Antenatal and postnatal care: a review of innovative models for improving availability, accessibility, acceptability and quality of services in low-resource settings

Magnitude, disparity, and predictors of poor-quality antenatal care service: A systematic review and meta-analysis

Background

Antenatal care is directed toward ensuring healthy pregnancy outcomes. Quality antenatal care increases the likelihood of receiving an effective intervention to maintain maternal, fetal, and neonatal well-being, while poor quality is linked to poor pregnancy outcomes. However, owing to the complex nature of quality, researchers have followed several approaches to systematically measure it. The evidence from these variable approaches appears inconsistence and poses challenges to programmers and policymakers. Hence, it is imperative to obtain a pooled estimate of the quality of antenatal care. Therefore, considering the scarcity of evidence on the quality of antenatal care, this study aimed to review, synthesize, and bring pooled estimates of accessible evidence.

Objective

This study aimed to estimate the pooled magnitude and predictors of quality of antenatal care services and compare regional disparity.

Method

We conducted a comprehensive systematic three-step approach search of published and unpublished sources from 2002 to 2022. The methodological quality of eligible studies was checked using Joanna Briggs Institute critical appraisal tool for cross-sectional studies. Meta-analysis was carried out using STATA version 16. Statistical heterogeneity was assessed using Cochran's Q test. In the presence of moderate heterogeneity (I2 more than 50%), sensitivity and subgroup analyses were conducted and presented in a forest plot. Effect size was reported using standardized mean difference and its 95% confidence interval. Funnel plots and Egger's regression test were used to measure publication bias at the 5% significance level. A trim-and-fill analysis was conducted to adjust for publication bias. Pooled estimates were computed using random-effects models and weighted using the inverse variance method in the presence of high heterogeneity among studies. A 95% CI and 5% significance level were considered to declare significance variables.

Results

The global pooled poor-quality antenatal care was 64.28% (95% CI: 59.58%-68.98%) (I2 = 99.97%, p = 0.001). The identified pooled predictors of good-quality antenatal care service were: number of antenatal care visits (fourth and above antenatal care visit) (Adjusted odds ratio (AOR) = 2.6, 95% CI: 1.37-3.84), family wealth index (AOR = 2.72, 95% CI: 1.89-3.55), maternal education attainment (AOR = 3.03, 95% CI: 2.24-3.82), residence (urban dwellers) (AOR = 4.06, 95% CI: 0.95-7.17), and confidentiality antenatal care (AOR = 2.23, 95% CI: -0.36 to -4.82).

Conclusions

The study found regional and country-level disparities in the quality of antenatal care services for pregnant women, where poor-quality antenatal care services were provided for more than two-thirds to three-fourths of antenatal care attendants. Therefore, policymakers and health planners should put a great deal of emphasis on addressing the quality of antenatal care services.

Adapting group care to the postpartum period using a human-centered design approach in Malawi

BACKGROUND

Responsive and resilient strategies to reduce high rates of maternal and infant mortality and clinician shortages are needed in low- and middle-income countries (LMICs). Malawi has some of the highest maternal and infant mortality rates globally. Group healthcare is a service delivery model that integrates these strategies. Although primarily implemented during the prenatal period, its potential for improving both maternal and infant health outcomes during the postpartum period has not been realized. The purpose of this study was to adapt and co-design the prototype for an evidence-based group care model for the postpartum period using a human-centered design approach with key stakeholders in Malawi.

METHODS

We completed steps of a framework guiding the use of human-centered design: 1) define the problem and assemble a team; 2) gather information through evidence and inspiration; 3) synthesize; and 4) intervention design: guiding principles and ideation. Qualitative methods were used to complete steps 2-4. In-depth interviews (n = 24), and incubator sessions (n = 6) that employed free listing, pile sorting and ranking were completed with key stakeholders. Data analysis consisted of content analysis of interviews and framework analysis for incubator sessions to produce the integrated group postpartum and well-child care model prototype. The fifth step is detailed in a separate paper.

RESULTS

All stakeholders reported a desire to participate in and offer group care in the postpartum period. Stakeholders worked collaboratively to co-create the prototype that included a curriculum of health promotion topics and interactive activities and the service delivery structure. Health promotion topic priorities were hygiene, breastfeeding, family planning, nutrition, and mental health. The recommended schedule included 6 sessions corresponding with the child vaccination schedule over the 12-month postpartum period.

CONCLUSIONS

Using a human-centered design approach to adapt an evidence-based group care model in an LMIC, specifically Malawi, is feasible and acceptable to key stakeholders and resulted in a prototype curriculum and practical strategies for clinic implementation.

Does armed conflict lead to lower prevalence of maternal health-seeking behaviours: theoretical and empirical research based on 55 683 women in armed conflict settings

BACKGROUND

Women and children bear a substantial burden of morbidity and mortality due to armed conflict. Life-saving maternal and child health (MCH) services are low-quality in most conflict-affected regions. Previous studies on armed conflict and MCH services have been mostly cross-sectional, and a causal relationship between armed conflict and MCH services utilisation cannot be inferred.

METHODS

First, we constructed a utility equation for maternal health-seeking behaviour. Next, we extracted MCH data from the Multiple Indicator Cluster Survey led by the UNICEF. Armed conflict data were obtained from the Uppsala Conflict Data Programme; 55 683 women aged 15-49 from Chad, the Central African Republic, the Democratic Republic of Congo (DRC) and the Republic of Iraq were selected as participants. We fitted a difference-in-differences (DID) model, taking before or after the conflict started as an exposure variable to estimate the effects of armed conflict on maternal health-seeking behaviours.

RESULTS

According to the results of the DID model, in the regional sample, armed conflict had a positive effect on tetanus vaccination (β=0.055, 95% CI 0.004 to 0.106, p<0.05), and had a negative effect on antenatal care at least eight visits (ANC8+) (β=-0.046, 95% CI -0.078 to -0.015, p<0.01). And, the effects of armed conflict on ANC, ANC4+, institutional delivery and early initiation of breast feeding (EIB) were not statistically significant. As for the country sample, we found that armed conflict had a negative effect on EIB (β=-0.085, 95% CI -0.184 to 0.015, p<0.1) in Chad. In Iraq, armed conflict had positive impacts on ANC (β=0.038, 95% CI -0.001 to 0.078, p<0.1) and tetanus vaccination (β=0.059, 95% CI 0.012 to 0.107, p<0.05), whereas it had a negative effect on ANC8+ (β=-0.039, 95% CI -0.080 to 0.002, p<0.1). No statistically significant associations were discovered in DRC based on the DID model.

CONCLUSIONS

There might be a mixed effect of armed conflict on maternal health-seeking behaviours. In the absence of humanitarian assistance, armed conflict reduces certain maternal health-seeking behaviours, such as ANC8+. When practical humanitarian health assistance is provided, the damage can be alleviated, and even the prevalence of maternal health-seeking behaviours can be improved, such as tetanus vaccination. Providing humanitarian assistance to conflict-affected regions improved the accessibility of MCH services for women living in those areas. However, the goals of saving lives and alleviating suffering still need to be achieved. In conflict-affected regions, humanitarian assistance on ANC, institutional delivery and breast feeding need strengthening.

Socioeconomic inequity in coverage and quality of maternal postnatal care in Ethiopia

OBJECTIVE

High-quality postnatal care is vital for improving maternal health. This study examined the relationship between household socioeconomic status and both coverage and quality of postnatal care in Ethiopia.

METHOD

Cross-sectional household survey data were collected in October-November 2013 from 12 zones in 4 regions of Ethiopia. Women reporting a live birth in the 3-24 months prior to the survey were interviewed about the care they received before, during and after delivery and their demographic characteristics. Using mixed effect logistic and linear regression, the associations between household socioeconomic status and receiving postnatal care, location of postnatal care (health facility vs. non-health facility), cadre of person providing care and the number of seven key services (including physical checks and advice) provided at a postnatal visit, were estimated.

RESULTS

A total of 16% (358/2189) of women interviewed reported receiving at least one postnatal care visit within 6 weeks of delivery. Receiving a postnatal care visit was strongly associated with socioeconomic status with women from the highest socioeconomic group having twice the odds of receiving postnatal care compared to women in the poorest quintile (OR [95% CI]: 1.98 [1.29, 3.05]). For each increasing socioeconomic status quintile there was a mean increase of 0.24 postnatal care services provided (95% CI: 0.06-0.43, p = 0.009) among women who did not give birth in a facility. There was no evidence that number of postnatal care services was associated with socioeconomic status for women who gave birth in a facility. There was no evidence that socioeconomic status was associated with the provider or location of postnatal care visits.

CONCLUSION

Postnatal care in Ethiopia shows evidence of socio-economic inequity in both coverage and quality. This demonstrates the need to focus on quality improvement as well as coverage, particularly among the poorest women who did not deliver in a facility.

Input, process, and output factors contributing to quality of antenatal care services: a scoping review of evidence

BACKGROUND

High-quality antenatal care (ANC) provides a lifesaving opportunity for women and their newborns through providing health promotion, disease prevention, and early diagnosis and treatment of pregnancy-related health issues. However, systematically synthesised evidence on factors influencing the quality of ANC services is lacking. This scoping review aims to systematically synthesize the factors influencing in provision and utilisation of quality ANC services.

METHODS

We conducted a scoping review of published evidence on the quality of ANC services. We searched records on four databases (PubMed, Scopus, Embase, and Google scholar) and grey literature from 1 to 2011 to 30 August 2021. We analysed data using Braun and Clarke's thematic analysis approach. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guideline for the review. We explained themes using the Donabedian healthcare quality assessment model (input-process-output).

RESULTS

Several inputs- and process-related factors contributed to suboptimal quality of ANC in many low and lower- or middle-income countries. Input factors included facility readiness (e.g., lack of infrastructure, provision of commodities and supplies, health workforce, structural and intermediary characteristics of pregnant women, and service delivery approaches). Processes-related factors included technical quality of care (e.g., lack of skilled adequate and timely care, and poor adherence to the guidelines) and social quality (lack of effective communication and poor client satisfaction). These input and process factors have also contributed to equity gaps in utilisation of quality ANC services.

CONCLUSION

Several input and process factors influenced the provision and utilization of optimum quality ANC services. Better health system inputs (e.g., availability of trained workforces, commodities, guidelines, context-specific programs) are essential to creating enabling facility environment for quality ANC services. Care processes can be improved by ensuring capacity-building activities for workforces (training, technical support visits), and mentoring staff working at peripheral facilities. Identifying coverage of quality ANC services among disadvantaged groups could be the initial step in designing and implementing targeted program approaches.

Timing of neonatal mortality and severe morbidity during the postnatal period: a systematic review

OBJECTIVE

The objective of this review was to determine the timing of overall and cause-specific neonatal mortality and severe morbidity during the postnatal period (1-28 days).

INTRODUCTION

Despite significant focus on improving neonatal outcomes, many newborns continue to die or experience adverse health outcomes. While evidence on neonatal mortality and severe morbidity rates and causes are regularly updated, less is known on the specific timing of when they occur in the neonatal period.

INCLUSION CRITERIA

This review considered studies that reported on neonatal mortality daily in the first week; weekly in the first month; or day 1, days 2-7, and days 8-28. It also considered studies that reported on timing of severe neonatal morbidity. Studies that reported solely on preterm or high-risk infants were excluded, as these infants require specialized care. Due to the available evidence, mixed samples were included (eg, both preterm and full-term infants), reflecting a neonatal population that may include both low-risk and high-risk infants.

METHODS

MEDLINE, Embase, Web of Science, and CINAHL were searched for published studies on December 20, 2019, and updated on May 10, 2021. Critical appraisal was undertaken by 2 independent reviewers using standardized critical appraisal instruments from JBI. Quantitative data were extracted from included studies independently by 2 reviewers using a study-specific data extraction form. All conflicts were resolved through consensus or discussion with a third reviewer. Where possible, quantitative data were pooled in statistical meta-analysis. Where statistical pooling was not possible, findings were reported narratively.

RESULTS

A total of 51 studies from 36 articles reported on relevant outcomes. Of the 48 studies that reported on timing of mortality, there were 6,760,731 live births and 47,551 neonatal deaths with timing known. Of the 34 studies that reported daily deaths in the first week, the highest proportion of deaths occurred on the first day (first 24 hours, 38.8%), followed by day 2 (24-48 hours, 12.3%). Considering weekly mortality within the first month (n = 16 studies), the first week had the highest mortality (71.7%). Based on data from 46 studies, the highest proportion of deaths occurred on day 1 (39.5%), followed closely by days 2-7 (36.8%), with the remainder occurring between days 8 and 28 (23.0%). In terms of causes, birth asphyxia accounted for the highest proportion of deaths on day 1 (68.1%), severe infection between days 2 and 7 (48.1%), and diarrhea between days 8 and 28 (62.7%). Due to heterogeneity, neonatal morbidity data were described narratively. The mean critical appraisal score of all studies was 84% (SD = 16%).

CONCLUSION

Newborns experience high mortality throughout the entire postnatal period, with the highest mortality rate in the first week, particularly on the first day. Ensuring regular high-quality postnatal visits, particularly within the first week after birth, is paramount to reduce neonatal mortality and severe morbidity.

Integrated Maternal Care Strategies in Low- and Middle-Income Countries: A Systematic Review

Background and aim:

Ineffective organisation of care leads to increased morbidity and mortality in neonates and their mothers. We aimed to identify and describe strategies used in low- and middle-income countries that attempt to deliver coherent, coordinated, and continuous services (i.e., integrated care) and how the various strategies affect the organisation of care.

Methods:

We conducted a systematic literature review to identify, appraise, and synthesise relevant evidence about strategies for integrating maternal care in low- and middle-income countries, searching multiple electronic databases.

Results:

Fourteen studies met our inclusion criteria. We identified five types of integration strategies: 1) organisational, 2) service/professional, 3) functional, 4) organisational combined with normative strategies, and 5) clinical combined with functional integration strategies. The most frequent types of strategies were organisational, and service/professional integration strategies. We did not identify any publications describing systemic integration strategies implemented in low- and middle-income countries.

Conclusions:

Most types of strategies described in theory have been implemented and studied in low- and middle-income countries. Our findings suggest that different types of strategies may lead to comparable organisational outcomes. For example, organisational integration strategies and professional or service integration strategies may similarly influence inter-organisational collaboration. Inter-organisational collaboration may play a particularly important role in the context of maternal care integration.

Level of Postnatal Checkup in Ethiopia - Implications for Child Health Services

Background

High neonatal mortality rates continue to be a major public health issue in Ethiopia. Despite different maternal and neonatal care interventions, neonatal mortality in Ethiopia is at a steady state. This could be due to the low utilization of neonatal checkups. Thus, nationally assessing the level and predictors of postnatal checkups could provide important information for further improving neonatal healthcare services.

Materials and Methods

A secondary data analysis of the 2016 Ethiopia Demographic and Health Survey (EDHS) was performed on 7,586 women who had live births in the 2 years before the survey. All variables with a p-value of ≤0.25 in the bivariable analysis were entered into the final model for multivariable analysis, and the level of statistical significance was declared at a P-value of <0.05.

Results

According to the national survey, only 8.3% [95% CI: 8.19, 8.41] of neonates received postnatal checkups. About two-thirds of women, 62.8% had antenatal care visits, 67.9%, gave birth at home, and 95.7% were unaware of neonatal danger signs. Distance from health care institutions [AOR = 1.42; 95% CI: 1.06, 1.89], giving birth in a healthcare facility [AOR = 1.55; 95% CI: 1.12, 2.15], antenatal care visit [AOR = 3.0; 95% CI: 1.99, 4.53], and neonatal danger signs awareness [AOR = 3.06; 95% CI: 2.09, 4.5] were all associated with postnatal care visits.

Conclusion

The number of neonates who had a postnatal checkup was low. Increasing antenatal care visit utilization, improving institutional delivery, raising awareness about neonatal danger signs, increasing access to health care facilities, and implementing home-based neonatal care visits by healthcare providers could all help to improve postnatal checkups.

Exploring the Unmet Needs of Postpartum Mothers: A Qualitative Study

This study aimed to identify unmet needs of mothers in the postpartum period. Semi-structured telephone interviews were conducted two weeks postpartum with a convenience sample of 26 mothers who gave birth at an academic medical center. Topics included mothers’ concerns, levels of preparedness, educational needs and preferences during antepartum, labor and birth, and postpartum periods. Data were qualitatively analyzed using NVivo and a combination of open coding and theoretical coding, based on the Perinatal Maternal Health Promotion Model. Three major themes emerged: concerns, expectations, and positive coping strategies, with variations by previous maternal experience. Findings suggest the need for different models of care with more anticipatory, mother-centered care to better meet mothers’ needs and enhance postpartum outcomes and breastfeeding success.

Prevalence and factors associated with utilisation of postnatal care in Sierra Leone: a 2019 national survey

Background

Within Sub-Saharan Africa, some countries still report unacceptably high rates of maternal and perinatal morbidity and mortality, despite improvements in the utilisation of maternity care services. Postnatal care (PNC) is one of the recommended packages in the continuum of maternity care aimed at reducing maternal and neonatal mortality. This study aimed to determine the prevalence and factors associated with PNC utilisation in Sierra Leone.

Methods

We used Sierra Leone Demographic and Health Survey (UDHS) 2019 data of 7326 women aged 15 to 49 years. We conducted multivariable logistic regression to determine the factors associated with PNC utilisation, using SPSS version 25.

Results

Out of 7326 women, 6625 (90.4, 95% CI: 89.9–91.2) had at least one PNC contact for their newborn, 6646 (90.7, 95% CI: 90.2–91.5) had a postnatal check after childbirth and 6274 (85.6, 95% CI: 85.0–86.6) had PNC for both their babies and themselves. Delivery by caesarean section (aOR 8.01, 95% CI: 3.37–19.07), having a visit by a health field worker (aOR 1.80, 95% CI: 1.46–2.20), having had eight or more ANC contacts (aOR 1.37, 95% CI: 1.08–1.73), having tertiary education (aOR 2.71, 95% CI: 1.32–5.56) and having no big problems seeking permission to access healthcare (aOR 1.51, 95% CI: 1.19–1.90) were associated with higher odds of PNC utilisation. On the other hand, being resident in the Northern (aOR 0.48, 95% CI: 0.29–0.78) and Northwestern regions (aOR 0.54, 95% CI: 0.36–0.80), belonging to a female headed household (aOR 0.69, 95% CI: 0.56–0.85) and being a working woman (aOR 0.66, 95% CI: 0.52–0.84) were associated with lower odds of utilizing PNC.

Conclusion

Factors associated with utilisation of PNC services operate at individual, household, community and health system/policy levels. Some of them can be ameliorated by targeted government interventions to improve utilisation of PNC services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12494-5.

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.

Utilization of Postnatal Care Service in Indonesia and its Association with Women's Empowerment: An Analysis of 2017 Indonesian Demographic Health Survey Data

Objective

The coverage of postnatal care (PNC) is among the lowest globally when compared with other maternal and child interventions. This study aims to assess PNC utilisation in Indonesia and its association with women’s empowerment indicators to provide evidence for the need for policy change.

Methods

Data from the 2017 Indonesian Demographic Health Surveys was analyzed for any use of PNC, early first PNC (within 2 days of birth) and PNC after discharge for newborns. Women’s empowerment factors were calculated using a principal component analysis of 17 indicators. The association between women’s empowerment factors and PNC was assessed using logistic regression adjusted for covariates and complex survey design.

Results

The prevalence of any PNC by skilled professionals in Indonesia was high but PNC after discharge was very low. Labor-force participation and women’s knowledge level were associated with any PNC, but the association between women’s knowledge level and any PNC was modified by place of birth. Disagreement towards justification of wife beating and women’s knowledge level were associated with early PNC but the association was modified by place of birth. Decision-making power was also associated with early PNC but modified by infant’s gender. Disagreement towards justification of wife beating was negatively associated with PNC after discharge, but the association between decision-making power and PNC after discharge was modified by the infant’s size at birth.

Conclusions for Practice

PNC coverage after discharge in Indonesia needs improvement. Women’s empowerment indicators need to be addressed in improving PNC coverage.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10995-021-03324-y.

Lived experiences of frontline healthcare providers offering maternal and newborn services amidst the novel corona virus disease 19 pandemic in Uganda: A qualitative study

BACKGROUND

The COVID-19 pandemic has brought many health systems in low resource settings to their knees. The pandemic has had crippling effects on the already strained health systems in provision of maternal and newborn healthcare. With the travel restrictions, social distancing associated with the containment of theCOVID-19 pandemic, healthcare providers could be faced with challenges of accessing their work stations, and risked burnout as they offered maternal and newborn services. This study sought to understand the experiences and perceptions of healthcare providers at the frontline during the first phase of the lockdown as they offered maternal and newborn health care services in both public and private health facilities in Uganda with the aim of streamlining patient care in face of the current COVID-19 pandemic and in future disasters.

METHODS

Between June 2020 and December 2020, 25 in-depth interviews were conducted among healthcare providers of different cadres in eight Public, Private-Not-for Profit and Private Health facilities in Kampala, Uganda. The interview guide primarily explored the lived experiences of healthcare providers as they offered maternal and newborn healthcare services during the COVID-19 pandemic. All of the in depth interviews were audio recorded and transcribed verbatim. Themes and subthemes were identified using both inductive thematic and phenomenological approaches.

RESULTS

The content analysis of the in depth interviews revealed that the facilitators of maternal and newborn care service delivery among the healthcare providers during the COVID-19 pandemic included; salary bonuses, the passion to serve their patients, availability of accommodation during the pandemic, transportation to and from the health facilities by the health facilities, teamwork, fear of losing their jobs and fear of litigation if something went wrong with the mothers or their babies. The barriers to their service delivery included; lack of transport means to access their work stations, fear of contracting COVID-19 and transmitting it to their family members, salary cuts, loss of jobs especially in the private health facilities, closure of the non-essential services to combat high patient numbers, inadequate supply of Personal Protective equipment (PPE), being put in isolation or quarantine for two weeks which meant no earning, brutality from the security personnel during curfew hours and burnout from long hours of work and high patient turnovers.

CONCLUSION

The COVID-19 Pandemic has led to a decline in quality of maternal and newborn service delivery by the healthcare providers as evidenced by shorter consultation time and failure to keep appointments to attend to patients. Challenges with transport, fears of losing jobs and fear of contracting COVID-19 with the limited access to personal protective equipment affected majority of the participants. The healthcare providers in Uganda despite the limitations imposed by the COVID-19 pandemic are driven by the inherent passion to serve their patients. Availability of accommodation and transport at the health facilities, provision of PPE, bonuses and inter professional teamwork are critical motivators that needed to be tapped to drive teams during the current and future pandemics.

Factors affecting the frequency and contents of routine antenatal care in remote rural China in 2009-2016: an observational study

OBJECTIVE

We assessed factors associated with frequency and contents of antenatal care (ANC) in remote rural China, including province of residence and individual level factors.

DESIGN

Survey-based cross-sectional study.

SETTING

Remote rural China, Five provinces- Jilin, Shaanxi, Hunan, Guizhou, and Ningxia.

SAMPLE

3,918 women with a live birth in 2009-2016.

METHODS

Poisson regression.

MAIN OUTCOME MEASURES

ANC frequency- 5+ visits starting in the first trimester. ANC contents- co-coverage of six care components, and overuse of ultrasound.

MAIN RESULTS

Three quarters (72.9%) of women had 5+ visits starting in the first trimester, 68.8% received all six care components, and 94.5% had 3+ ultrasounds. Only 30.9% women sought ANC from township hospitals, paying between $3.8 and 25.8 per-visit. ANC frequency and contents were associated with women's socio-economic characteristics, but provincial effects were much stronger, even after adjusting for individual factors. Women living in Guizhou and Ningxia, the two poorest provinces with high proportions of ethnic minorities, were particularly underserved. Compared to women in Shaanxi, women in Guizhou were 33% (adjusted RR 0.67, 95%CI 0.61-0.74) less likely to receive 5+ ANC starting in the first trimester; women in Ningxia were 17% less likely (adjusted RR 0.83, 95% CI 0.76-0.90) to receive all six care components.

CONCLUSION

The province of residence was a stronger predictor of ANC frequency and contents than women's individual characteristics in China, suggesting that strengthening the decentralised system of financing and organisation of ANC at province level is crucial to achieving success. Future efforts are warranted to engage sub-regional administrations.

Using the Consolidated Framework for Implementation Research to design and implement a perinatal education program in a large maternity hospital

BACKGROUND

Implementation science aims to embed evidence-based practice as 'usual care' using theoretical underpinnings to guide these processes. Conceptualising the complementary purpose and application of theoretical approaches through all stages of an implementation project is not well understood and is not routinely reported in implementation research, despite call for this. This paper presents the synthesis and a collective approach to application of a co-design model, a model for understanding need, theories of behaviour change with frameworks and tools to guide implementation and evaluation brought together with the Consolidated Framework for Implementation Research (CFIR).

METHOD

Using a determinant framework such as the CFIR provides a lens for understanding, influencing, and explaining the complex and multidimensional variables at play within a health service that contribute to planning for and delivering effective patient care. Complementary theories, models, frameworks, and tools support the research process by providing a theoretical and practical structure to understanding the local context and guiding successful local implementation.

RESULTS

This paper provides a rationale for conceptualising the multidimensional approach for implementation using the worked example of a pregnancy, birth, postnatal and early parenting education intervention for expectant and new parents at a large maternity hospital.

CONCLUSION

This multidimensional theoretical approach provides useful, practical guidance to health service researchers and clinicians to develop project specific rationale for their theoretical approach to implementation projects.

Just-in-time postnatal education programees to improve newborn care practices: needs and opportunities in low-resource settings

Worldwide, many newborns die in the first month of life, with most deaths happening in low/middle-income countries (LMICs). Families’ use of evidence-based newborn care practices in the home and timely care-seeking for illness can save newborn lives. Postnatal education is an important investment to improve families’ use of evidence-based newborn care practices, yet there are gaps in the literature on postnatal education programmes that have been evaluated to date. Recent findings from a 13 000+ person survey in 3 states in India show opportunities for improvement in postnatal education for mothers and families and their use of newborn care practices in the home. Our survey data and the literature suggest the need to incorporate the following strategies into future postnatal education programming: implement structured predischarge education with postdischarge reinforcement, using a multipronged teaching approach to reach whole families with education on multiple newborn care practices. Researchers need to conduct robust evaluation on postnatal education models incorporating these programee elements in the LMIC context, as well as explore whether this type of education model can work for other health areas that are critical for families to survive and thrive.

A qualitative study exploring barriers to adequate uptake of antenatal care in pre-conflict Syria: low cost interventions are needed to address disparities in antenatal care

BACKGROUND

Syria has made progress in reducing maternal mortality and morbidity before the conflict in 2011. Despite the improvement in antenatal care (ANC) coverage and patterns of use, analyses of national surveys demonstrated wide regional variations in uptake, timing and number of visits even after controlling for women's socio-demographic characteristics. This study compares two governorates: Latakia, where uptake of ANC was high and Aleppo, where uptake of ANC was low to highlight the barriers to women's adequate uptake of ANC that existed in Syria pre-conflict.

METHODS

This qualitative study carried out 30 semi-structured interviews with (18-45-year-old) pregnant women from Aleppo and Latakia (recruited purposively from different types of health facilities in rural and urban areas), and 15 observation sessions at health facilities. Transcripts and fieldnotes were analyzed using the Framework Method with attention to the dimensions of availability, accessibility and acceptability of services.

RESULTS

Inadequate uptake of ANC in Aleppo included not attending ANC, seeking care with providers who are not trained to provide ANC or discontinuing care. Three themes explained the regional disparities in the uptake of ANC in Aleppo and Latakia: women's assessment of their health status and reasoning of causes of ill health in pregnancy; women's evaluation of the risks of seeking ANC; and women's appraisal of the value of different types of service providers. Poor experiences at public health facilities were reported by women in Aleppo but not by women in Latakia. Evaluations of ANC services were connected with the availability, accessibility (geographical and financial) and acceptability of ANC services, however, women's views were shaped by the knowledge and prevailing opinions in their families and community.

CONCLUSIONS

Findings are utilized to discuss low-cost interventions addressing the disparities in ANC uptake. Interventions should aim to enable vulnerable women to make informed decisions focusing on regions of low uptake. Women's groups that foster education and empowerment, which have been effective in other low resource settings, could be of value in Syria. Increased use of mobile phones and social media platforms suggests mobile health technologies (mHealth) may present efficient platforms to deliver these interventions.

Patient feedback surveys among pregnant women in Eswatini to improve antenatal care retention

Background

Uptake and retention in antenatal care (ANC) is critical for preventing adverse pregnancy outcomes for both mothers and infants.

Methods

We implemented a rapid quality improvement project to improve ANC retention at seven health facilities in Eswatini (October-December 2017). All pregnant women attending ANC visits were eligible to participate in anonymous tablet-based audio assisted computer self-interview (ACASI) surveys. The 24-question survey asked about women’s interactions with health facility staff (HFS) (nurses, mentor mothers, receptionists and lab workers) with a three-level symbolic response options (agree/happy, neutral, disagree/sad). Women were asked to self-report HIV status. Survey results were shared with HFS at monthly quality improvement sessions. Chi-square tests were used to assess differences in responses between months one and three, and between HIV-positive and negative women. Routine medical record data were used to compare retention among pregnant women newly enrolled in ANC two periods, January-February 2017 (‘pre-period’) and January-February 2018 (‘post-period’) at two of the participating health facilities. Proportions of women retained at 3 and 6 months were compared using Cochran-Mantel-Haenszel and Wilcoxon tests.

Results

A total of 1,483 surveys were completed by pregnant women attending ANC, of whom 508 (34.3%) self-reported to be HIV-positive. The only significant change in responses from month one to three was whether nurses listened with agreement increasing from 88.3% to 94.8% (p<0.01). Overall, WLHIV had significantly higher proportions of reported satisfaction with HFS interactions compared to HIV-negative women. A total of 680 pregnant women were included in the retention analysis; 454 (66.8%) HIV-negative and 226 (33.2%) WLHIV. In the pre- and post-periods, 59.4% and 64.6%, respectively, attended at least four ANC visits (p = 0.16). The proportion of women retained at six months increased from 60.9% in the pre-period to 72.7% in the post-period (p = 0.03). For HIV-negative women, pre- and post-period six-month retention significantly increased from 56.6% to 71.6% (p = 0.02); however, the increase in WLHIV retained at six months from 70.7% (pre-period) to 75.0% (post-period) was not statistically significant (p = 0.64).

Conclusion

The type of rapid quality improvement intervention we implemented may be useful in improving patient-provider relationships although whether it can improve retention remains unclear.

Evaluation of a pilot program that integrated prenatal screening into routine antenatal care in western rural China: an interrupted time-series study

Background

We evaluated a large-scale pilot program in Shaanxi Province, western rural China, which integrated prenatal screening interventions for congenital abnormalities into routine antenatal programs.

Methods

We surveyed 1,597 mothers who gave birth between 2009 and 2016. Adopting the interrupted time-series design, we evaluated the program's impact on awareness, coverage, and cost, by comparing two counties with only supply-side policies, and two counties from the neighbouring province with no policies; and among the two counties with both supply- and demand-side policies and the two counties with only supply-side policies. We adjusted the sampling procedure and women's background characteristics. We conducted subgroup analyses by women's education.

Findings

After one year of implementation, the coverage of prenatal foetal aneuploidies and B-ultrasound screening rose by 25.0% and 23.5%. The program's supply-side policies attributed to 17.2 percentage points (90%CI 7.8–26.6%) and 27.3 percentage points (90%CI 16.2–38.5%) in coverage, and contributed to a higher median cost of 796.5RMB (90%CI 595.5–997.5). These significantly affected women with secondary education and above. However, the program's demand-side measures, that is, vouchers, seemed to be effective only in the mountainous regions, which raised awareness, and increased coverage of prenatal foetal aneuploidies screening by 28.6 percentage points (90%CI 13.4–43.8%), while not increasing costs. These significantly affected women with primary education and below. Education-related inequalities widened post-program in counties with only supply-side policies, but no inequalities existed in counties with demand-side policies.

Interpretation

Shaanxi's program made a pilot study to other provinces of China to integrate antenatal services. Government subsidies might be more effective in targeting specific geographic locations and people with primary education and lower.

High dropout rate from maternity continuum of care after antenatal care booking and its associated factors among reproductive age women in Ethiopia, Evidence from Demographic and Health Survey 2016

Background

Maternal continuums of care were vital to reducing maternal and neonatal mortalities. While the dropout rate remains high and limited studies were found on risk factors associated with a high dropout rate of the maternal continuum of care.

Objective

This study aimed to assess the magnitude of dropout rate and its associated factors of maternity continuum of care in Ethiopia, 2016

Methods

An in-depth secondary data analysis was conducted from the Ethiopian Demographic and Health Survey 2016 data. A total of 4,693 women who were booked for antenatal care visit were included to the final analysis. A community-based cross-sectional study design and a pre-tested and standardized questionnaire were used to collect the survey data. Data were weighted using women data weighting variables. Chi-square and multicollinearity assumptions were checked for independent variables. Bi-variable and multivariable logistics regression used to identify associated factors with a cut of the p-value of 0.2 and 0.05 respectively. Adjusted Odds Ratio (AOR) with 95%CI was reported for the final model.

Results

Of the total 4,693 women who were booked for antenatal care visits, 2,092(44.58%), 2,183 (46.52%), and 4,086(87.07%) dropped from a recommended number of ANC, Institutional delivery and postnatal care visit respectively. Only 308 (6.56%, 95%CI: 5.89, 7.31) women used all the complete continuum of care. Not married, and poorest wealth index were significantly associated with dropout from ANC visit. Being a protestant religious follower was significantly associated with dropout from PNC after antenatal care booking. While not exposed to media, distance from health facility as a big problem, protestant affiliation, parity of 2 to 4 and above4, Wealth index of the poorest, poorer, middle, and richer significantly associated with dropout from institutional delivery. Not being informed about pregnancy complications during their ANC visit was significantly associated with dropout from ANC, PNC, and institutional delivery.

Conclusions

Dropout of women from the maternity continuum of care after antenatal care booking was a public health problem in Ethiopia. Socio-demographic, pregnancy, and health service-related factors were significant determinants of dropout from the maternity continuum of care. Improving the family wealth index, increasing access to health facilities, media exposure, and giving more information during the antenatal care visit is important to reduce the dropout rate from the maternity continuum of care.

Perinatal and newborn care in a two years retrospective study in a first level peripheral hospital in Sicily (Italy)

BACKGROUND

Two hundred seventy-five thousand maternal deaths, 2.7 million neonatal deaths, and 2.6 million stillbirths have been estimated in 2015 worldwide, almost all in low-income countries (LICs). Moreover, more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. A significant decrease of mortality/morbidity rates could be achieved by providing effective perinatal and newborn care also in high-income countries (HICs), especially in peripheral hospitals and/or rural areas, where the number of childbirths per year is often under the minimal threshold recognized by the reference legislation. We report on a 2 years retrospective cohort study, conducted in a first level peripheral hospital in Cefalù, a small city in Sicily (Italy), to evaluate care provided and mortality/morbidity rates. The proposed goal is to improve the quality of care, and the services that peripheral centers can offer.

METHODS

We collected data from maternity and neonatal records, over a 2-year period from January 2017 to December 2018. The informations analyzed were related to demographic features (age, ethnicity/origin area, residence, educational level, marital status), diagnosis at admission (attendance of birth training courses, parity, type of pregnancy, gestational age, fetal presentation), mode of delivery, obstetric complications, the weight of the newborns, their feeding and eventual transfer to II level hospitals, also through the Neonatal Emergency Transport Service, if the established criteria were present.

RESULTS

Eight hundred sixteen women were included (age 18-48 years). 179 (22%) attended birth training courses. 763 (93%) were Italian, 53 foreign (7%). 175 (21%) came from outside the province of Palermo. Eight hundred ten were single pregnancies, 6 bigeminal; 783 were at term (96%), 33 preterm (4%, GA 30-41 WG); 434 vaginal deliveries (53%), 382 caesarean sections (47%). One maternal death and 28 (3%) obstetric complications occurred during the study period. The total number of children born to these women was 822, 3 of which stillbirths (3.6‰). 787 (96%) were born at term (>37WG), 35 preterm (4%), 31 of which late preterm. Twenty-one newborns (2.5%) were transferred to II level hospitals. Among them, 3 for moderate/severe prematurity, 18 for mild prematurity/other pathology. The outcome was favorable for all women (except 1 hysterectomy) and the newborns transferred, and no neonatal deaths occurred in the biennium under investigation. Of the remaining 798 newborns, 440 were breastfed at discharge (55%), 337 had a mixed feeding (breastfed/formula fed, 42%) and 21 were formula fed (3%).

CONCLUSIONS

Although the minimal standard of adequate perinatal care in Italy is >500 childbirths/year, the aims of the Italian legislation concern the rationalization of birth centers as well as the structural, technological and organizational improvement of health facilities. Therefore, specific contexts and critical areas need to be identified and managed. Adequate resources and intervention strategies should be addressed not only to perinatal emergencies, but also to the management of mild prematurity/pathology, especially in vulnerable populations for social or orographic reasons. The increasing availability and spread of health care offers, even in HICs, cannot be separated from the goal of quality of care, which is an ethic and public health imperative.

mHealth communication to strengthen postnatal care in rural areas: a systematic review

Background

Postnatal care (PNC) in rural areas is characterised by low uptake, with possible effect on maternal and neonatal mortality rates. Mobile health (mHealth) communication has been proposed to promote the uptake of health services; however, there is limited information on how mHealth can strengthen PNC in rural areas. The objective of this review was to gather the best available evidence regarding mHealth communication to strengthen PNC in rural areas.

Methods

Studies published between 1 January 2008 and 31 August 2018 were searched in electronic databases hosted by EBSCO Host. Reference list checking and contact with authors were also done. Critical appraisal of the eligible studies was also done.

Results

The results of 11 articles were synthesised to report the determinants of PNC uptake. Determinants were aligned to the Integrative Model of Behaviural Prediction (IMBP). One-way mobile phone messaging was the most common type of mHealth communication used. mHealth communication influenced mothers’ intentions, skills, and environmental constraints associated with uptake of PNC. Intentions were influenced by attitudes, perceived norms and self-efficacy. Positive attitudes, as well as changed attitudes toward PNC practices were observed. Perceived norms that were enhanced were delivery at a health facility with immediate PNC, seeking of reinforcement and professional health support of newborn care practices, and male partner support. Improved self-efficacy was demonstrated by mothers who attended scheduled appointments and they were confident with regard to newborn care practices. Skills for PNC that were improved included cord care, thermal care, appropriate breastfeeding and problem-solving. The environmental constraints faced and which were addressed in the studies included inaccessibility, unavailability and unaffordability of PNC services in rural areas.

Conclusions

Results from the literature included in this study show that one-way mobile phone messaging is the common type of mHealth communication used to strengthen PNC in rural areas. mHealth communication can influence intentions, skills and environmental constraints as determinants of PNC uptake. mHealth communication is recommended to strengthen PNC in rural areas. To widen the evidence, more studies in the field of mHealth communication that report a variety of both maternal and neonatal outcomes are needed.

A cross sectional study to assess the sFlt-1:PlGF ratio in pregnant women with and without preeclampsia

BACKGROUND

Preeclampsia is a multisystem disorder characterized by vascular endothelial malfunction occurring after 20 weeks of gestation. Placental soluble fms-like tyrosine kinase-1 (sFlt-1) is an antiangiogenic factor and placental growth factor (PlGF) is a potent angiogenic factor. The imbalance between these factors during placenta and fetal development has been shown to play a role in endothelial damage in preeclampsia. Preeclampsia is the leading cause of maternal mortality in Nepal. This study was designed to compare the sFlt1:PLGF ratio in pregnant women with and without preeclampsia attending Tribhuvan University Teaching Hospital (TUTH).

METHOD

An observational cross-sectional study was performed in the Gynecology and Obstetrics Department of TUTH involving forty-four subjects with preeclampsia and forty-four age- and gestational-week-matched normal pregnant subjects as controls. Blood pressure, urinary protein levels, serum sFlt-1 levels, serum PlGF levels and the sFlt-1:PlGF ratio was compared in both the cases and control. The concentrations of sFlt-1 and PlGF were measured with commercially available ELISA kits. SPSS ver. 20.0 was used to analyze the data.

RESULTS

There was no significant difference in age or gestational age in either study group. The ratio of the sFlt-1 and PlGF concentrations was significantly higher in women with preeclampsia (31.6 ± 9.6) than in the controls (3.2 ± 1.3). Likewise, diastolic blood pressure was significantly associated (p-value 0.000), whereas the severity of proteinuria was not associated (p-value 0.773) with the sFlt-1:PlGF ratio in women with preeclampsia. The significantly higher ratio (35.51 ± 8.1 versus 25.4 ± 8.7) was found in women with preeclampsia who developed complications than the group of women with preeclampsia who did not develop complication.

CONCLUSION

The sFlt-1:PlGF ratio is significantly higher in Nepalese women with preeclampsia than in normal controls and this finding can be applied for further planned clinical trials.

Maternity waiting homes as part of a comprehensive approach to maternal and newborn care: a cross-sectional survey

Background

Increased encounters with the healthcare system at multiple levels have the potential to improve maternal and newborn outcomes. The literature is replete with evidence on the impact of antenatal care and postnatal care to improve outcomes. Additionally, maternity waiting homes (MWHs) have been identified as a critical link in the continuum of care for maternal and newborn health yet there is scant data on the associations among MWH use and antenatal/postnatal attendance, family planning and immunization rates of newborns.

Methods

A cross-sectional household survey was conducted to collect data from women who delivered a child in the past 13 months from catchment areas associated with 40 healthcare facilities in seven rural Saving Mothers Giving Life districts in Zambia. Multi-stage random sampling procedures were employed with a final sample of n = 2381. Logistic regression models with adjusted odds ratios and 95% confidence intervals were used to analyze the data.

Results

The use of a MWH was associated with increased odds of attending four or more antenatal care visits (OR = 1.45, 95% CI = 1.26, 1.68), attending all postnatal care check-ups (OR = 2.00, 95% CI = 1.29, 3.12) and taking measures to avoid pregnancy (OR = 1.31, 95% CI = 1.10, 1.55) when compared to participants who did not use a MWH.

Conclusions

This is the first study to quantitatively examine the relationship between the use of MWHs and antenatal and postnatal uptake. Developing a comprehensive package of services for maternal and newborn care has the potential to improve acceptability, accessibility, and availability of healthcare services for maternal and newborn health. Maternity waiting homes have the potential to be used as part of a multi-pronged approach to improve maternal and newborn outcomes.

Trial registration

National Institutes of Health Trial Registration NCT02620436, Impact Evaluation of Maternity Homes Access in Zambia, Date of Registration - December 3, 2015.

The quality of maternal-fetal and newborn care services in Jordan: a qualitative focus group study

Background

The antenatal, intrapartum, and postnatal periods are considered high-risk periods for the health of mothers and their newborns. Although the current utilization rate of some maternal and child care services in Jordan is encouraging, detailed information about the quality of these services is limited. Therefore, this study aimed to explore the quality of maternal-fetal and newborn antenatal care (ANC), delivery, and postnatal care (PNC) services in Jordan.

Methods

We conducted 12 focus group discussions (FGDs) with pregnant and postpartum women who attended maternal-child care services in three major hospitals in Jordan. All FGDs were recorded and transcribed verbatim. An inductive thematic analysis approach was used to identify themes and subthemes.

Results

The content analysis of the FGDs revealed a consensus among the discussants regarding the importance of ANC and PNC services for the health of mothers and their newborns. However, the participating women viewed ANC to be much more important than PNC. With regards to the choice between public and private antenatal care services, some of the discussants were disposed towards the private sector. Reasons for this included longer consultation time, a higher quality of services, better interpersonal and communication skills of healthcare providers, better treatment, more advanced equipment and devices, availability of female obstetricians, and more flexible appointment times. These women only perceived public hospital services to be necessary in cases of pregnancy-related complications and labor, as the costs of private sector services in such cases are too high. The findings also revealed that mothers usually only seek PNC services to check up on their newborn’s health and not their own.

Conclusion

Visiting private ANC clinics throughout pregnancy while giving birth in public facilities leads to the discontinuity and fragmentation in maternal-fetal and child healthcare services. To address this fragmentation, healthcare systems are proposed to establish interprofessional teamwork that requires different healthcare providers with complementary skills and practices in both public and private settings to work co-operatively and collectively. Investment in new technologies and interventions which enhance coordination and collaboration between public and private healthcare settings is necessary for the provision of non-traditional maternal healthcare.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4232-9) contains supplementary material, which is available to authorized users.

Policy, evidence and practice for post-birth care plans: a scoping review

BACKGROUND

Postnatal care continually attracts less attention than other parts of the childbirth year. Many regions consistently report poor maternal satisfaction with care in the post-birth period. Despite policy recommending post-birth planning be part of maternity services there remains a paucity of empirical evidence and reported experience using post-birth care plans. There is a need to report on post-birth care plans, identify policy and guideline recommendations and gaps in the current empirical research, as well as experiences creating and using post-birth care plans.

METHODS

This scoping review accessed empirical literature and government and professional documents from 2005 to present day to build a picture of current understanding of policy imperatives and existent published empirical evidence. The review was informed by the Arksey and O'Malley approach employing five stages.

RESULTS

The review revealed that post-birth care planning is promoted extensively in health policy and there is emergent evidence for its implementation. Yet there is a paucity of practice examples and only one evaluation in the UK. The review identified four overarching themes: 'Positioning of post-birth care planning in policy; 'Content and approach'; 'Personalised care and relational continuity'; Feasibility and acceptability in practice'.

CONCLUSIONS

Empirical evidence supports post-birth care planning, but evidence is limited leaving many unanswered questions. Health care policy reflects evidence and recommends implementation of post-birth care plans, however, there remains a paucity of information in relation to post-birth care planning experience and implementation in practice. Women need consistent information and advice and value personalised care. Models of care that facilitate these needs are focused on relational continuity and lead to greater satisfaction. It remains unclear if a combination of post-birth care planning and continuity of carer interventions would improve post-birth outcomes and satisfaction. Gaps in research knowledge and practice experience are identified and implications for practice and further research suggested.

How the health-seeking behaviour of pregnant women affects neonatal outcomes: findings of system dynamics modelling in Pakistan

Background

Limited studies have explored how health-seeking behaviour during pregnancy through to delivery affect neonatal outcomes. We modelled health-seeking behaviour across urban and rural settings in Pakistan, where poor neonatal outcomes persist with wide disparities.

Methods and findings

A system dynamics model was developed and parameterised. Following validation tests, the model was used to determine neonatal mortality for pregnant women considering their decisions to access, refuse and switch antenatal care services in four provider sectors: public, private, traditional and charitable. Four health-seeking scenarios were tested across different pregnancy trimesters. Health-seeking behaviour in different subgroups by geographical locations and social network effect was modelled. The largest reduction in neonatal mortality was achieved with antenatal care provided by skilled providers in public, private or charitable sectors, combined with the use of institutional delivery. Women’s social networks had strong influences on if, when and where to seek care. Interventions by Lady Health Workers had a minimal impact on health-seeking behaviour and neonatal outcomes after trimester 1. Optimal benefits were achieved for urban women when antenatal care was accessed within trimester 2, but for rural women within trimester 1. Antenatal care access delayed to trimester 3 had no protective impact on neonatal mortality.

Conclusions

System dynamics modelling enables capturing the complexity of health-seeking behaviours and impact on outcomes, informing intervention design, implementation of targeted policies and uptake of services specific to urban/rural settings considering structural enablers/barriers to access, cultural contexts and strong social network influences.

Associations between increased intervention coverage for mothers and newborns and the number and quality of contacts between families and health workers: An analysis of cluster level repeat cross sectional survey data in Ethiopia

Background

Survival of mothers and newborns depends on life-saving interventions reaching those in need. Recent evidence suggests that indicators of contact with health services are poor proxies for measures of coverage of life saving care and attention has shifted towards the quality of care provided during contacts.

Methods and findings

Regression analysis using data from representative cluster-based household surveys and surveys of the frontline health workers and primary health facilities in four regions of Ethiopia in 2012 and 2015 was used to explore associations between increased numbers of contacts or improvements in quality and any change in the coverage of interventions (intervention coverage). In pregnancy, in multiple regression, an increase in the quality indicator ‘focused ANC behaviours’ was associated with a change in both the coverage of iron supplementation and syphilis prevention ((regression coefficients (95% CI)) 0·06 (0·01, 0·11); 0·07 (0·04, 0·10)). This equates to a 0.6% increase in the proportion of women taking iron supplementation and a 0.7% in women receiving syphilis prevention for a 10% increase in the quality indicator ‘focused ANC behaviours’. At delivery, in multiple regression the quality indicator ‘availability of uterotonic supplies amongst birth attendants’ was associated with improved coverage of prophylactic uterotonics (0·72 (0·50, 0·94)). No evidence of any relationships between contacts, quality and intervention coverage were observed within the early postnatal period.

Conclusions

Increases in both contacts and in quality of care are needed to increase the coverage of life saving interventions. For interventions that need to be delivered at multiple visits, such as antenatal vaccination, increasing the number of contacts had the strongest association with coverage. For those relying on a single point of contact, such as those delivered at birth, we found strong evidence to support current commitments to invest in both input and process quality.

Can a midwife-led continuity model improve maternal services in a low-resource setting? A non-randomised cluster intervention study in Palestine

OBJECTIVES

To improve maternal health services in rural areas, the Palestinian Ministry of Health launched a midwife-led continuity model in the West Bank in 2013. Midwives were deployed weekly from governmental hospitals to provide antenatal and postnatal care in rural clinics. We studied the intervention's impact on use and quality indicators of maternal services after 2 years' experience.

DESIGN

A non-randomised intervention design was chosen. The study was based on registry data only available at cluster level, 2 years before (2011and2012) and 2 years after (2014and2015) the intervention.

SETTING

All 53 primary healthcare clinics in Nablus and Jericho regions were stratified for inclusion.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome was number of antenatal visits. Important secondary outcomes were number of referrals to specialist care and number of postnatal home visits. Differences in changes within the two groups before and after the intervention were compared by using mixed effect models.

RESULTS

14 intervention clinics and 25 control clinics were included. Number of antenatal visits increased by 1.16 per woman in the intervention clinics, while declined by 0.39 in the control clinics, giving a statistically significant difference in change of 1.55 visits (95% CI 0.90 to 2.21). A statistically significant difference in number of referrals was observed between the groups, giving a ratio of rate ratios of 3.65 (2.78-4.78) as number of referrals increased by a rate ratio of 3.87 in the intervention group, while in the control the rate ratio was only 1.06.Home visits increased substantially in the intervention group but decreased in the control group, giving a ratio of RR 97.65 (45.20 - 210.96) CONCLUSION: The Palestinian midwife-led continuity model improved use and some quality indicators of maternal services. More research should be done to investigate if the model influenced individual health outcomes and satisfaction with care.

TRIAL REGISTRATION NUMBER

NCT03145571; Results.

Provision of medical supply kits to improve quality of antenatal care in Mozambique: a stepped-wedge cluster randomised trial

Background

High levels of maternal and newborn mortality and morbidity remain a daunting reality in many low-income countries. Several interventions delivered during antenatal care have been shown to improve maternal and newborn outcomes, but stockouts of medical supplies at point of care can prevent implementation of these services. We aimed to evaluate whether a supply chain strategy based on the provision of kits could improve quality of care.

Methods

We did a pragmatic, stepped-wedge, cluster-randomised controlled trial at ten antenatal care clinics in Mozambique. Clinics were eligible if they were not already implementing the proposed antenatal care package; they served at least 200 new pregnant women per year; they had Maternal and Child Health (MCH) nurses; and they were willing to participate. All women attending antenatal care visits at the participating clinics were included in the trial. Participating clinics were randomly assigned to shift from control to intervention on prespecified start dates. The intervention involved four components (kits with medical supplies, a cupboard to store these supplies, a tracking sheet to monitor stocks, and a one-day training session). The primary outcomes were the proportion of women screened for anaemia and proteinuria, and the proportion of women who received mebendazole in the first antenatal care visit. The intervention was delivered under routine care conditions, and analyses were done according to the intention-to-treat principle. This trial is registered with the Pan African Clinical Trial Registry, number PACTR201306000550192.

Findings

Between March, 2014, and January, 2016, 218 277 antenatal care visits were registered, with 68 598 first and 149 679 follow-up visits. We found significant improvements in all three primary outcomes. In first visits, 5519 (14·6%) of 37 826 women were screened for anaemia in the control period, compared with 30 057 (97·7%) of 30 772 in the intervention period (adjusted odds ratio 832·40; 99% CI 666·81–1039·11; p<0·0001); 3739 (9·9%) of 37 826 women were screened for proteinuria in the control period, compared with 29 874 (97·1%) of 30 772 in the intervention period (1875·18; 1447·56–2429·11; p<0·0001); and 17 926 (51·4%) of 34 842 received mebendazole in the control period, compared with 24 960 (88·2%) of 28 294 in the intervention period (1·88; 1·70–2·09; p<0·0001). The effect was immediate and sustained over time, with negligible heterogeneity between sites.

Interpretation

A supply chain strategy that resolves stockouts at point of care can result in a vast improvement in quality during antenatal care visits, when compared with the routine national process for procurement and distribution of supplies.

Funding

Government of Flanders and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Identifying gaps in the practices of rural health extension workers in Ethiopia: a task analysis study

Background

Health extension workers (HEWs) are the frontline health workers for Ethiopia’s primary health care system. The Federal Ministry of Health is seeking to upgrade and increase the number of HEWs, particularly in remote areas, and address concerns about HEWs’ pre-service education and practices. The aim of this study was to identify gaps in HEWs’ practices and recommend changes in their training and scope of practice.

Methods

A cross-sectional descriptive task analysis was conducted to assess the work of rural HEWs who had been in practice for six months to five years. One hundred participants were invited from 100 health posts in five regions of Ethiopia. HEWs self-reported on 62 tasks on: frequency, criticality (importance), where the task was learned, and ability to perform the task. Descriptive statistics, including frequencies and percentages, were computed for each variable. Task combinations were examined to identify tasks performed infrequently or for which HEWs are inadequately prepared.

Results

A total of 82 rural HEWs participated in the study. Nearly all HEWs rated every task as highly critical to individual and public health outcomes. On average, most HEWs (51.5%–57.4%) reported learning hygiene and environmental sanitation tasks, disease prevention and control tasks, family health tasks, and health education and communication tasks outside of their pre-service education, primarily through in-service and on-the-job training. Over half of HEWs reported performing certain critical tasks infrequently, including management of supplies, stocks and maintenance at the facility and management of the cold chain system. Almost all HEWs (95.7–97.2%) perceived themselves as competent and proficient in performing tasks in all program areas.

Conclusion

HEWs were insufficiently prepared during pre-service education for all tasks that fall within their scope of practice. Many learned tasks through in-service or on-the-job training, and some tasks were not learned at all. Some tasks that are part of expected HEW practice were performed infrequently, potentially reducing the effectiveness of the Health Extension Program to provide preventive and basic curative health care services to communities. Findings should alert policy makers to the need to review HEWs’ scope of practice, update pre-service education curricula and prioritize in-service training modules.

Supply kits for antenatal and childbirth care: a systematic review

INTRODUCTION

It is critical to increase the uptake of interventions proven to be effective to improve maternal and perinatal outcomes. Supply kits have been suggested to be a feasible strategy designed to ensure timely availability and effective follow-up of care.

OBJECTIVE

We conducted a systematic review to summarize the evidence on the uptake, effectiveness and safety of supply kits for maternal care.

SEARCH STRATEGY

MEDLINE, the Cochrane Pregnancy and Childbirth Group's Trials Register, Campbell Collaboration, Lilacs, Embase and unpublished studies were searched.

SELECTION CRITERIA

Studies that reported the efficacy, safety and use of supply kits for maternal healthcare were eligible. Participants were pregnant women or in childbirth. Supply kits were defined as a collection of medicines, supplies or instruments packaged together with the aim of conducting a healthcare task.

DATA COLLECTION AND ANALYSIS

Two reviewers independently performed the screening, data extraction, and methodological and quality assessment.

MAIN RESULTS

24 studies were included: 4 of them were systematic reviews and 20 primary studies. Eighteen studies evaluated a so-called "clean delivery kit". In all but two studies, the kits were used by more than half of the participants. A meta-analysis was deemed inappropriate due to the heterogeneity in study design, in the components of the interventions implemented, in the content of the kits, and in outcomes. Nine studies assessed neonatal outcomes and found statistically significant reductions in cord infection, sepsis and tetanus-related mortality in the intervention group. Three studies showed evidence of reduced neonatal mortality (OR 0.52, 0.60 and 0.71) with statistically significant confidence intervals in all cases. Four studies reported odd ratios for maternal mortality, but only one showed evidence of a statistically significant decrease in this outcome but it was ascribed to hand washing prior to childbirth and not with the use of kits.

CONCLUSION

This review suggests potential benefits in the use of supply kits to improve maternal and neonatal health. However, the observational nature of the studies, the heterogeneity and the use of kits incorporated within complex interventions limit the interpretation of the findings.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 2. maternal health findings

BACKGROUND

We summarize the findings of assessments of projects, programs, and research studies (collectively referred to as projects) included in a larger review of the effectiveness of community-based primary health care (CBPHC) in improving maternal, neonatal and child health (MNCH). Findings on neonatal and child health are reported elsewhere in this series.

METHODS

We searched PUBMED and other databases through December 2015, and included assessments that underwent data extraction. Data were analyzed to identify themes in interventions implemented, health outcomes, and strategies used in implementation.

RESULTS

152 assessments met inclusion criteria. The majority of assessments were set in rural communities. 72% of assessments included 1-10 specific interventions aimed at improving maternal health. A total of 1298 discrete interventions were assessed. Outcome measures were grouped into five main categories: maternal mortality (19% of assessments); maternal morbidity (21%); antenatal care attendance (50%); attended delivery (66%) and facility delivery (69%), with many assessments reporting results on multiple indicators. 15 assessments reported maternal mortality as a primary outcome, and of the seven that performed statistical testing, six reported significant decreases. Seven assessments measured changes in maternal morbidity: postpartum hemorrhage, malaria or eclampsia. Of those, six reported significant decreases and one did not find a significant effect. Assessments of community-based interventions on antenatal care attendance, attended delivery and facility-based deliveries all showed a positive impact. The community-based strategies used to achieve these results often involved community collaboration, home visits, formation of participatory women's groups, and provision of services by outreach teams from peripheral health facilities.

CONCLUSIONS

This comprehensive and systematic review provides evidence of the effectiveness of CBPHC in improving key indicators of maternal morbidity and mortality. Most projects combined community- and facility-based approaches, emphasizing potential added benefits from such holistic approaches. Community-based interventions will be an important component of a comprehensive approach to accelerate improvements in maternal health and to end preventable maternal deaths by 2030.

Understanding maternal postpartum needs: A descriptive survey of current maternal health services

AIM AND OBJECTIVE

To assess mothers' learning needs and concerns after giving birth and to examine whether these needs were met at 6-8 weeks postpartum.

BACKGROUND

Women experience many physiologic and psychological changes during postpartum period, which is considered a vital transitional time. Exploring and meeting women's needs help woman to pass this period with little complications and enhance healthcare provider's ability to provide appropriate care following childbirth.

DESIGN

A prospective cohort design was employed in this study.

METHODS

A prospective cohort design was employed. A convenience sample of 150 postpartum women have completed perceived leaning needs scale prior to hospital discharge, at southern region of Jordan, and have completed perceived met learning needs scale at 6-8 weeks after giving birth.

RESULTS

Women reported a high level of concern across all eight learning needs subscales. The most common concerns were related to new baby care, episiotomy care and breastfeeding. At 6-8 weeks postpartum, the primary unmet learning needs postpartum were danger signs post-Caesarean section, physical changes, breastfeeding and new baby care. Attending postpartum check-up clinic was found as a significant predictor for postpartum meeting women's needs, particularly emotional changes and family planning-related information.

CONCLUSIONS

The current maternal health services are not at the optimum level to meet women's individual needs and concerns, which could increase the risk for postpartum complications. Some women's characteristics, such as employment status and educational level, have increased women's concerns and unmet needs in some of the learning needs.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers and policymakers should consider women's concerns and needs at early postpartum period to establish patient-centred postpartum care that is based on women's needs and concerns during this transitional period, with a focus on newborn baby care, episiotomy care and breastfeeding.

Variation in quality of primary-care services in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania

Objective

To analyse factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries.

Methods

We pooled nationally representative data from service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania (survey year range: 2006–2014). Based on World Health Organization protocols, we created indices of process quality for antenatal care (first visits) and for sick-child visits. We assessed national, facility, provider and patient factors that might explain variations in quality of care, using separate multilevel regression models of quality for each service.

Findings

Data were available for 2594 and 11  402 observations of clinical consultations for antenatal care and sick children, respectively. Overall, health-care providers performed a mean of 62.2% (interquartile range, IQR: 50.0 to 75.0) of eight recommended antenatal care actions and 54.5% (IQR: 33.3 to 66.7) of nine sick-child care actions at observed visits. Quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better-managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better- and less-equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined.

Conclusion

The quality of two essential primary-care services for women and children was weak and varied across and within the countries. Analysis of reasons for variations in quality could identify strategies for improving care.

Micronutrient Status among Pregnant Women in Zinder, Niger and Risk Factors Associated with Deficiency

Anemia and micronutrient (MN) deficiencies in pregnant women are associated with adverse pregnancy outcomes. In Niger, 58.6% of pregnant women are anemic; however, MN statuses are unknown. The study objectives were to estimate the prevalence of MN deficiencies among pregnant women in Zinder, Niger and explore associated risk factors. Pregnant women living in randomly selected rural villages (n = 88) were included. Capillary and venous blood samples (n = 770) were analyzed for hemoglobin (Hb) and plasma ferritin, soluble transferrin receptor (sTfR), zinc (pZn), retinol binding protein (RBP), folate and vitamin B12. C-reactive protein and alpha-1-acid glycoprotein were measured to adjust for inflammation. The prevalence of MN deficiencies in pregnant woman was high, indicative of a severe public health problem. Prevalence of iron deficiency was 20.7% and 35.7%, by ferritin (<15 µg/L) and sTfR (>8.3 mg/L), respectively. In total, 40.7% of women had low pZn (<50 µg/dL), 79.7% had marginal RBP (<1.32 µmol/L), 44.3% of women had low folate (<10 nmol/L) and 34.8% had low B12 concentrations (<148 pmol/L). Common risk factors associated with MN status included gravidity, mid-upper-arm circumference, geophagy, malaria, and result of the woman's last pregnancy. Interventions to promote the strengthening of antenatal care, and access and adherence to nutrition and health interventions are critical among pregnant women in this population.

Framework for the establishment of a feasible, tailored and effective perinatal education programme

BACKGROUND

Antenatal education needs to be renewed and adapted to the needs of women.

OBJECTIVES

to assess women needs, identify factors that influence the desired outcomes, and propose a framework for developing new perinatal education based on the guidance published by the UK Medical Research Council for the development and evaluation of complex interventions in primary care.

METHODS

For this study: (a) four focus group sessions were held from October to November 2010 in Bizkaia (Spain) with 30 women exploring their needs during pregnancy and postpartum; (b) two literature reviews were conducted on women's needs at these times and theoretical models of healthcare education; and (c) seven discussion and consensus sessions were run with a group of experts composed of midwifes, gynaecologists, paediatricians, and paediatric and postpartum nurses.

RESULTS

Various areas for improvement were identified: needs assessment of each woman/family, consideration of pregnancy and childbirth as normal physiological processes, participation of fathers, establishment of social networks, continuity of postpartum care, better access to and training for midwives, and more flexible format and contents for the programme. We propose a woman-focused framework that includes three exploratory interviews during pregnancy, personalized interventions coordinated between professionals, empowerment to choose the type of birth, and postpartum activities.

CONCLUSION

New perinatal education should be on-going and focused on each woman. It is necessary to assess the feasibility of implementing this type of programme, depending on the context, professionals' readiness for change and characteristics of the proposed interventions. Then, its effectiveness and sustainability must be assessed.