leone.

Method

This study analyzed secondary data from the 2019 Sierra Leone Demographic Health Survey. Analysis was restricted to women who had a live birth in the 5 years preceding the survey (n = 7326). Complete continuum of care was considered when a woman reported having had at least eight antenatal care contacts, skilled birth attendance and mother and baby had at least one postnatal check-up. Bi-variable and multivariable logistic regression were performed using the statistical package for the social sciences software version 25.

Results

Only 17.9% (95% CI: 17.4–19.1) of the women utilized complete continuum of care for maternal and newborn health services in Sierra Leone. About 22% (95% CI: 21.3–23.1) utilized 8 or more antenatal care contacts, 88% (95% CI: 87.9–89.4) had skilled birth attendance while 90.7% (95% CI: 90.2–91.5) and 90.4% (95% CI: 89.9–91.2) of mothers and neonates utilized postnatal care respectively. Having started antenatal care within the first trimester (aOR 1.71, 95% CI: 1.46–2.00), being resident in the Southern region (aOR 1.85, 95% CI: 1.23–2.80), belonging to richer wealth quintile (aOR 1.76, 95% CI: 1.27–2.44), using internet (aOR 1.49, 95% CI: 1.12–1.98) and having no big problems seeking permission to access healthcare (aOR 1.34, 95% CI: 1.06–1.69) were significantly associated with utilization of continuum of care.

Conclusion

The overall completion of continuum of maternal care is low, with ANC being the lowest utilized component of continuum of care. These findings call for urgent attention for maternal health stakeholders to develop and implement tailored interventions prioritizing women empowerment, access to affordable internet services, timely initiation of ANC contacts, women in developed regions such as the Western and those from poor households.

Factors associated with utilization of quality antenatal care: a secondary data analysis of Rwandan Demographic Health Survey 2020

Background

Over the last decade, progress in reducing maternal mortality in Rwanda has been slow, from 210 deaths per 100,000 live births in 2015 to 203 deaths per 100,000 live births in 2020. Access to quality antenatal care (ANC) can substantially reduce maternal and newborn mortality. Several studies have investigated factors that influence the use of ANC, but information on its quality is limited. Therefore, this study aimed to identify the determinants of quality antenatal care among pregnant women in Rwanda using a nationally representative sample.

Methods

We analyzed secondary data of 6,302 women aged 15–49 years who had given birth five years prior the survey from the Rwanda Demographic and Health Survey (RDHS) of 2020 data. Multistage sampling was used to select RDHS participants. Good quality was considered as having utilized all the ANC components. Multivariable logistic regression was conducted to explore the associated factors using SPSS version 25.

Results

Out of the 6,302 women, 825 (13.1%, 95% CI: 12.4–14.1) utilized all the ANC indicators of good quality ANC); 3,696 (60%, 95% CI: 58.6–61.1) initiated ANC within the first trimester, 2,975 (47.2%, 95% CI: 46.1–48.6) had 4 or more ANC contacts, 16 (0.3%, 95% CI: 0.1–0.4) had 8 or more ANC contacts. Exposure to newspapers/magazines at least once a week (aOR 1.48, 95% CI: 1.09–2.02), lower parity (para1: aOR 6.04, 95% CI: 3.82–9.57) and having been visited by a field worker (aOR 1.47, 95% CI: 1.23–1.76) were associated with more odds of receiving all ANC components. In addition, belonging to smaller households (aOR 1.34, 95% CI: 1.10–1.63), initiating ANC in the first trimester (aOR 1.45, 95% CI: 1.18–1.79) and having had 4 or more ANC contacts (aOR 1.52, 95% CI: 1.25–1.85) were associated with more odds of receiving all ANC components. Working women had lower odds of receiving all ANC components (aOR 0.79, 95% CI: 0.66–0.95).

Conclusion

The utilization of ANC components (13.1%) is low with components such as having at least two tetanus injections (33.6%) and receiving drugs for intestinal parasites (43%) being highly underutilized. Therefore, programs aimed at increasing utilization of ANC components need to prioritize high parity and working women residing in larger households. Promoting use of field health workers, timely initiation and increased frequency of ANC might enhance the quality of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08169-x.

Access to mass media and teenage pregnancy among adolescents in Zambia: a national cross-sectional survey

OBJECTIVE

Teenage pregnancies and childbirths are associated with negative health outcomes. Access to health information enables adolescents to make appropriate decisions. However, the relationship between access to health information through mass media and teenage pregnancy has not received much attention in existing literature. We therefore examined the association between access to mass media and teenage pregnancy in Zambia.

DESIGN

Cross-sectional.

SETTING

Zambia.

PARTICIPANTS

Weighted sample of 3000 adolescents aged 15-19 years.

OUTCOME MEASURE

Teenage pregnancy that included adolescents who were currently pregnant or had had an abortion or had given birth in the last 5 years preceding the survey.

RESULTS

Out of 3000 adolescents, 897 (29.9%, 95% CI: 28.1% to 31.3%) were pregnant or had ever been pregnant. Majority of the adolescents resided in rural areas (55.9%) and had secondary education (53.6%). Adolescents who had exposure to internet, newspapers or magazines, radio and television were 10.5%, 22.6%, 43.1% and 43.1%, respectively. Adolescents who had daily access to newspapers or magazines (adjusted OR (AOR): 0.33, 95% CI: 0.13 to 0.82) or using internet (AOR: 0.54, 95% CI: 0.30 to 0.95) were less likely to be pregnant or to have had a pregnancy compared with those with no access to newspapers and internet, respectively.

CONCLUSION

Our study suggests that internet use and reading of newspapers or magazines may trigger behavioural change as an effective approach to reducing teenage pregnancy. Behavioural change communicators can implement mass media campaigns using newspapers, magazines and the internet to publicise adolescent health messages that can encourage adolescents to adopt healthy behaviours and prevent teenage pregnancies.

Rural-urban correlates of skilled birth attendance utilisation in Sierra Leone: evidence from the 2019 Sierra Leone Demographic Health Survey

OBJECTIVES

Understanding the rural-urban context-specific correlates of skilled birth attendance (SBA) is important to designing relevant strategies and programmes. This analysis aimed to assess for the rural-urban correlates of SBA in Sierra Leone.

SETTING

The latest nationally representative Sierra Leone Demographic and Health Survey of 2019.

PARTICIPANTS

The study included a weighted sample of 7326 women aged 15-49 years. Each of them had a live birth within 5 years prior to the survey (4531 in rural areas and 2795 women in urban areas).

PRIMARY AND SECONDARY OUTCOME MEASURE

SBA (primary) and predictors of SBA (secondary).

RESULTS

SBA was higher in urban areas at 94.9% (95% CI 94.1% to 95.7%) compared with 84.2% (95% CI 83.8% to 85.9%) in rural areas. Rural women resident in the Southern, Northern and Eastern regions, with postprimary education (adjusted OR (aOR) 1.8; 95% CI 1.3 to 2.5), exposure to mass media (aOR 1.5; 95% CI 1.1 to 1.9), not having difficulties with distance to the nearest health facility (aOR 2.3; 95% CI 1.7 to 3.0) were associated with higher odds of SBA. Urban women resident in the Southern, Eastern region, with households having less than seven members (aOR 1.5; 95% CI 1.1 to 2.3), exposure to mass media (aOR 1.8; 95% CI 1.1 to 2.9) and not having difficulties with distance to the nearest health facility (aOR 1.6; 95% CI 1.1 to 2.5) were associated with higher odds of SBA.

CONCLUSION

Given the observed differences, improving SBA requires programmes and strategies that are context-specific.