Optimizing maternal and neonatal outcomes with postpartum contraception: impact on breastfeeding and birth spacing

Integrating a Postpartum Contraception Intervention in the Maternal and Child Health Care System of China: A Randomized Clinical Trial

Importance

The interpregnancy intervals are suboptimal worldwide, and women lack access to high-quality postpartum contraceptive services in China.

Objective

To evaluate the effectiveness of integrating postpartum contraceptive interventions into the existing maternal and child health care (MCH) system.

Design, Setting, and Participants

This cluster randomized trial randomly allocated 13 communities in Minhang District in Shanghai, China, to the intervention or the control group. Data were collected between September 2020 and February 2023. Eligible participants included women who registered their pregnancy in community health centers and were followed up to 1 year post partum. Data analysis was conducted from April 2023 to May 2024.

Interventions

Participants in the intervention group received postpartum contraception consultations, online educational videos, a 45-minute class, health prescriptions, and educational pamphlets at 5 stages in alignment with the MCH system of China. The control group received routine MCH services.

Main Outcomes and Measures

The primary outcome was incidence of unintended pregnancy within 1 year after childbirth. The secondary outcomes included knowledge level of postpartum contraception, utilization rate of reliable long-acting reversible contraception (LARC), and incidence of induced abortion.

Results

A total of 1279 participants (698 in intervention from 7 clusters and 581 in control from 6 clusters) were recruited, and 995 (521 older than 30 years [40.7%]; 539 intervention [54.2%] and 456 control [45.8%]) completed the trial. The incidence of unintended pregnancy, LARC utilization, and induced abortion within 1 year after childbirth was 1.5% (8 participants), 3.2% (17 participants), and 0.6% (3 participants), respectively, in the intervention group, and 3.9% (18 participants), 1.1% (5 participants), and 2.0% (9 participants), respectively, in the control group. Participants in the intervention group were significantly less likely to experience unintended pregnancy (adjusted odds ratio [aOR], 0.33; 95% CI, 0.16-0.70), had a higher rate of LARC utilization (aOR, 2.47; 95% CI, 1.02-5.98), and a lower rate of induced abortion due to unintended pregnancy (aOR, 0.30; 95% CI, 0.09-0.99). The postpartum contraception knowledge level in the intervention group was substantially higher than the control group (β = 24.20; 95% CI, 20.92-27.47).

Conclusions and Relevance

This cluster randomized clinical trial demonstrated the designed postpartum contraceptive interventions were effective in reducing unintended pregnancy and induced abortion and increasing postpartum contraception knowledge and LARC utilization among women at 1-year post partum.

Trial Registration

Chictr.org.cn Identifier: ChiCTR2000034603.

Predictors of Post-Caesarean Surgical Site Infections at Mubende Regional Referral Hospital, Central Uganda: Prospective Cohort Study (July-September 2023)

Background

Post-caesarean surgical site infections (PCSSIs) significantly impact maternal morbidity, mortality, and healthcare costs in low- and middle-income countries, particularly in sub-Saharan Africa, where preventive measures are often inadequate. Despite this burden, data on PCSSIs in this context are limited. This study aimed to evaluate the incidence and factors associated with PCSSIs at Mubende Regional Referral Hospital.

Methods

This prospective cohort study included 204 women who underwent caesarean sections from July to September 2023. Data was collected and participants were monitored for up to 28 days post-delivery to identify occurrences of surgical site infections (SSIs). Statistical analysis was conducted using STATA, with significance defined as a p-value of < 0.05.

Results

Most participants (63.2%) were aged 18-35 years, with over 67% having a parity of ≤4. Preoperative antibiotics were administered to 77.5% of participants. Most surgeries (64.2%) lasted 1-2 hours, and the overall incidence of surgical site infections (SSIs) was 16.18%. Significant risk factors associated with more than a twofold increase in SSI risk included unstable referral status (aRR = 2.02), obstructed labor (aRR = 2.97), chorioamnionitis (aRR = 2.73), and prolonged premature rupture of membranes (PROM) (aRR = 2.05). Prolonged labor increased SSI risk by 1.37-fold (aRR = 1.37), while receipt of preoperative antibiotics was linked to a reduced SSI risk (aRR = 0.77).

Conclusion

The post-caesarean SSI rate at Mubende Regional Referral Hospital is notably high, with key risk factors including unstable referral status, obstructed labor, prolonged labor, chorioamnionitis, and prolonged premature rupture of membranes (PROM). Administering preoperative antibiotics 30 minutes to 1 hour prior to surgery is linked to a reduced risk of SSI.

The challenges of delivery in pre-hospital emergency medical services ambulances in Iran: a qualitative study

BACKGROUND

Although unplanned deliveries in ambulances are uncommon, Emergency Medical Services (EMS) providers may encounter this situation before reaching the hospital. This research aims to gather insights from Emergency Medical Technicians (EMTs), midwives, and expectant mothers to examine the causes of giving birth in ambulances and the challenges EMTs, pregnant women, and midwives face during delivery.

METHODS

A qualitative study was conducted, and 28 EMTs, midwives, and pregnant women who had experience with pre-hospital births in the ambulance were interviewed. Data were analyzed using thematic content analysis. The MAXQDA/10 software was employed for data analysis and code extraction.

RESULTS

The analysis of the interviews revealed two main categories: factors that cause delivery in the ambulance and its challenges. The factors include cultural problems, weak management, and inaccessibility to facilities. The challenges consist of fear and anxiety, native culture, and lack of resources.

CONCLUSIONS

Several approaches should be implemented to reduce the number of births in ambulances and Pre-hospital Emergency Medical Services (PEMS). These include long-term community cultural activities, public education, awareness campaigns, education and follow-up for pregnant women, and improved accessibility to health facilities. Additionally, EMTS need to receive proper education and training for ambulance deliveries. Enhancing ambulance services and supporting EMTs in dealing with litigation claims are also critical.

The level of utilization and associated factors of WHO recommended antenatal care visits in South Asian countries

Background

Antenatal care can play an important role in reducing the death of both mothers and children. This study was designed to find out the determinants of world health organization recommended antenatal care visits in six South Asian countries to achieve the targets for Sustainable Development Goal.

Methods

This study used recent demographic and health survey data from six South Asian countries such as Afghanistan (2015), Bangladesh (2017-18), India (2015-16), Maldives (2016-17), Nepal (2016), and Pakistan (2047-18). Descriptive statistics were calculated for the distribution and prevalence of antenatal care visits. Bivariate and multivariable logistic regressions were used to investigate the influencing factors of antenatal care visits.

Results

71,862 women aged 15 to 49 years were included in this study, and 46.64% (95% Confidence Interval = 45.59 - 47.69%) had world health organization recommended antenatal care visits. In the pooled data, urban women (AOR ([Adjusted Odds Ratio]=1.48; 95% CI [Confidence Interval]=1.33-1.66), richest family (AOR=1.48; 95% CI=1.25-1.76), women's higher education (AOR=3.76; 95% CI=3.33-4.25), women's partner/husband's higher education (AOR=1.69; 95% CI=1.50-1.92), 35-49 years (AOR=1.25, 95% CI=1.11-1.42), women's age at first birth >25 years (AOR=1.51, 95% CI=1.36-1.68) and fully media exposure (AOR=2.11; 95% CI=1.74-2.56) were significantly positively associated with WHO recommended antenatal care visits. Whereas, working women (AOR=0.82; 95% CI=0.76-0.88), healthcare decision maker by their husband/others (AOR=0.71, 95% CI=0.60-0.84), ≥7 children (AOR=0.59; 95% CI=0.50-0.69), and ≥7 family members (AOR=0.82; 95% CI=0.73-0.93) had significant negative effect on antenatal care visits. In country specific analysis, overall, media exposure, secondary and above education of women, ≥25 of years age at first birth, and <4 living children were the key factors of antenatal care visits.

Conclusions

This study reveals an overall scenario of the WHO-recommended antenatal care visit in South Asian countries, and significant factors related to ANC that we can concentrate onto improve accessibility to healthcare services and promote education and media exposure, especially for rural and less educated women, to increase the prevalence of WHO-recommended antenatal visits in South Asian countries In addition, evidence from this study can be used to assist the policymakers in planning and taking proper steps to increase WHO-recommended antenatal care visits by focusing on the related factors in South Asian countries.

Sustainable Breastfeeding: A State-of-the Art Review

BACKGROUND

Disparities in breastfeeding rates and exclusivity exist across regions and countries despite multifaceted breastfeeding promotion efforts in recent decades. Markets for artificial milk formula continue to grow as its substitution for breastfeeding is common. A new approach is needed for breastfeeding promotion strategies.

RESEARCH AIM

This state-of-the-art review aimed to describe the implications of not-breastfeeding on the environment within the context of food system sustainability.

METHOD

A total of 19 peer-reviewed articles within a 20-year timeframe were included in this review. Authors searched five databases for articles including Science Direct, GreenFILE, Springer Link, ProQuest, and PubMed.

RESULTS

The demand for artificial milk formula production as a replacement for breastfeeding results in increased greenhouse gas emissions, water pollution, and waste, thereby aggravating problems with freshwater scarcity. A short duration of breastfeeding and limited exclusivity have been associated with close birth spacing and contributing to global population growth. Breastfeeding is a healthy, sustainable diet, and a culturally acceptable first food. It advances health equity and food security. Exclusive breastfeeding for the first 6 months of life can be promoted with emphasis on total carbon footprint reduction, prevention of waterway degradation, and natural birth spacing, thereby sustaining food systems at large.

CONCLUSION

It is important to reform food, nutrition, and environmental policies to protect exclusive breastfeeding while decarbonizing artificial milk formula production. More research is needed to provide directions for new breastfeeding promotion strategies connecting breastfeeding with environmental stewardship.

Postpartum long-acting reversible contraceptive use among active-duty, female US Army soldiers

BACKGROUND

Postpartum use of long-acting reversible contraception has been found to be effective at increasing interpregnancy intervals, reducing unintended pregnancies, and optimizing health outcomes for mothers and babies. Among female active-duty military service members, reproductive planning may be particularly important, yet little is known about postpartum long-acting reversible contraceptive use among active-duty soldiers.

OBJECTIVE

This study aimed to (1) quantify postpartum uptake of long-acting reversible contraception among active-duty female US Army soldiers and (2) identify demographic and military-specific characteristics associated with use.

STUDY DESIGN

This retrospective cohort study used longitudinal data of all digitally recorded health encounters for active-duty US Army soldiers from 2014 to 2017. The servicewomen included in our analysis were aged 18 to 44 years with at least one delivery and a minimum of 4 months of total observed time postdelivery within the study period. We defined postpartum long-acting reversible contraception use as initiation of use within the delivery month or in the 3 calendar months following delivery and identified likely immediate postpartum initiation via the proxy of placement recorded during the same month as delivery. We then evaluated predictors of postpartum long-acting reversible contraception use with multivariable logistic regression.

RESULTS

The inclusion criteria were met by 15,843 soldiers. Of those, 3162 (19.96%) initiated the use of long-acting reversible contraception in the month of or within the 3 months following delivery. Fewer than 5% of these women used immediate postpartum long-acting reversible contraception. Among women who initiated postpartum long-acting reversible contraceptive use, 1803 (57.0%) received an intrauterine device, 1328 (42.0%) received an etonogestrel implant, and 31 received both (0.98%). Soldiers of younger age, self-reported White race, and those who were married or previously married were more likely to initiate long-acting reversible contraception in the postpartum period. Race-stratified analyses showed that self-reported White women had the highest use rates overall. When compared with these women, the adjusted odds of postpartum use among self-reported Black and Asian or Pacific Islander women were 18% and 30% lower, respectively (both P<.001). There was also a trend of decreasing postpartum use with increasing age within each race group. Differences observed between age groups and race identities could partially be attributed to differential use of permanent contraception (sterilization), which was found to be significantly more prevalent among both women aged 30 years or older and among women who identified as Black.

CONCLUSION

Among active-duty US Army servicewomen, 1 in 5 used postpartum long-acting reversible contraception, and fewer than 5% of these women used an immediate postpartum method. Within this population with universal healthcare coverage, we observed relatively low rates of use and significant differences in the uptake of effective postpartum long-acting contraceptive methods across self-reported race categories.

Socio-demographic and antenatal care-related factors associated with early post-partum family planning use in Ethiopia: evidence from Ethiopian Demographic and Health Survey 2016 data

Introduction

Initiation of family planning in the early post-partum period is a strategic move to reduce maternal, neonatal, and child mortality due to the negative consequences of short interbirth interval and the complications of unintended pregnancy. Antenatal care (ANC) is the noteworthy predictor of scaling up early initiation of post-partum family planning (PPFP) and preventing unintended pregnancy before menses resume. Despite the great role of ANC, information is scant about the effect of content, timing, and the number of ANC visits on the early initiation of PPFP in Ethiopia.

Objective

This study aimed to assess the association of ANC services with the early initiation of PPFP in Ethiopia.

Methods

The study was based on Ethiopian Demographic and Health Survey 2016 data, which was a cross-sectional survey from 18 January 2016 to 27 June 2016. A total weighted sample size of 2,920 post-partum women was included. A multilevel logistic regression model was used because of the hierarchical data, and variables with a p-value of ≤0.2 in the bivariable multilevel analysis were taken to multivariable multilevel analysis. An adjusted odds ratio with a 95% confidence interval (CI) was used to declare both the direction and strength of the association, and variables with a p-value of <0.05 were considered as statistically significant for the outcome variable.

Results

The early initiation of PPFP was 20.4%. Women with at least four ANC visits [adjusted odds ratio (AOR) = 1.31; CI 1.12-2.32], women who started ANC within the first trimester (AOR = 1.25; CI 1.10-2.23), complete routine ANC (AOR = 1.11; CI 1.01-2.03), post-natal care (AOR = 1.45; CI 1.19-1.87), resumption of menses (AOR = 1.67; CI 1.18-1.93), urban residency (AOR = 2.14; CI 1.18-2.51), and high community women's education (AOR = 1.71; CI 1.51-2.11) were variables significantly associated with the early initiation of PPFP.

Conclusion

The early initiation of PPFP in Ethiopia was very low. Attention needs to be given to the quality of ANC, post-natal care, resumption of menses, residency, and community-level education of women to increase the prevalence of the early initiation of PPFP in Ethiopia. Therefore, the government should design a program targeting the quality of ANC in rural communities, considering women without menses and scaling up the education of women at the community level to the culture of the early initiation of PPFP in order to achieve reduced maternal, neonatal, and child mortality.

Effects of a community-level intervention on maternal health care utilization in a resource-poor setting of Northern Ghana

BACKGROUND

This study aimed to assess the effects of health education and community-level participatory interventions at the community level and the use of community maternal health promoters on the utilization of maternal health care services in poor rural settings of northern Ghana.

METHODS

A randomized controlled survey design was conducted from June 2019 to July 2020 in two rural districts of northern Ghana. A multistage cluster sampling technique was used to select the participants. Data were collected from a repeated cross-sectional household survey. Descriptive analysis, bivariate and covariates adjusted simple logistic regression analyses were performed using STATA version 16 statistical software.

RESULTS

At post-intervention, the two groups differed significantly in terms of ANC (p = 0.001), skilled delivery (SD) (p = 0.003), and PNC (p < 0.0001). Women who received health education on obstetric danger signs had improved knowledge by 50% at the end of the study. Women who received the health education intervention (HEI) on practices related to ANC and skilled delivery had increased odds to utilize ANC (AOR = 4.18; 95% CI = 2.48-7.04) and SD (AOR = 3.90; 95% CI = 1.83-8.29) services. Institutional delivery and PNC attendance for at least four times significantly increased from 88.5 to 97.5% (p < 0.0001), and 77.3-96.7% (p < 0.0001) respectively at postintervention. Women who had received the HEI were significantly more likely to have good knowledge about obstetric danger signs (AOR = 10.17; 95% CI = 6.59-15.69), and BPCR (AOR = 2.10; 95% CI = 1.36-3.24). Women who had obtained tertiary education were significantly more likely to make at least four visits to ANC (AOR = 2.38; 95% CI = 0.09-1.67).

CONCLUSIONS

This study suggests that the use of health education and participatory sessions led by community-based facilitators could be a potentially effective intervention to improve the knowledge of women about obstetric danger signs and encourage the uptake of maternity care services in resource-poor settings of Ghana.

Socioeconomic and geographical inequalities in using skilled birth attendants during delivery in Bangladesh over two decades

BACKGROUND

Maternal and neonatal mortality is a major public health concern globally. Evidence supports that skilled birth attendants (SBA) can significantly reduce maternal and neonatal mortality. Despite the improvement in SBA use, Bangladesh lacks evidence of equality in SBA use across socioeconomic and geographic regions. Therefore, we aim to estimate the trends and magnitude of inequality in SBA use in Bangladesh over the last two decades.

METHODS

Data from the last 5 rounds of Bangladesh Demographic and Health Surveys (BDHS; 2017-18, 2014, 2011, 2007, and 2004) were used to measure the inequalities in the SBA use utilizing the WHO's Health Equity Assessment Toolkit (HEAT) software. Inequality was assessed by four summary measures, namely, Population Attributable Risk (PAR), Population Attributable Fraction (PAF), Difference (D), and Ratio (R) based on the four equity dimensions: wealth status, education level, place of residence, and subnational regions (divisions). Point estimates and a 95% confidence interval (CI) were reported for each measure.

RESULTS

An increasing trend in the overall prevalence of SBA use was observed (From 15.6% in 2004 to 52.9% in 2017). We found significant inequalities in SBA use in every wave of BDHS (from 2004 to 2017), with the result concentrating on the rich (in 2017, PAF: 57.1; 95% CI: 52.5-61.7), educated (in 2017, PAR: 9.9; 95% CI: 5.2-14.5),  and people from urban areas (in 2017, PAF: 28.0; 95% CI: 26.4-29.5). We also identified geographic disparities in SBA use favoring Khulna and Dhaka divisions (in 2017, PAR: 10.2; 95% CI: 5.7-14.7). Our study also observed inequality in using SBA among Bangladeshi women decreased over time.

CONCLUSION

To increase SBA use and to decrease inequality in all four equity dimensions, disadvantaged sub-groups should be prioritized in policies and planning for program implementation.

Sensitivity of uterine artery Doppler pulsatility index in screening for adverse pregnancy outcome in first and second trimesters

PURPOSE

In a poor resource country where screening for adverse pregnancy outcomes using maternal biomarkers seems unattainable, there is a need to search for credible alternatives. This study is, therefore, aimed at determining the sensitivity of uterine artery Doppler pulsatility index (UtAD-PI) in predicting pregnancy outcomes in the first and second trimesters and to establish any statistical difference in mean UtAD-PI in first and second trimesters screening of women with normal and abnormal pregnancy outcomes respectively.

METHODS

This clinical-based, longitudinal, and unpaired cohort study involved 500 pregnant women, who were screened for adverse outcomes using UtAD-PI and delivered in the hospital. These were divided into two groups, each having a training set and a test set. The training set was used to generate the receiver operator characteristic curve and cut-off point while the test set was used to test for sensitivity and specificity of the Ut-ADI in each trimester.

RESULTS

The sensitivity and specificity of UtAD-PI in first-trimester screening are 97% and 76.5% while second-trimester gave sensitivity and specificity of 57.5% and 63.3% respectively. The uterine artery Doppler pulsatility index shows statistically significant differences between normal pregnancy and pregnancy with adverse outcomes (p-value = 0.000).

CONCLUSION

The uterine artery Doppler pulsatility index is a good screening tool for adverse pregnancy outcomes. First-trimester screening of patients for adverse outcomes is more sensitive than the second-trimester screening using UtAD-PI. There is also a statistically significant difference between mean UtAD-PI between normal pregnancy and pregnancy with adverse pregnancy outcomes.

Integrating contraceptive services into existing perinatal care: protocol for a community-based cluster randomised controlled trial in Shanghai, China

INTRODUCTION

Postpartum contraception is essential to preventing unintended pregnancies and short interpregnancy intervals. The first year after childbirth is a critical period with a high risk of unintended pregnancy and induced abortion. However, the postpartum contraceptive services are weak in China's existing maternal and child healthcare system. We propose to evaluate the effects of integrating postpartum contraceptive services into the existing perinatal care system via a cluster randomised controlled trial.

METHODS AND ANALYSIS

This cluster randomised controlled trial involves all 13 communities of Minhang District, Shanghai, China. Communities will be randomly allocated, seven in the intervention group and six in the control group. One thousand and three hundred women, 100 women in each community, will be recruited in the study. Women assigned to the intervention group will receive postpartum contraceptive education and counselling during pregnancy, childbirth hospitalisation, postpartum home visits and the 42-day postpartum clinic check-up. Women in the control group will receive routine antenatal and postpartum care. Participants will be recruited in the first trimester during pregnancy and followed up to 1 year postpartum. The primary outcome is the incidence of unintended pregnancy within 1 year after childbirth.

ETHICS AND DISSEMINATION

The trial received ethical approval from the Ethics Committee of Shanghai Minhang District Maternal and Child Health Care Hospital (#[2020]KS-02, #[2020]KS-05, #[2020]KS-05-EX). Results will be published in academic journals and disseminated in multiple formats for the health professionals and the public.

TRIAL REGISTRATION NUMBER

ChiCTR2000034603.

Late initiation of antenatal care among pregnant women in Addis Ababa city, Ethiopia: a facility based cross-sectional study

BACKGROUND

Antenatal care (ANC) is the care given to pregnant women to prevent poor feto-maternal outcomes during pregnancy. The World Health Organization recommends first ANC visit be started as early as possible within in 12 weeks of gestation. Although there is improvement in overall ANC coverage, a sizable proportion of pregnant women in Ethiopia delay the time to initiate their first ANC visit. Therefore, this study aimed to investigate factors associated with late ANC initiation among pregnant women attending public health centers in Addis Ababa, Ethiopia.

METHODS

A facility-based cross-sectional study was conducted among 407 randomly selected pregnant women who attended ANC at selected public health centers in Addis Ababa from December 2020 to January 2021. Data were collected using pretested and structured questionnaires through a face-to-face interview and reviewing medical records. Binary and multivariable logistic regressions were fitted sequentially to identify predictors for late ANC initiation. Adjusted odds ratios with 95% CI were computed to measure the strength of associations and statistical significance was declared at a p-value < 0.05.

RESULT

This study showed that 47% of pregnant women started their first ANC visit late.The age of 30 years and above, being married, unplanned pregnancy, having a wrong perception about the timing of the first ANC visit, and not having ANC for previous pregnancy was significantly associated with late ANC initiation.

CONCLUSION

Nearly half of the women initiated their first ANC visit late. Tailored interventions aimed at promoting early ANC initiation should target married women, women with an unplanned pregnancy, women who perceived the wrong timing of their first ANC, and those who have no ANC for their previous pregnancy.

The effect of a postpartum intrauterine device programme on choice of contraceptive method in Tanzania: a secondary analysis of a cluster-randomized trial

Vertical global health programmes often evaluate success with a narrow focus on programmatic outcomes. However, evaluation of broader patient-centred and unintended outcomes is critical to assess impacts on patient choice and autonomy. Here, we evaluate the effects of a postpartum intrauterine device (PPIUD) intervention on outcomes related to contraceptive method choice. The stepped-wedge cluster randomized contolled trial (RCT) took place in five Tanzanian hospitals. Hospitals were randomized to receive immediate (Group 1; n = 11 483 participants) or delayed (Group 2; n = 8148 participants) intervention. The intervention trained providers on PPIUD insertion and counselling. The evaluation surveyed eligible women (18+, resided in Tanzania, gave birth at a study hospital) on provider postpartum contraceptive counselling during pregnancy or immediately postpartum. In our completed study, participants were considered exposed (n = 9786) or unexposed (n = 10 145) to the intervention based on the location and timing of their birth (no blinding). Our secondary analysis examined differences by intervention exposure on the likelihood of being counselled on IUD only, multiple methods, multiple method durations, a broad method mix; and on the number of methods women were counselled across two samples: all eligible women, and only women who reported receiving any contraceptive counselling. Among all eligible women, counselling on the IUD alone was 7% points higher among the exposed (95% confidence interal (CI): 0.02, 0.12). Among women who received any counselling, those exposed to the intervention were counselled on 1.12 fewer contraceptive methods (95% CI: 0.10, 2.34). The likelihood of receiving counselling on any non-IUD method decreased among those exposed, while the likelihood of being counselled on an IUD alone was 14% points higher among the exposed (95% CI: 0.06, 0.22), suggesting this intervention increased IUD-specific counselling but reduced informed contraceptive choice. These findings underscore the importance of broad metrics that capture autonomy and rights (in addition to programmatic goals) at all stages of health programme planning and implementation.

The impact of perception on institutional delivery service utilization in Northwest Ethiopia: the health belief model

BACKGROUND

Ethiopia has been striving to promote institutional delivery through community wide programs. However, home is still the preferred place of delivery for most women encouraged by the community`s perception that delivery is a normal process and home is the ideal environment. The proportion of women using institutional delivery service is below the expected level. Therefore, we examined the impact of perception on institutional delivery service use by using the health belief model.

METHODS

A community-based cross-sectional study was conducted among 1,394 women who gave birth during the past 1 year from September to December 2019. A multistage sampling technique was used to select the study participants. Data were collected by using health belief model constructs, and structured and pretested questionnaire. Binary logistic regression was performed to identify factors associated with the outcome variable at 95% confidence level.

RESULTS

Institutional delivery service was used by 58.17% (95% CI: 55.57- 60.77%) of women. The study showed that high perceived susceptibility (AOR = 1.87; 95% CI 1.19-2.92), high cues to action (AOR = 1.57; 95% CI: 1.04-2.36), husbands with primary school education (AOR = 1.43; 95% CI 1.06-1.94), multiparty(5 or more) (AOR = 2.96; 95% CI 1.85-4.72), discussion on institutional delivery at home (AOR = 4.25; 95% CI 2.85-6.35), no close follow-up by health workers (AOR = 0.59;95% CI 0.39-0.88), regular antenatal care follow-up (AOR = 1.77;95% CI 1.23,2.58), health professionals lack of respect to clients (AOR = 2.32; 95% CI 1.45-3.79), and lack of health workers (AOR = 0.43;95% CI 0.29-0.61) were significantly associated with the utilization health behavior of institutional delivery service.

CONCLUSION

The prevalence of institutional delivery in the study area was low. The current study revealed that among the health belief model construct perceived susceptibility and cues to action were significantly associated with the utilization behavior of institutional delivery service. On top of that strong follow-up of the community and home based discussion was a significant factor for the utilization behavior of institutional delivery service.

Effectiveness of targeted antenatal family planning information provision on early postpartum family planning uptake in Kisumu County: Protocol for a simple randomized control trial (I DECIDE Study)

Overlooking the contraceptive needs of postpartum women constitutes missed opportunities in health system. Inter-birth interval of at least three years can prevent poor maternal, perinatal and neonatal outcomes and afford women socio-economic benefits of family planning (FP). The unmet need for FP in the postpartum period remains unacceptably high and far exceeds the FP unmet need of other women. The Kenya Demographic and Health Survey (KDHS) estimate the unmet need for postpartum FP to be 74%. Maternal and Child Health (MCH) continuum provides a great opportunity for postpartum FP (PPFP) interventions integration especially antenatal targeted FP information giving and gauging of fertility intentions. However, there is no protocol for structured, targeted antenatal FP information giving and behavioural contracting to influence postpartum fertility intentions of mothers before delivery. Knowledge gap regarding fertility intentions and best antenatal strategies for postpartum FP still exists. The available evidence differs across settings and demography. Equally, there has been inadequate exploration of operationally-feasible ways to integrate FP counselling into existing ANC services with limited number of methodologically rigorous trials. The current protocol will therefore examine the effectiveness of targeted antenatal family planning information provision on early postpartum FP uptake using a randomized control trial in Kisumu County, Kenya. The protocol will assess socio-cultural beliefs towards PPFP and perceived individual control of PPFP choice, analyze knowledge and intention for PPFP, and finally compare and examine the determinants of PPFP uptake between study groups. Through simple sampling, a group of 246 antenatal mothers will be randomly assigned to control, community and facility intervention groups as per eligibility criteria in the study facilities. After at least 3 months of intervention and postpartum follow-up, clinical superiority will be used to gauge which intervention was effective and the model superiority. Questionnaire and Case Report Forms will be the main source of data. The participant will form the unit of analysis which will be by intention to treat. Bivariate analysis will be applied as the selection criteria for inclusion of predictors of intention and uptake in the final logistic regression model. Odds Ratios and 95% confidence interval (CI) will be used to demonstrate significance and the strength of association between selected variables. Dissemination will be through conference presentations and peer reviewed journals. The trial has been registered with the Pan African Clinical Trials Registry PACTR202109586388973 on the 28^th September 2021.

Reproductive Women’s Knowledge on Possibility of Pregnancy after Birth but before Resumption of Menstruation and Its Associated Factors in Ethiopia: A Population-Based Study Using the 2016 Ethiopian Demographic Health Survey

Introduction

Worldwide, specifically in developing countries, women believe that a woman cannot become pregnant unless she sees her first postpartum menstruation. Due to this knowledge gap, most women did not use any contraceptives till their 1^st postpartum menstruation. Hence, about 44% of women were susceptible to unintended pregnancy in the postpartum period. Assessing women knowledge on possibility of pregnancy after giving birth but before returning of menses and its associated factors will help to increase women's recognition on the issue and for early commencement of appropriate postpartum family planning methods to reduce burden of unintended pregnancy.

Objective

To assess the level of knowledge on possibility of pregnancy after giving birth but before returning of menses and its associated factors among reproductive women in Ethiopia.

Methods

A secondary data analysis using the 2016 Ethiopian Demographic Health Survey was employed. Samples were selected using two-stage stratified sampling technique. Descriptive statistics and logistic regressions were used. Adjusted odds ratio (AOR) with 95% confidence interval was used to interpret associations, and a significant association was declared at a p value of <0.05.

Result

A total of 15,683 reproductive women aged from 15 to 49 years were included. Of them, about 53% did not know that a woman can get pregnant after giving birth but before resumption of her menstruation. Age being 35 years and above (AOR = 1.50; 95%CI = 1.34, 1.67), educational status of secondary and above (AOR = 1.18; 95%CI = 1.06, 1.32), being ever married (AOR = 1.67; 95%CI = 1.47, 1.89), knowledge of any family planning method (AOR = 1.81; 95%CI = 1.52, 2.16), getting counseling on family planning methods (AOR = 1.41; 95%CI = 1.28, 1.55), and being knowledgeable on their ovulatory cycle (AOR = 1.68; 95%CI = 1.55, 1.82) were found to be significantly associated with being knowledgeable on the issue.

Conclusion

Reproductive women's level of knowledge on the possibility of pregnancy after giving birth but before returning of menses was low. Factors associated with being knowledgeable on the issue were identified. Therefore, strategies should be developed to increase their level of knowledge for reducing unintended pregnancy and its complications by integrating family planning counseling with infant immunization services.

Magnitude and Factors Associated with Late Initiation of Antenatal Care Booking on First Visit Among Women in Rural Parts of Ethiopia

BACKGROUND

Early antenatal care visits enhance early detection and treatment of pregnancy problems, resulting in optimal delivery management. This study aimed to assess the late initiation of antenatal care visits among pregnant women in rural parts of Ethiopia.

METHODS

A 2016 Ethiopian Demographic and Health Survey provided the data for this study and a population-based cross-sectional study was conducted during data collection. Only 3065 women from rural areas were included in this study due to having complete information from all eligible women aged 15 to 49 who participated in the interview during data collection. SPSS-20 and R-4.1.2 statistical software were used to examine the data. The factors associated with the late initiation of antenatal care visits were identified using descriptive analysis and a binary logistic regression model.

RESULTS

This finding revealed that only 31% of women visited their initial antenatal care within the first 3 months. The distance between the health facility and the participants was a concern for 87.7% of the participants. Our research found that women's education, maternal age, region, media access, women's occupation, distance from the health facility, wealth index, pregnancy complication, and pregnancy plan all had significant effects on the late initiation of antenatal care visits. When compared to the reference group, women with a secondary and above education (AOR = 1.52, p-value = 0.02), women in age group 30-34 (AOR = 1.57, p-value = 0.02), and women in age group 35-39 (AOR = 1.56, p-value = 0.03), women with media access (AOR = 2.4, p-value = 0.04), richer women's (AOR = 1.29, p-value ≤ 0.001), women with pregnancy previous complication (AOR = 1.58, p-value ≤ 0.001), and women who had plan to the pregnancy (AOR = 1.26, p-value = 0.02) were more likely to start visiting ANC service earlier. In addition, private worker mothers, housewife women, and mothers having distance problems were less likely to visit antenatal care service before or at 12 weeks of gestation compared to those mothers in reference categories of each variable.

CONCLUSION

In Ethiopia, particularly in rural areas, early registration to antenatal care visits was extremely low. Community-based services such as media coverage, education, transportation, and raising awareness about the need of receiving antenatal care services early are required to encourage expecting mothers to attend their ANC appointment on time.

Associations of antenatal care visit with utilization of institutional delivery care services in Afghanistan: intersections of education, wealth, and household decision-making autonomy

Background

The importance of antenatal care (ANC) visits in safe motherhood and childbirth is well-documented. However, less is known how social determinants of health interact with ANC visits in shaping the uptake of professional delivery care services in low-income countries. This study examines the associations of ANC visits with institutional delivery care utilization outcomes in Afghanistan. Further, we assess the extent to which ANC visits intersect with education, wealth, and household decision-making autonomy in predicting two outcomes of delivery care utilization- delivery at a health facility and delivery assisted by a skilled birth attendant.

Methods

We used data from the Afghanistan Demographic and Health Survey (AfDHS) 2015. The analytic sample included 15,590 women of reproductive age (15–49). We assessed the associations using logistic regression models, estimated the predicted probability of delivery care outcomes using statistical interactions, and presented estimates in margins plot.

Results

Multivariable adjusted analyses suggest that women who had 4 or more ANC visits were 5.7 times (95% CI = 4.78, 7.11; P < 0.05) more likely to use delivery care at a health facility and 6.5 times (95% CI = 5.23, 8.03; P < 0.05) more likely to have a delivery assisted by a skilled birth attendant compared to women who had no ANC visit. Estimates from models with statistical interactions of ANC visits with education, wealth, and decision-making autonomy suggest that women with higher social status were more advantageous in utilizing institutional delivery care services compared to women with lower levels of social status.

Conclusion

Our findings suggest that the associations of ANC visits with institutional delivery care services are stronger among women with higher social status. The results have implications for promoting safe motherhood and childbirth through improving women’s social status.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04588-0.

Female genital mutilation and skilled birth attendance among women in sub-Saharan Africa

BACKGROUND

There is evidence that women who have had their genitals cut suffer substantial difficulties during and/or after childbirth, including the need for a caesarean section, an episiotomy, an extended hospital stay, post-partum bleeding, and maternal fatalities. Whether or not women in sub-Saharan Africa who have undergone female genital mutilation utilize the services of skilled birth attendants during childbirth is unknown. Hence, we examined the association between female genital mutilation and skilled birth attendance in sub-Saharan Africa.

METHODS

The data for this study were compiled from 10 sub-Saharan African countries' most recent Demographic and Health Surveys. In the end, we looked at 57,994 women between the ages of 15 and 49. The association between female genital mutilation and skilled birth attendance was investigated using both fixed and random effects models.

RESULTS

Female genital mutilation and skilled birth attendance were found to be prevalent in 68.8% and 58.5% of women in sub-Saharan Africa, respectively. Women with a history of female genital mutilation had reduced odds of using skilled birth attendance (aOR = 0.91, 95% CI = 0.86-0.96) than those who had not been circumcised. In Ethiopia, Guinea, Liberia, Kenya, Nigeria, Senegal, and Togo, women with female genital mutilation had reduced odds of having a trained delivery attendant compared to women in Burkina Faso.

CONCLUSION

This study shed light on the link between female genital mutilation and skilled birth attendance among sub-Saharan African women. The study's findings provide relevant information to government agencies dealing with gender, children, and social protection, allowing them to design specific interventions to prevent female genital mutilation, which is linked to non-use of skilled birth attendance. Also, health education which focuses on childbearing women and their partners are necessary in enhancing awareness about the significance of skilled birth attendance and the health consequences of female genital mutilation.

Spatial inequalities in skilled birth attendance in India: a spatial-regional model approach

BACKGROUND

Despite a significant increase in the skilled birth assisted (SBA) deliveries in India, there are huge gaps in availing maternity care services across social gradients - particularly across states and regions. Therefore, this study applies the spatial-regression model to examine the spatial distribution of SBA across districts of India. Furthermore, the study tries to understand the spatially associated population characteristics that influence the low coverage of SBA across districts of India and its regions.

METHODS

The study used national representative cross-sectional survey data obtained from the fourth round of National Family Health Survey, conducted in 2015-16. The effective sample size was 259,469 for the analysis. Moran's I statistics and bivariate Local Indicator for Spatial Association maps were used to understand spatial dependence and clustering of deliveries conducted by SBA coverage in districts of India. Ordinary least square, spatial lag and spatial error models were used to examine the correlates of deliveries conducted by SBA.

RESULTS

Moran's I value for SBA among women was 0.54, which represents a high spatial auto-correlation of deliveries conducted by SBA over 640 districts of India. There were 145 hotspots for deliveries conducted by SBA among women in India, which includes almost the entire southern part of India. The spatial error model revealed that with a 10% increase in exposure to mass media in a particular district, the deliveries conducted by SBA increased significantly by 2.5%. Interestingly, also with the 10% increase in the four or more antenatal care (ANC) in a particular district, the deliveries conducted by SBA increased significantly by 2.5%. Again, if there was a 10% increase of women with first birth order in a particular district, then the deliveries conducted by SBA significantly increased by 6.1%. If the district experienced an increase of 10% household as female-headed, then the deliveries conducted by SBA significantly increased by 1.4%.

CONCLUSION

The present study highlights the important role of ANC visits, mass media exposure, education, female household headship that augment the use of an SBA for delivery. Attention should be given in promoting regular ANC visits and strengthening women's education.

Putative Mental, Physical, and Social Mechanisms of Hormonal Influences on Postpartum Sexuality

Purpose of Review

Much research has documented changes in postpartum sexuality, including changes in sexual functioning and satisfaction for both the birthing parent and their partner(s). These changes are often linked to postpartum changes in hormonal and immune responses, which can have both direct and indirect effects on sexuality.

Recent Findings

Here, we review how postpartum sexuality may be changed via mental, physical, and social/relationship effects of a variety of hormones, including estrogens, progestogens, androgens, cortisol, and oxytocin. We also review the ways in which inflammation may act alongside hormones to influence postpartum sexuality.

Summary

We argue that, as each of these factors strongly influence the action of others, the next phase of research in postpartum sexuality must examine the bidirectional interactions of hormones and their effects on behavior, cognition, and social relationships.

Doppler abnormalities and perinatal outcomes in pregnant women with early-onset fetal growth restriction

OBJECTIVE

To compare Doppler alterations and perinatal outcomes in pregnant women who evolved with early- and late-onset fetal growth restriction (FGR).

METHODS

A retrospective, observational cohort study with pregnant women who evolved with FGR treated between January 2018 and April 2019, in which all live births from singleton pregnancies, over 24 weeks, with FGR ultrasound diagnosis and under 2700 g weight were included in the study.

RESULTS

Pregnancies with early-onset FGR were more associated with hypertensive disorders (p = .00) and placental vascular insufficiency, resulting in a high degree of umbilical artery Doppler involvement (p = .00) in a short period of pregnancy and higher rates of adverse perinatal outcomes (p = .00). The time of prenatal follow-up of early- and late-onset FGR cases was similar, but the degree of prematurity of the former made the evolution more unfavorable.

CONCLUSION

Early-onset FGR had a lower prevalence but was associated with higher maternal and fetal morbidity and mortality than late-onset FGR.

Risk factors for the development of neonatal sepsis in a neonatal intensive care unit of a tertiary care hospital of Nepal

BACKGROUND

Sepsis is an overwhelming and life-threatening response to bacteria in bloodstream and a major cause of neonatal morbidity and mortality. Understanding the etiology and potential risk factors for neonatal sepsis is urgently required, particularly in low-income countries where burden of infection is high and its epidemiology is poorly understood.

METHODS

A prospective observational cohort study was conducted between April 2016 and October 2017 in a level three NICU at a tertiary care hospital in Nepal to determine the bacterial etiology and potential risk factors for neonatal sepsis.

RESULTS

Among 142 NICU admitted neonates, 15% (21/142) and 32% (46/142) developed blood culture-positive and -negative neonatal sepsis respectively. Klebsiella pneumoniae (34%, 15/44) and Enterobacter spp. (25%, 11/44) were the most common isolates. The antimicrobial resistance of isolates to ampicillin (100%, 43/43), cefotaxime (74%, 31/42) and ampicillin-sulbactam (55%, 21/38) were the highest. BlaTEM (53%, 18/34) and blaKPC (46%, 13/28) were the commonest ESBL and carbapenemase genes respectively. In univariate logistic regression, the odds of sepsis increased with each additional day of use of invasive procedures such as mechanical ventilation (OR 1.086, 95% CI 1.008-1.170), umbilical artery catheter (OR 1.375, 95% CI 1.049-1.803), intravenous cannula (OR 1.140, 95% CI 1.062-1.225); blood transfusion events (OR 3.084, 95% CI 1.407-6.760); NICU stay (OR 1.109, 95% CI 1.040-1.182) and failure to breast feed (OR 1.130, 95% CI 1.060-1.205). Sepsis odds also increased with leukopenia (OR 1.790, 95% CI 1.04-3.082), increase in C-reactive protein (OR 1.028, 95% CI 1.016-1.040) and decrease in platelets count (OR 0.992, 95% CI 0.989-0.994). In multivariate analysis, increase in IV cannula insertion days (OR 1.147, 95% CI 1.039-1.267) and CRP level (OR 1.028, 95% CI 1.008-1.049) increased the odds of sepsis.

CONCLUSIONS

Our study indicated various nosocomial risk factors and underscored the need to improve local infection control measures so as to reduce the existing burden of sepsis. We have highlighted certain sepsis associated laboratory parameters along with identification of antimicrobial resistance genes, which can guide for early and better therapeutic management of sepsis. These findings could be extrapolated to other low-income settings within the region.

Measuring quality of family planning counselling and its effects on uptake of contraceptives in public health facilities in Uttar Pradesh, India: A cross-sectional analysis

BACKGROUND

Quality of care in family planning traditionally focuses on promoting awareness of the broad array of contraceptive options rather than on the quality of interpersonal communication offered by family planning (FP) providers. There is a growing emphasis on person-centered contraceptive counselling, care that is respectful and focuses on meeting the reproductive needs of a couple, rather than fertility regulation. Despite the increasing global focus on person-centered care, little is known about the quality of FP care provided in low- and middle- income countries like India. This study involves the development and psychometric testing of a Quality of Family Planning Counselling (QFPC) measure, and assessment of its associations with contraceptives selected by clients subsequently.

METHODS

We analyzed cross-sectional survey data from N = 237 women following their FP counselling in 120 public health facilities (District Hospitals and Community Health Centers) sampled across the state of Uttar Pradesh in India. The study captured QFPC, contraceptives selected by clients post-counselling, as well as client and provider characteristics. Based on formative research and using Principal Component Analysis, we developed a 13-item measure of quality of FP counselling. We used adjusted regression models to assess the association between QFPC and contraceptive selected post-counselling.

RESULTS

The QFPC measure demonstrated good internal reliability (Cronbach alpha = 0.80) as well as criterion validity, as indicated by client reports of high QFPC being significantly more likely for clients with trained versus untrained counsellors. We found that each point increase in QFPC, including increasing quality of counselling, is associated with higher odds of clients selecting an intrauterine device (IUD) (aRR:1.03; 95% CI:1.01-1.05) and sterilization (aRR:1.06; 95% CI:1.03-1.08), compared to no method selected.

CONCLUSIONS

High-quality FP counselling is associated with clients subsequently selecting more effective contraceptives, including IUD and sterilization, in India. High-quality counselling is also more likely among FP-trained providers, highlighting the need for focused training and monitoring of quality care.

TRIAL REGISTRATION

CTRI/2015/09/006219. Registered 28 September 2015.

Counseling at all contacts for postpartum contraceptive use: can paper-based tools help community health workers improve continuity of care? A qualitative study from Ethiopia

Background: Globally, there has been a resurgence of interest in postpartum family planning (PPFP) to advance reproductive health outcomes. Few programs have systematically utilized all contacts a woman and her baby have with the health system, from pregnancy through the first year postpartum, to promote PPFP. Nested into a larger study covering two districts, this study assessed the use, acceptability, and feasibility of tools for tracking women's decision-making and use of PPFP in the community health system in Oromia region, Ethiopia. Community-level tracking tools included a modified Integrated Maternal and Child Health (IMCH) card with new PPFP content, and a newly developed tool for pregnant and postpartum women for use by Women Development Armies (WDAs). Proper completion of the tools was monitored during supervision visits. Methods: In-depth interviews and focus group discussions were conducted with health officials, health extension workers, and volunteers. A total of 34 audio-files were transcribed and translated into English, double-coded using MAXQDA, and analyzed using a thematic approach. Results: The results describe how HEWs used the modified IMCH card to track women's decision making through the continuum of care, to assess pregnancy risk and to strengthen client-provider interaction. Supervision data demonstrated how well HEWs completed the modified IMCH card. The WDA tool was intended to promote PPFP and encourage multiple contacts with facilities from pregnancy to extended postpartum period. HEWs have reservations about the engagement of WDAs and their use of the WDA tool. Conclusions: To conclude, the IMCH card improves counseling practices through the continuum of care and is acceptable and feasible to apply. Some elements have been incorporated into a revised national tool and can serve as example for other low-income countries with similar community health systems. Further study is warranted to determine how to engage WDAs in promoting PPFP.

Barriers to post-placental intrauterine device receipt among expectant minority women

PURPOSE

We aimed to identify barriers to breastfeeding-compatible post-placental intrauterine devices (IUDs) for expectant predominantly non-Hispanic African-American women.

MATERIALS AND METHODS

This cross-sectional survey study, conducted at 3 Cleveland community partner locations, enrolled 119 expectant predominantly unmarried but partnered non-Hispanic African-American women. The survey assessed contraceptive, IUD-specific and breastfeeding attitudes and intentions. Survey responses were described with percentages and frequencies, and compared by feeding intention using 2-sided Chi-Square tests. Factor analysis with Varimax rotation identified 2 potential measures of reluctance to post-placental IUD acceptance. The relationship of factors scores to maternal characteristics was assessed.

RESULTS

Feeding intention (breastfeeding versus not) was not related to perceived barriers to post-placental IUD receipt among expectant minority women. A "Personal Risks Reluctance" factor included low risk IUD events (migration and expulsion), misconceptions (delayed fertility return), menstrual changes and partner preference: a higher score was significantly associated with younger age group but no other maternal characteristics. A "Not Me Reasons" factor included provider and insurance barriers, and was not related to any maternal characteristics.

CONCLUSIONS

Expectant minority women's perceived barriers to post-placental IUDs are not related to prenatal feeding intentions. We identified two clinically relevant factors that appear to measure barriers to post-placental IUD acceptance.

Do Expectant Mothers' Breastfeeding Plans Influence Provider Prenatal Contraceptive Counseling?

BACKGROUND

Breastfeeding and optimal birth spacing are associated with improved maternal and infant health outcomes worldwide. Provision of contraceptive advice that is aligned with recommendations for breastfeeding has potential to maximize maternal and infant health. Although there is broad agreement regarding the breastfeeding compatibility of specific postpartum contraceptive methods, it is not known whether maternal breastfeeding intention influences prenatal provider contraceptive counseling.

RESEARCH AIM

We aimed to determine if maternal feeding intention is considered by prenatal providers during contraceptive counseling.

METHODS

This was a cross-sectional online author-created survey including all prenatal providers (N = 40) at two academic safety-net institutions in Cleveland, Ohio. Of 100 obstetrics/gynecology faculty members, 40 (40%) completed the survey, which included multiple-choice questions. Nominal and ordinal survey results were reported with percentages and frequencies, and categorical variables were compared using the Fisher exact test.

RESULTS

Participants appropriately promoted breastfeeding-compatible postplacental intrauterine device placement, even though maternal feeding intention was specifically considered by just 12 (30%). Endorsed barriers to contraception for breastfeeding mothers included provider medical worries, patient concerns, and colleague resistance. Postplacental levonorgestrel intrauterine devices were recommended for all mothers by 92.5% of participants (n = 37). Recommendations regarding progestin-only and combined oral contraceptive pills were influenced by maternal breastfeeding versus formula-feeding intention.

CONCLUSION

Asking expectant women about their feeding intentions within each contraceptive discussion may create opportunities for shared decision making that can optimize perinatal outcomes for both mother and infant worldwide.

Lactational amenorrhoea among adolescent girls in low-income and middle-income countries: a systematic scoping review

INTRODUCTION

Fertility levels among adolescents remain high in many settings. The objective of this paper was to review the available literature about postpartum and lactational amenorrhoea among adolescents in low-income and middle-income countries (LMICs).

METHODS

We searched Medline, Embase, Global Health and CINAHL Plus databases using terms capturing adolescence and lactational or postpartum amenorrhoea. Inclusion criteria included publication date since 1990, data from LMICs, and topic related to lactational amenorrhoea as a postpartum family planning method or as an effect of (exclusive) breast feeding among adolescents. Thematic analysis and narrative synthesis were applied to summarise and interpret the findings.

RESULTS

We screened 982 titles and abstracts, reviewed 75 full-text articles and included nine. Eight studies assessed data from a single country (three from India, two from Bangladesh, two from Turkey, one from Nigeria). One study using Demographic and Health Survey data included 37 different LMICs. The five studies measuring duration of postpartum or lactational amenorrhoea reported a wide range of durations across the contexts examined. Four studies (from Bangladesh, Nigeria and Turkey) examined outcomes related to the use of lactational amenorrhoea as a family planning method among adolescents. We did not find any studies assessing adolescents' knowledge of lactational amenorrhoea as a postpartum family planning method. Likewise, little is known about the effectiveness of lactational amenorrhoea method among adolescents using sufficiently large samples and follow-up time.

CONCLUSION

The available evidence on lactational amenorrhoea among adolescents in LMICs is scarce. Given the potential contribution of lactational amenorrhoea to prevention of short interpregnancy intervals among adolescents and young women, there is a need for a better understanding of the duration of lactational amenorrhoea, and the knowledge and effective use of lactational amenorrhoea method for family planning among adolescents in a wider range of LMIC settings.

Exploring spatial variations and factors associated with skilled birth attendant delivery in Ethiopia: geographically weighted regression and multilevel analysis

BACKGROUND

Skilled birth attendant (SBA) delivery is vital for the health of mothers and newborns, as most maternal and newborn deaths occur at the time of childbirth or immediately after birth. This problem becomes worsen in Ethiopia in which only 28% of women give birth with the help of SBA. Therefore, this study aimed to explore the spatial variations of SBA delivery and its associated factors in Ethiopia.

METHODS

A secondary analysis was carried out using the 2016 Ethiopian Demographic and Health Survey. A total weighted sample of 11,023 women who had a live birth in the 5 years preceding the survey was included in the analysis. Arc-GIS software was used to explore the spatial distribution of SBA and a Bernoulli model was fitted using SaTScan software to identify significant clusters of non-SBA delivery. The Geographic Weighted Regression (GWR) was employed in modeling spatial relationships. Moreover, a multilevel binary logistic regression model was fitted to identify factors associated with SBA delivery.

RESULTS

In this study, SBA delivery had spatial variations across the country. The SaTScan spatial analysis identified the primary clusters' spatial window in southeastern Oromia and almost the entire Somalia. The GWR analysis identified different predictors of non- SBA delivery across regions of Ethiopia. In the multilevel analysis, mothers having primary and above educational status, health insurance coverage, and mothers from households with higher wealth status had higher odds of SBA delivery. Being multi and grand multiparous, perception of distance from the health facility as big problem, rural residence, women residing in communities with medium and higher poverty level, and women residing in communities with higher childcare burden had lower odds of SBA delivery.

CONCLUSION

Skilled birth attendant delivery had spatial variations across the country. Areas with non-skilled birth attendant delivery and mothers who had no formal education, not health insured, mothers from poor households and communities, Primiparous women, mothers from remote areas, and mothers from communities with higher childcare burden could get special attention in terms of allocation of resources including skilled human power, and improved access to health facilities.

Predictors of puerperal menstruation

Background

Puerperal period is an important and thought-provoking period for puerperal mothers. Surprisingly, reports have indicated that there is increasing number of women resuming menstruation within six weeks of childbirth (puerperal menstruation). To the best of knowledge, there is no prior study on predictors of puerperal menstruation.

Objective

To determine frequency and predictors of puerperal menstruation.

Methods

This was a single tertiary health institution cross-sectional study at ESUT Teaching Hospital, Parklane, Enugu, Nigeria that included data from May 2015 to December 2018. Women were interviewed at the end of the first six weeks of their childbirth. Women with HIV positive or had uterine rupture or peripartum hysterectomy were excluded. Bivariate analysis was performed by the chi-squared test and conditional logistic regression analysis was used to determine variables associated with puerperal menstruation. Statistical significance was accepted when P- value is <0.05.

Results

A total of 371 women met the inclusion criteria. The return of menses within 6 weeks was present in 118(31.8%) women versus 253 (68.2%) women without puerperal menstruation, given a ratio of 1:3. Of the 371 women, 249 (67.1%) were on exclusive breastfeeding. The significant associated risk factors were age (p = 0.009), parity (p<0.001), early use of family planning (p = 0.001), socio-economic status (p<0.001) and manual removal of placenta (p = 0.007). At conditional logistic regression analysis, early use of family planning (p = 0.001), exclusive breastfeeding (p = 0.027) and manual removal of placenta (p = 0.012) were independently associated with puerperal menstruation. Induction/augmentation of labor, postpartum misoprostol use and mode of delivery were not statistically significant (p>0.05, for all)

Conclusion

One in 3 women resumes menstruation within 6 weeks of childbirth. The major predictor was early initiation of family planning, and exclusive breastfeeding with manual removal of placenta a major protective factor. These interesting issues require further investigation to better understand the mechanism of puerperal menstruation.

Factors influencing the use of reproductive health services among young women in Nepal: analysis of the 2016 Nepal demographic and health survey

Background

Utilization of reproductive health services is a key component for preventing young women from different sexual and reproductive health problems. Thus, the objective of this study is to determine the factors influencing the use of reproductive health services among young women in Nepal.

Methods

Data have been extracted from the 2016 Nepal Demographic and Health Survey (NDHS) datasets wherein the weighted sample population size was restricted for modern contraceptive use to 1593 whereas for the antenatal care and skilled birth attendants to1606. This study has selected three reproductive health indicators as outcome variables of reproductive health service utilization for the analysis viz, modern contraceptive use, at least four antenatal care visits, and use of skilled birth attendants. Likewise, all calculations are based on standard sample weight of NDHS.

Results

The study has found that 21% of young women used modern contraception, 71% attended at least four ANC visits, and 67% utilized a skilled birth attendant at delivery. Young Janajati women, women having 1–2, and 3 or more living children, women participating household decision-making, and the ones having exposure to media were more likely to use modern contraceptives, whereas the women who want more children were less likely to use them. Higher education attainments, higher wealth quintile, and lower birth order were associated with higher level of receiving at least four ANC visits and SBAs. However, the young women willing to have more children and having access to media have higher odds of receiving at least four ANC visits; and the women attending four and more ANC visits have higher odds of using SBAs.

Conclusions

In order to improve the use of reproductive health services among young women, efforts should be made to enrich the young women of lower educational level, lower economic status, higher birth order, and lower exposure to media. Further research is required to detect the causes that affect the use of reproductive health services.

Identifying barriers to post-placental intrauterine device placement: male partners' views

Objective: The use of post-placental intrauterine devices (IUDs) has potential to address the health issues of suboptimal breastfeeding rates and short inter-pregnancy intervals. An understudied factor that may influence choice of breastfeeding-compatible contraception among postpartum women is their romantic partner. We aimed to identify male partner influences on women's postpartum breastfeeding-compatible contraception choices.Methods: Questionnaires were administered to 75 men in Cleveland, OH, USA. Data on partner priorities, opinions and knowledge about breastfeeding and contraception, and barriers to partner IUD receipt were collected. Survey data were summarised using frequencies and percentages, and univariate logistic regression models were used to explore associations between responses.Results: Participants were predominantly African American, unmarried and had at least one child. Twenty-six participants (36%) reported using contraception with their current partner; men who had discussions and agreed about contraception with their partner were more likely to use it. Thirty-nine men (54%) intended for a future child to breastfeed; this intention was more likely for men who had a child that was breastfed previously and for those with knowledge of breastfeeding benefits. Only 25 (35%) thought a post-placental IUD was safe for breastfeeding mothers; correct IUD knowledge and a partner's positive IUD experience were significantly associated with this response.Conclusion: Our findings suggest that knowledge about breastfeeding and contraception as well as experiential learning regarding breastfeeding and contraception within a partnered relationship are important and that minimal prior experience and low knowledge in these areas may be a male partner barrier to post-placental IUD placement for breastfeeding mothers.

Counseling at all contacts for postpartum contraceptive use: can paper-based tools help community health workers improve continuity of care? A qualitative study from Ethiopia

Background: Globally, there has been a resurgence of interest in postpartum family planning (PPFP) to advance reproductive health outcomes. Few programs have systematically utilized all contacts a woman and her baby have with the health system, from pregnancy through the first year postpartum, to promote PPFP. Nested into a larger study covering two districts, this study assessed the use, acceptability, and feasibility of tools for tracking women's decision-making and use of PPFP in the community health system in Oromia region, Ethiopia. Community-level tracking tools included a modified Integrated Maternal and Child Health (IMCH) card with new PPFP content, and a newly developed tool for pregnant and postpartum women for use by Women Development Armies (WDAs). Proper completion of the tools was monitored during supervision visits. Methods: In-depth interviews and focus group discussions were conducted with health officials, health extension workers, and volunteers. A total of 34 audio-files were transcribed and translated into English, double-coded using MAXQDA, and analyzed using a thematic approach. Results: The results describe how HEWs used the modified IMCH card to track women's decision making through the continuum of care, to assess pregnancy risk and to strengthen client-provider interaction. Supervision data demonstrated how well HEWs completed the modified IMCH card. The WDA tool was intended to promote PPFP and encourage multiple contacts with facilities from pregnancy to extended postpartum period. HEWs have reservations about the engagement of WDAs and their use of the WDA tool. Conclusions: To conclude, the IMCH card improves counseling practices through the continuum of care and is acceptable and feasible to apply. Some elements have been incorporated into a revised national tool and can serve as example for other low-income countries with similar community health systems. Further study is warranted to determine how to engage WDAs in promoting PPFP.

Associations Between Prenatal Intention and Postpartum Choice: Infant Feeding and Contraception Decisions Among Inner-City Women

Purpose: We sought to understand how women's prenatal infant feeding and contraception intentions were related to postpartum choices. Materials and Methods: Expectant women ≥14 years of age receiving care at MacDonald Women's Hospital, Cleveland Ohio were previously surveyed regarding feeding and contraceptive intentions. Here, we asked: (1) What were postpartum feeding choices, and did prenatal intention predict postpartum choice?, (2) What were postpartum contraceptive choices, and did prenatal intention predict postpartum choice?, and (3) What was the relationship of postpartum contraceptive choice to postpartum feeding choice? Results: Of 223 women interviewed prenatally, 214 (96%) were followed to postpartum in-hospital, and 119 out of 214 (56%) were followed to the postpartum visit. The mean age was 25 years, 185 out of 206 (89.8%) were African American, and 149 out of 200 (75.0%) were multiparous. Prenatal feeding and contraceptive intent were significantly associated with postpartum feeding and contraceptive choices, respectively (both p < 0.0001). More women who initiated breastfeeding chose no contraception (54.5% for any breastfeeding versus 32.2% for exclusive formula feeding) versus long-acting reversible contraception (LARC), tubal ligation, or other contraceptive types (χ² = 9.28, p = 0.03). After adjusting for known confounders, only receipt of other contraceptive types (not LARC, not tubal ligation) was significantly associated with decreased odds of any breastfeeding (p = 0.02). Conclusions: Among low-income predominantly African American inner-city women, prenatal intentions were significantly associated with postnatal choices for infant feeding and contraception. After controlling for confounders, women receiving less effective types of contraception (not LARC and not tubal ligation) had reduced odds of any breastfeeding (p = 0.02).

Maternal health outcomes for incarcerated women: A scoping review

AIMS AND OBJECTIVES

To inform a systematic synthesis of what is known about the maternal health outcomes of incarcerated women, this scoping review uses a theoretical framework of intersectional feminism.

BACKGROUND

Despite rising imprisonment of women, there is a lack of research, from a feminist perspective, on perinatal health outcomes among incarcerated women.

DESIGN

Systematic scoping review using the Joanna Briggs Institute scoping review methodology.

METHODS

In consultation with a medical research librarian, key databases and journals were searched for English and French-language articles published up to February 2018. Two authors independently screened titles and abstracts to identify articles for full-text review. Study quality was appraised using the McGill Mixed Methods Appraisal Tool. The study adheres to PRISMA-EQUATOR guidelines.

RESULTS

Forty-five studies met the preset criteria and were reviewed in full text. In addition, 13 studies met consensus for inclusion. Method, setting, participants, sample, relevant outcomes and relevant findings were extracted from each study for synthesis. Included studies had varied methods and were published from 1989-2014. Participants included women imprisoned during the perinatal period up to six months postpartum. All studies were conducted in carceral contexts, with 12 based in the USA and one in Australia. Outcomes of interest included breastfeeding, operative deliveries, gestational complications, depression, stress, experiences, bonding and sterilisation.

CONCLUSION

The research on maternal health outcomes pertaining to incarcerated women is limited. There is a need for in-depth examination of breastfeeding with this population. Researchers need to examine the prevalence and impact of carceral force, such as shackling, solitary confinement, strip-searching and restraints in pregnancy. There is a need for research that asks what health outcomes matter to the women themselves.

RELEVANCE TO CLINICAL PRACTICE

Providers must be conscious of intersecting layers of discrimination and trauma incarcerated women experience and its impact on maternal health in the perinatal period and advocate for women.

Postpartum hormonal contraception use and incidence of postpartum depression: a systematic review

PURPOSE

To evaluate the association between postpartum hormonal contraceptive use and postpartum depression.

MATERIALS AND METHODS

We searched the literature through March 2018 on the association between postpartum hormonal contraception use and incident postpartum depression. We used the United States Preventive Services Task Force framework to assess study quality.

RESULTS

Of 167 articles identified, four met inclusion criteria. Two studies found no differences in rates of postpartum depression between women using postpartum depot medroxyprogesterone and those not using hormonal contraception; however, a study of women receiving injectable norethisterone enanthate immediately postpartum found a 2-3-fold increased risk of depression at 6 weeks, though not at 3 months. One study compared combined hormonal contraception, progestin-only pills (POPs), etonogestrel implants and levonorgestrel intrauterine devices (LNG-IUDs) with no hormonal contraception, and found a 35-44% decreased risk of postpartum depression with POPs and LNG-IUDs, a small increased risk of postpartum antidepressant use among women using the etonogestrel implant and vaginal ring, and a decreased risk of antidepressant use with POPs.

CONCLUSIONS

Limited evidence found no consistent associations between hormonal contraceptive use and incidence of postpartum depression. Future research would be strengthened by using validated diagnostic measures, careful consideration of confounders, and ensuring adequate follow-up time.

Resumption of sexual intercourse post partum and the utilisation of contraceptive methods in China: a cross-sectional study

OBJECTIVE

This is a cross-sectional study that aimed to examine the resumption of sexual intercourse post partum, the utilisation of contraceptive methods and the influencing factors among Chinese women at a tertiary teaching hospital.

DESIGN

This is a questionnaire survey by written and online interview for participants.

PARTICIPANTS

Based on medical records, we sent online questionnaires about postpartum sexual intercourse and contraception plans to 550 eligible women.

MAIN OUTCOME MEASURES

Potential factors affecting postpartum sexual intercourse and utilisation of contraception were determined by analysis of epidemiological and clinical factors and sexual experiences during and after pregnancy.

RESULTS

Of 550 eligible participants, 406 women (73.8%) with a postpartum period of 8.5 months (range 6-10) completed the questionnaires; 146 of 406 (36.0%) resumed sexual intercourse within 3 months, and 259 of 279 (92.8%) used contraceptive methods. In univariate and multivariate analyses, sexual intercourse during pregnancy (adjusted OR 4.4, 95% CI 2.8 to 6.9) and resumption of menstruation (adjusted OR 2.5, 95% CI 1.5 to 4.3) were significant influencing factors in resumption of sexual intercourse within 3 months after childbirth. No factor was found to be associated with using contraceptive methods or the general resumption of sexual intercourse post partum. The questionnaire had good reliability and validity.

CONCLUSIONS

Having sexual intercourse during pregnancy and resuming menstruation earlier were independent factors for resumption of sexual intercourse within 3 months after delivery. Almost all women who had postpartum sexual intercourse used various contraceptive methods.

Prevention of Prematurity: Advances and Opportunities

Preterm birth (PTB) rate varies widely and has significant racial and ethnic disparities. Although causal mechanisms are ill understood, socioenvironment, phenotype, and genotype provide insight into pathways for preventing PTB. Data suggest varied response to current medical interventions is explicable Approved by underlying pharmacogenomics. Currently, prevention focuses on minimizing iatrogenic PTB and risk reduction especially in those with prior PTB using proven medical and public health strategies. In the future, preventive approaches will be based on better understanding of sociodemography, nutrition, lifestyles, and underlying individual genetic and epigenetic variation. Statistical approaches and "big-data" models are critical in future study.

[Health effects of breastfeeding on the mother]

We evaluated the effect of breastfeeding on maternal health outcomes. We distinguished between long-term effects (breast carcinoma, ovarian carcinoma, endometrial carcinoma, osteoporosis, and type 2 diabetes mellitus) and short-term effects (lactational amenorrhea, postpartum depression, and postpartum weight change).Predominant breastfeeding increases the duration of lactational amenorrhea, which has a short-term effect on the reduction of fertility. There are many studies that show that breastfeeding is protective against breast, ovarian carcinoma, and endometrial carcinoma. The effects depend on the duration of breastfeeding. There is evidence that breastfeeding reduces the risk of type 2 diabetes and metabolic syndrome and cardiac diseases. However, an association between breastfeeding and bone mineral density or maternal depression or postpartum weight change was not clearly evident.