In Low- And Middle-Income Countries, Is Delivery In High-Quality Obstetric Facilities Geographically Feasible?

Impact of disrespectful maternity care on childbirth complications: a multicentre cross-sectional study in Ethiopia

BACKGROUND

Globally, disrespectful, and abusive childbirth practices negatively impact women's health, create barriers to accessing health facilities, and contribute to poor birth experiences and adverse outcomes for both mothers and newborns. However, the degree to which disrespectful maternity care is associated with complications during childbirth is poorly understood, particularly in Ethiopia.

AIM

To determine the extent to which disrespectful maternity care is associated with maternal and neonatal-related complications in central Ethiopia.

METHODS

A multicentre cross-sectional study was conducted in the West Shewa Zone of Oromia, Ethiopia. The sample size was determined using the single population proportion formula. Participants (n = 440) were selected with a simple random sampling technique using computer-generated random numbers. Data were collected through face-to-face interviews with a pretested questionnaire and were entered into Epidata and subsequently exported to STATA version 17 for the final analysis. Analyses included descriptive statistics and binary logistic regression, with a 95% confidence interval (CI) and an odds ratio (OR) of 0.05. Co-founders were controlled by adjusting for maternal sociodemographic characteristics. The primary exposure was disrespectful maternity care; the main outcomes were maternal and neonatal-related complications.

RESULTS

Disrespectful maternity care was reported by 344 women (78.2%) [95% CI: 74-82]. Complications were recorded in one-third of mothers (33.4%) and neonates (30%). Disrespectful maternity care was significantly associated with maternal (AOR = 2.22, 95% CI: 1.29, 3.8) and neonatal-related complications (AOR = 2.78, 95% CI: 1.54, 5.04).

CONCLUSION

The World Health Organization advocates respectful maternal care during facility-based childbirth to improve the quality of care and outcomes. However, the findings of this study indicated high mistreatment and abuse during childbirth in central Ethiopia and a significant association between such mistreatment and the occurrence of both maternal and neonatal complications during childbirth. Therefore, healthcare professionals ought to prioritise respectful maternity care to achieve improved birth outcomes and alleviate mistreatment and abuse within the healthcare sector.

Evaluation of an obstetric and neonatal care upskilling program for community health workers in Papua New Guinea

BACKGROUND

60% of women in Papua New Guinea (PNG) give birth unsupervised and outside of a health facility, contributing to high national maternal and perinatal mortality rates. We evaluated a practical, hospital-based on-the-job training program implemented by local health authorities in PNG between 2013 and 2019 aimed at addressing this challenge by upskilling community health workers (CHWs) to provide quality maternal and newborn care in rural health facilities.

METHODS

Two provinces, the Eastern Highlands and Simbu Provinces, were included in the study. In the Eastern Highlands Province, a baseline and end point skills assessment and post-training interviews 12 months after completion of the 2018 training were used to evaluate impacts on CHW knowledge, skills, and self-reported satisfaction with training. Quality and timeliness of referrals was assessed through data from the Eastern Highlands Province referral hospital registers. In Simbu Province, impacts of training on facility births, stillbirths and referrals were evaluated pre- and post-training retrospectively using routine health facility reporting data from 2012 to 2019, and negative binomial regression analysis adjusted for potential confounders and correlation of outcomes within facilities.

RESULTS

The average knowledge score increased significantly, from 69.8% (95% CI:66.3-73.2%) at baseline, to 87.8% (95% CI:82.9-92.6%) following training for the 8 CHWs participating in Eastern Highlands Province training. CHWs reported increased confidence in their skills and ability to use referral networks. There were significant increases in referrals to the Eastern Highlands provincial hospital arriving in the second stage of labour but no significant difference in the 5 min Apgar score for children, pre and post training. Data on 11,345 births in participating facilities in Simbu Province showed that the number of births in participating rural health facilities more than doubled compared to prior to training, with the impact increasing over time after training (0-12 months after training: IRR 1.59, 95% CI: 1.04-2.44, p-value 0.033, > 12 months after training: IRR 2.46, 95% CI:1.37-4.41, p-value 0.003). There was no significant change in stillbirth or referral rates.

CONCLUSIONS

Our findings showed positive impacts of the upskilling program on CHW knowledge and practice of participants, facility births rates, and appropriateness of referrals, demonstrating its promise as a feasible intervention to improve uptake of maternal and newborn care services in rural and remote, low-resource settings within the resourcing available to local authorities. Larger-scale evaluations of a size adequately powered to ascertain impact of the intervention on stillbirth rates are warranted.

Midwife-led birthing centres in Bangladesh, Pakistan and Uganda: an economic evaluation of case study sites

INTRODUCTION

Achieving the Sustainable Development Goals to reduce maternal and neonatal mortality rates will require the expansion and strengthening of quality maternal health services. Midwife-led birth centres (MLBCs) are an alternative to hospital-based care for low-risk pregnancies where the lead professional at the time of birth is a trained midwife. These have been used in many countries to improve birth outcomes.

METHODS

The cost analysis used primary data collection from four MLBCs in Bangladesh, Pakistan and Uganda (n=12 MLBC sites). Modelled cost-effectiveness analysis was conducted to compare the incremental cost-effectiveness ratio (ICER), measured as incremental cost per disability-adjusted life-year (DALY) averted, of MLBCs to standard care in each country. Results were presented in 2022 US dollars.

RESULTS

Cost per birth in MLBCs varied greatly within and between countries, from US$21 per birth at site 3, Bangladesh to US$2374 at site 2, Uganda. Midwife salary and facility operation costs were the primary drivers of costs in most MLBCs. Six of the 12 MLBCs produced better health outcomes at a lower cost (dominated) compared with standard care; and three produced better health outcomes at a higher cost compared with standard care, with ICERs ranging from US$571/DALY averted to US$55 942/DALY averted.

CONCLUSION

MLBCs appear to be able to produce better health outcomes at lower cost or be highly cost-effective compared with standard care. Costs do vary across sites and settings, and so further exploration of costs and cost-effectiveness as a part of implementation and establishment activities should be a priority.

The effect of "typical case discussion and scenario simulation" on the critical thinking of midwifery students: Evidence from China

BACKGROUND

Assessment ability lies at the core of midwives' capacity to judge and treat clinical problems effectively. Influenced by the traditional teaching method of "teacher-led and content-based", that teachers involve imparting a large amount of knowledge to students and students lack active thinking and active practice, the clinical assessment ability of midwifery students in China is mostly at a medium or low level. Improving clinical assessment ability of midwifery students, especially critical thinking, is highly important in practical midwifery education. Therefore, we implemented a new teaching program, "typical case discussion and scenario simulation", in the Midwifery Health Assessment course. Guided by typical cases, students were organized to actively participate in typical case discussions and to promote active thinking and were encouraged to practice actively through scenario simulation. In this study, we aimed to evaluate the effect of this strategy on the critical thinking ability of midwifery students.

METHOD

A total of 104 midwifery students in grades 16-19 at the West China School of Nursing, Sichuan University, were included as participants through convenience sampling. All the students completed the Midwifery Health Assessment course in the third year of university. Students in grades 16 and 17 were assigned to the control group, which received routine teaching in the Midwifery Health Assessment, while students in grades 18 and 19 were assigned to the experimental group, for which the "typical case discussion and scenario simulation" teaching mode was employed. The Critical Thinking Disposition Inventory-Chinese Version (CTDI-CV) and Midwifery Health Assessment Course Satisfaction Questionnaire were administered after the intervention.

RESULTS

After the intervention, the critical thinking ability of the experimental group was greater than that of the control group (284.81 ± 27.98 and 300.94 ± 31.67, p = 0.008). Furthermore, the experimental group exhibited higher scores on the four dimensions of Open-Mindedness (40.56 ± 5.60 and 43.59 ± 4.90, p = 0.005), Analyticity (42.83 ± 5.17 and 45.42 ± 5.72, p = 0.020), Systematicity (38.79 ± 4.70 and 41.88 ± 6.11, p = 0.006), and Critical Thinking Self-Confidence (41.35 ± 5.92 and 43.83 ± 5.89, p = 0.039) than did the control group. The course satisfaction exhibited by the experimental group was greater than that exhibited by the control group (84.81 ± 8.49 and 90.19 ± 8.41, p = 0.002).

CONCLUSION

The "typical case discussion and scenario simulation" class mode can improve the critical thinking ability of midwifery students and enhance their curriculum satisfaction. This approach carries a certain degree of promotional significance in medical education.

Respectful Maternal Care Experience in Low- and Middle-Income Countries: A Systematic Review

Background and Objectives: Respectful maternity care promotes practices that acknowledge women's preferences and women and newborns' needs. It is an individual-centered strategy founded on ethical and human rights principles. The objective of this systematic review is to identify the impact of income on maternal care and respectful maternity care in low- and middle-income countries. Materials and Methods: Data were searched from Google Scholar, PubMed, Web of Science, NCBI, CINAHL, National Library of Medicine, ResearchGate, MEDLINE, EMBASE database, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Maternity and Infant Care database. This review followed PRISMA guidelines. The initial search for publications comparing low- and middle-income countries with respectful maternity care yielded 6000 papers, from which 700 were selected. The review articles were further analyzed to ensure they were pertinent to the comparative impact of income on maternal care. A total of 24 articles were included, with preference given to those published from 2010 to 2023 during the last fourteen years. Results: Considering this study's findings, respectful maternity care is a crucial component of high-quality care and human rights. It can be estimated that there is a direct association between income and maternity care in LMICs, and maternity care is substandard compared to high-income countries. Moreover, it is determined that the evidence for medical tools that can enhance respectful maternity care is sparse. Conclusions: This review highlights the significance of improving maternal care experiences, emphasizing the importance of promoting respectful practices and addressing disparities in low- and middle-income countries.

Practice of non-institutional delivery and its associated factors among women who gave birth in Southern Ethiopia, 2022

BACKGROUND

Non-institutional delivery is one of the major reasons that results in high mortality rates for a mother and her neonate. The World Health Organization estimates that only 43% of mothers have access to skilled delivery services. A recent Ethiopian Mini Demographic Survey indicated that more than half of Ethiopian women have given birth non-institutionally. This shows that maternal health remains a major public health challenge in Ethiopia, irrespective of the government's measures for institutional delivery. So, the aim of this study was to assess the practice of non-institutional delivery and its associated factors among women who gave birth in the study area.

METHODS

A community-based cross-sectional study was carried out on 260 study participants from June 1 to July 1, 2022, in Boloso Bombe Woreda. Data collection was done using a structured questionnaire, and systematic sampling techniques were used to select the study subjects. The data was entered into the EPI data version 3.1 and analyzed using SPSS version 25. The adjusted odds ratio, along with 95% confidence intervals, was used, and the level of statistical significance was declared at a P-value of 0.05.

RESULT

Out of 260 women interviewed, 252 (97%) pregnant women participated in the interview. The prevalence of non-institutional delivery among study participants was 68.7% (95% CI: 63.1-72.9). Mothers who were a daily laborer [AOR = 6.6;95%CI(3.6(1.2-11.2), last pregnancy planned [AOR = 0.4; 95%CI (0.4(0.2-0.8)), an absence of antenatal care contacting history [AOR = 3.3; 95%CI (1.3-8.6)], respondents' knowledge on the labor complication [AOR = 3; (95%CI); 3.5(2.2-6.1)], and place of first delivery [AOR = 8.7 95%CI(3.2-23)] were factors that significantly associated with practice of non-institutional delivery.

CONCLUSION

This study indicated that the majority of study participants practiced non-institutional delivery in this study area. Thus, we strongly recommend that all responsible bodies take immediate action, such as community health education on pregnancy-related complications, encouraging ANC visits, and raising awareness of the advantages of preventing non-institutional delivery in order to reduce non-institutional pregnancy practices and improve the factors identified.

Practice of Non-Institutional Delivery and Its Associated Factors Among Women Who Gave Birth in Southern Ethiopia, 2022

Background

Since 2000, the Ethiopian ministries of health and other stakeholders have taken some measures to enhance institutional delivery. However, the Ethiopian Demographic Health Survey 2019 report indicated that more than 50% of Ethiopian reproductive-age women gave birth outside health facilities. Therefore, the purpose of this study was to assess the practice of noninstitutional delivery among women who gave birth at Boloso Bombe Woreda (district) in southern Ethiopia.

Methods

A community-based cross-sectional study was carried out on 252 study participants from June to July 2022 in Boloso Bombe Woreda. Data collection was done using a structured questionnaire and systematic sampling techniques were used to select the study subjects. Data were entered into the EPI data, version 3.1, and analyzed using SPSS, version 25. Adjusted odds ratios (AORs), along with 95% confidence intervals (CIs), were used and the level of statistical significance was declared at a p-value of 0.05.

Results

In this study, 252 participants completed the survey, with a 97% response rate. The prevalence of noninstitutional delivery among study participants was 68.7% (95% CI: 63.1-72.9). In this study, mother's occupation, such as working as a daily laborer (AOR = 3.6; 95% CI [1.2-11.2]); absence of antenatal care history (AOR = 3.3; 95% CI [1.3-8.6]); poor knowledge of labor complications (AOR = 3.5; 95% CI [2.2-6.1]); and place of first delivery (AOR = 8.7; 95% CI [3.2-23]) were factors that were positively and significantly associated with the practice of noninstitutional delivery. However, last pregnancy planned was negatively associated with the practice of noninstitutional delivery (AOR = 0.4; 95% CI [0.2-0.8]).

Conclusions

This study indicated that the majority of study participants practiced noninstitutional delivery in this study area. Therefore, we strongly recommend that all responsible bodies should take immediate action to reduce the practice of noninstitutional delivery and improve those identified factors.

The effects of mHealth interventions on improving institutional delivery and uptake of postnatal care services in low-and lower-middle-income countries: a systematic review and meta-analysis

BACKGROUND

Maternal mortality due to pregnancy, childbirth and postpartum is a global challenge. Particularly, in low-and lower-income countries, the outcomes of these complications are quite substantial. In recent years, studies exploring the effect of mobile health on the improvement of maternal health are increasing. However, the effect of this intervention on the improvement of institutional delivery and postnatal care utilization was not well analyzed systematically, particularly in low and lower-middle-income countries.

OBJECTIVE

The main aim of this review was to assess the effect of mobile heath (mHealth) interventions on improving institutional delivery, postnatal care service uptake, knowledge of obstetric danger signs, and exclusive breastfeeding among women of low and lower-middle-income countries.

METHODS

Common electronic databases like PubMed, EMBASE, the Web of Science, Medline, CINAHL, Cochrane library, Google scholar, and gray literature search engines like Google were used to search relevant articles. Articles that used interventional study designs and were conducted in low and lower-middle-income countries were included. Sixteen articles were included in the final systematic review and meta-analysis. Cochrane's risk of bias tool was used to assess the quality of included articles.

RESULTS

The overall outcome of the systematic review and meta-analysis showed that MHealth intervention has a positive significant effect in improving the institutional delivery (OR = 2.21 (95%CI: 1.69-2.89), postnatal care utilization (OR = 4.13 (95%CI: 1.90-8.97), and exclusive breastfeeding (OR = 2.25, (95%CI: 1.46-3.46). The intervention has also shown a positive effect in increasing the knowledge of obstetric danger signs. The subgroup analysis based on the intervention characteristics showed that there was no significant difference between the intervention and control groups based on the intervention characteristics for institutional delivery (P = 0.18) and postnatal care utilizations (P = 0.73).

CONCLUSIONS

The study has found out that mHealth intervention has a significant effect on improving facility delivery, postnatal care utilization, rate of exclusive breastfeeding, and knowledge of danger signs. There were also findings that reported contrary to the overall outcome which necessitates conducting further studies to enhance the generalizability of the effect of mHealth interventions on these outcomes.

To what extent is antenatal care in public health facilities associated with delivery in public health facilities? Findings from a cross-section of women who had facility deliveries in Nigeria

BACKGROUND

Facility delivery remains an important public health issue in Nigeria. Studies have confirmed that antenatal care may improve the uptake of facility delivery. However, information is rarely available in Nigeria on the extent to which antenatal care in public health facilities is associated with delivery in public health facilities. The objective of the study was thus to examine the extent of the association between antenatal care in public health facilities and delivery in public health facilities in Nigeria. The study was guided by the Andersen behavioral model of health services use.

METHODS

The cross-sectional design was adopted. Data were extracted from the most recent Nigeria Demographic and Health Survey (NDHS). A sample of 9,015 women was analyzed. The outcome variable was the facility for delivery. The main explanatory variable was the antenatal care facility. The predisposing factors were maternal age, age at first birth, parity, exposure to mass media, and, religion. The enabling factors were household wealth, work status, partners' education, women's autonomy, health insurance, and, perception of distance to the health facility. The need factors were pregnancy wantedness, the number of antenatal care visits, and the timing of the first antenatal care. Statistical analyses were performed with the aid of Stata version 14. Two binary logistic regression models were fitted.

RESULTS

Findings showed that 69.6% of the women received antenatal care in public health facilities, while 91.6% of them subsequently utilized public health facilities for deliveries. The significant predisposing factors were age at first birth, parity, maternal education, and religion, while household wealth, work status, women's autonomy, and partners' education were the significant enabling factors. The timing of the first antenatal contact, pregnancy wantedness, and the number of antenatal care visits were the important need factors.

CONCLUSION

To a significant extent, antenatal care in public health facilities is associated with deliveries in public health facilities in Nigeria. It is imperative for governments in the country to take more steps to ensure the expanded availability of public health facilities in all parts of the country since their use for antenatal care is well-associated with their use for delivery care.

Intra-regional variations and contextual effects on facility-based delivery in Bangladesh: A multi-level analysis

We examined intra-regional variations and contextual influences on institutional delivery of women using the nationally representative 2014 Bangladesh Demographic and Health Survey data. Due to the hierarchical structure of the data, we employed multi-level logistic regression analysis. Of the women who had had a live birth in the last three years preceding the survey, only 38% availed the opportunity of institutional delivery. From the findings of this study, we observed that women of the Eastern region were less likely and those of the Western region were more likely to use FBD compared to the women of the Central region. Both individual- and community-level factors influence women to use facility-based delivery. Community-level programs aimed at improving availability and easy accessibility to economically deprived and geographically disadvantaged areas may increase safe motherhood practices among women.

A global study of the association of cesarean rate and the role of socioeconomic status in neonatal mortality rate in the current century

Introduction

Caesarean section (C/S) rates have significantly increased across the world over the past decades. In the present population-based study, we sought to evaluate the association between C/S and neonatal mortality rates.

Material and methods

This retrospective ecological study included longitudinal data of 166 countries from 2000 to 2015. We evaluated the association between C/S rates and neonatal mortality rate (NMR), adjusting for total fertility rate, human development index (HDI), gross domestic product (GDP) percentage, and maternal age at first childbearing. The examinations were also performed considering different geographical regions as well as regions with different income levels.

Results

The C/S rate and NMR in the 166 included countries were 19.97% ± 10.56% and 10 ± 10.27 per 1000 live birth, respectively. After adjustment for confounding variables, C/S rate and NMR were found correlated (r = -1.1, p < 0.001). Examination of the relationship between C/S rate and NMR in each WHO region resulted in an inverse correlation in Africa (r = -0.75, p = 0.005), Europe (r = -0.12, p < 0.001), South-East Asia (r = -0.41, p = 0.01), and Western Pacific (r = -0.13, p = 0.02), a direct correlation in America (r = 0.06, p = 0.04), and no correlation in Eastern Mediterranean (r = 0.01, p = 0.88). Meanwhile, C/S rate and NMR were inversely associated in regions with upper-middle (r = -0.15, p < 0.001) and lower-middle (r = -0.24, p < 0.001) income levels, directly associated in high-income regions (r = 0.02, p = 0.001), and not associated in low-income regions (p = 0.13). In countries with HDI below the centralized value of 1 (the real value of 0.9), the correlation between C/S rate and NMR was negative while it was found positive in countries with HDI higher than the mentioned cut-off.

Conclusions

This study indicated that NMR associated with C/S is dependent on various socioeconomic factors such as total fertility rate, HDI, GDP percentage, and maternal age at first childbearing. Further attentions to the socioeconomic status are warranted to minimize the NMR by modifying the C/S rate to the optimum cut-off.

Determinants and Trends of Health Facility Delivery in Bangladesh: A Hierarchical Modeling Approach

Background

Most maternal deaths occur during childbirth and after childbirth. This study was aimed at determining the trends of health facilities during delivery in Bangladesh, as well as their influencing factors.

Methods

This study used secondary data from three Bangladesh Multiple Indicator Cluster Surveys (MICSs) in 2006, 2012–13, and 2019. The study's target sample was those women who gave birth in the last two years of the survey. A two-level logistic regression was applied to determine the effects on health facility delivery separately in these two survey points (MICSs 2012–13 and 2019).

Results

The results show that the delivery of health facilities has increased by almost 37.4% in Bangladesh, from 16% in 2006 to 53.4% in 2019. The results of two-level logistic regression show that the total variation in health facility delivery across the community has decreased over recent years. After adding community variables, various individual-level factors such as women with secondary education (OR = 0.55 in 2012-13 vs. OR =0.60 in 2019), women from middle wealth status (OR = 0.49 in 2012-13 vs. OR = 0.65 in 2019), religion, and child ever born showed a strong relationship with health facility delivery in both survey years. At the community level, residents showed significant association only in the 2012-13 survey and indicated a 43% (OR = 1.43 for 2012-13) greater availability of health facilities in urban residences than in rural residences. Using media showed a highly significant connection with health facility delivery in both years as well as an increasing trend over the years in Bangladesh (OR = 1.19 in 2012-13 vs. OR = 1.38 in 2019). However, division, prenatal care, and skilled services all contribute greatly to increasing the delivery of health facilities in Bangladesh.

Conclusions

The results of this study suggest that policymakers need to pay attention to individual and community-level factors, especially women's education, poverty reduction, and adequate prenatal care provided by well-trained caregivers.

Geospatial mapping of timely access to inpatient neonatal care and its relationship to neonatal mortality in Kenya

Globally, 2.4 million newborns die in the first month of life, with neonatal mortality rates (NMR) per 1,000 livebirths being highest in sub-Saharan Africa. Improving access to inpatient newborn care is necessary for reduction of neonatal deaths in the region. We explore the relationship between distance to inpatient hospital newborn care and neonatal mortality in Kenya. Data on service availability from numerous sources were used to map hospitals that care for newborns with very low birth weight (VLBW). Estimates of livebirths needing VLBW services were mapped from population census data at 100 m spatial resolution using a random forest algorithm and adjustments using a systematic review of livebirths needing these services. A cost distance algorithm that adjusted for proximity to roads, road speeds, land use and protected areas was used to define geographic access to hospitals offering VLBW services. County-level access metrics were then regressed against estimates of NMR to assess the contribution of geographic access to VLBW services on newborn deaths while controlling for wealth, maternal education and health workforce. 228 VLBW hospitals were mapped, with 29,729 births predicted as requiring VLBW services in 2019. Approximately 80.3% of these births were within 2 hours of the nearest VLBW hospital. Geographic access to these hospitals, ranged from less than 30% in Wajir and Turkana to as high as 80% in six counties. Regression analysis showed that a one percent increase in population within 2 hours of a VLBW hospital was associated with a reduction of NMR by 0.24. Despite access in the country being above the 80% threshold, 17/47 counties do not achieve this benchmark. To reduce inequities in NMR in Kenya, policies to improve care must reduce geographic barriers to access and progressively improve facilities' capacity to provide quality care for VLBW newborns.

Developing guideline-based key performance indicators for recurrent miscarriage care: lessons from a multi-stage consensus process with a diverse stakeholder group

BACKGROUND

Standardised care pathways tailored to women/couples who experience recurrent miscarriage are needed; however, clinical practice is inconsistent and poorly organised. In this paper, we outline our processes and experiences of developing guideline-based key performance indicators (KPIs) for recurrent miscarriage care with a diverse stakeholder group which will be used to evaluate national services. To date, such exercises have generally only involved clinicians, with the need for greater stakeholder involvement highlighted.

METHODS

Our study involved six stages: (i) identification and synthesis of recommendations for recurrent miscarriage care through a systematic review of clinical practice guidelines; (ii) a two-round modified e-Delphi survey with stakeholders to develop consensus on recommendations and outcomes; (iii) four virtual meetings to develop this consensus further; (iv) development of a list of candidate KPIs; (v) survey to achieve consensus on the final suite of KPIs and a (vi) virtual meeting to agree on the final set of KPIs. Through participatory methods, participants provided feedback on the process of KPI development.

RESULTS

From an initial list of 373 recommendations and 14 outcomes, 110 indicators were prioritised for inclusion in the final suite of KPIs: (i) structure of care (n = 20); (ii) counselling and supportive care (n = 7); (iii) investigations (n = 30); treatment (n = 34); outcomes (n = 19). Participants' feedback on the process comprised three main themes: accessibility, richness in diversity, streamlining the development process.

CONCLUSIONS

It is important and feasible to develop guideline-based KPIs with a diverse stakeholder group. One hundred and ten KPIs were prioritised for inclusion in a suite of guideline-based KPIs for recurrent miscarriage care. Insights into our experiences may help others undertaking similar projects, particularly those undertaken in the absence of a clinical guideline and/or involving a range of stakeholders.

Travel of pregnant women in emergency situations to hospital and maternal mortality in Lagos, Nigeria: a retrospective cohort study

Introduction

Prompt access to emergency obstetrical care (EmOC) reduces the risk of maternal mortality. We assessed institutional maternal mortality by distance and travel time for pregnant women with obstetrical emergencies in Lagos State, Nigeria.

Methods

We conducted a facility-based retrospective cohort study across 24 public hospitals in Lagos. Reviewing case notes of the pregnant women presenting between 1 November 2018 and 30 October 2019, we extracted socio-demographic, travel and obstetrical data. The extracted travel data were exported to Google Maps, where driving distance and travel time data were extracted. Multivariable logistic regression was conducted to determine the relative influence of distance and travel time on maternal death.

Findings

Of 4181 pregnant women with obstetrical emergencies, 182 (4.4%) resulted in maternal deaths. Among those who died, 60.3% travelled ≤10 km directly from home, and 61.9% arrived at the hospital ≤30 mins. The median distance and travel time to EmOC was 7.6 km (IQR 3.4–18.0) and 26 mins (IQR 12–50). For all women, travelling 10–15 km (2.53, 95% CI 1.27 to 5.03) was significantly associated with maternal death. Stratified by referral, odds remained statistically significant for those travelling 10–15 km in the non-referred group (2.48, 95% CI 1.18 to 5.23) and for travel ≥120 min (7.05, 95% CI 1.10 to 45.32). For those referred, odds became statistically significant at 25–35 km (21.40, 95% CI 1.24 to 36.72) and for journeys requiring travel time from as little as 10–29 min (184.23, 95% CI 5.14 to 608.51). Odds were also significantly higher for women travelling to hospitals in suburban (3.60, 95% CI 1.59 to 8.18) or rural (2.51, 95% CI 1.01 to 6.29) areas.

Conclusion

Our evidence shows that distance and travel time influence maternal mortality differently for referred women and those who are not. Larger scale research that uses closer-to-reality travel time and distance estimates as we have done, rethinking of global guidelines, and bold actions addressing access gaps, including within the suburbs, will be critical in reducing maternal mortality by 2030.

Hirschsprung's disease in low- and middle-income countries

Hirschsprung's disease (HD) is one of the most common causes of pediatric bowel obstruction in low- and middle-income countries (LMICs). This paper describes the unique aspects of presentation, diagnosis, management and post-operative care and outcomes of HD in LMICs. In LMICs, patients with HD are much more likely to present in a delayed fashion with subsequent increased morbidity and mortality including higher rates of chronic obstruction, malnutrition with failure to thrive, complete obstruction and perforation. There are multifactorial causes for delay, with opportunities to improve initial timely diagnosis and referral, support families to address socioeconomic and cultural barriers, and improve workforce and infrastructure resources to provide definitive care. In LMICs, the diagnosis is often made based on clinical presentation and radiographic findings as pathological services may be limited. Initial diversion with multi-stage procedure, instead of a single-stage pull-through, predominates. This is also a result of multifactorial causes, including initial presentation to general surgeons at first-level hospitals instead of pediatric surgeons, delayed presentation with sick, malnourished children with significantly distended bowel, and a lack of fresh-frozen pathological services to guide the extent of resection. Post-operatively, HD patients in LMICs experience higher complication and mortality rates - likely stemming from sicker baseline presentations and more limited resources. Significant recent advances in care have occurred for patients with HD in LMICs, while opportunities to continue to improve care remain.

Effect of emergency obstetric care and proximity to comprehensive facilities on facility-based delivery in Malawi and Haiti

Proximity of households to comprehensive obstetric care is a key determinant for preventing maternal mortality due to obstetric emergencies. The relationship between proximity to comprehensive care and facility delivery is further complicated by the use of varied methods in measuring facility obstetric capacity-which may misrepresent the real scenario of obstetric care availability in a service environment. We investigated the joint effects of proximity and two emergency obstetric care assessment (EmOC) methods on women's place of delivery in Malawi and Haiti. Household level and health facility data were obtained from the 2013-2018 Demographic and Health Surveys and Service Provision Assessment surveys. Records of women aged 15 to 49 years who had a childbirth in the last 5 years were linked to obstetric facilities within 5km, 10km and 15km from their households using Kernel Density Estimation. Log-binomial models were fitted to estimate the joint effects of proximity to comprehensive facilities on place of delivery and two EmOC methods (1. the facility's recent performance of signal functions only, and 2. a composite index of obstetric care), and whether this varied by urban/rural setting. Proximity to comprehensive facilities was significantly associated with facility delivery in Malawi among women living 5km of a comprehensive facility (using EmOC method 2), in addition, living further (15km) from facilities with high capacity of EmOC was associated with reduced likelihood for facility delivery in urban settings in stratified analyses. In contrast, positive associations were present in Haiti in both urban and rural settings, with the likelihood of facility delivery being higher with greater proximity of women to comprehensive facilities, regardless of methods to define EmOC. Women living within 5km of a comprehensive facility in Haiti were the most likely to deliver in facilities based on EmOC method 1 (APR: 1.81, 95% CI 1.56, 2.09). Findings from Malawi elucidates the relevance of context and suggests the need for research in diverse settings.

Respiratory distress syndrome management in resource limited settings-Current evidence and opportunities in 2022

The complications of prematurity are the leading cause of neonatal mortality worldwide, with the highest burden in the low- and middle-income countries of South Asia and Sub-Saharan Africa. A major driver of this prematurity-related neonatal mortality is respiratory distress syndrome due to immature lungs and surfactant deficiency. The World Health Organization's Every Newborn Action Plan target is for 80% of districts to have resources available to care for small and sick newborns, including premature infants with respiratory distress syndrome. Evidence-based interventions for respiratory distress syndrome management exist for the peripartum, delivery and neonatal intensive care period- however, cost, resources, and infrastructure limit their availability in low- and middle-income countries. Existing research and implementation gaps include the safe use of antenatal corticosteroid in non-tertiary settings, establishing emergency transportation services from low to high level care facilities, optimized delivery room resuscitation, provision of affordable caffeine and surfactant as well as implementing non-traditional methods of surfactant administration. There is also a need to optimize affordable continuous positive airway pressure devices able to blend oxygen, provide humidity and deliver reliable pressure. If the high prematurity-related neonatal mortality experienced in low- and middle-income countries is to be mitigated, a concerted effort by researchers, implementers and policy developers is required to address these key modalities.

Universal coverage of the first antenatal care visit but poor continuity of care across the maternal and newborn health continuum among Nepalese women: analysis of levels and correlates

Background

Routine maternity care visits (MCVs) such as antenatal care (ANC), institutional delivery, and postnatal care (PNC) visits are crucial to utilisation of maternal and newborn health (MNH) interventions during pregnancy-postnatal period. In Nepal, however, not all women complete these routine MCVs. Therefore, this study examined the levels and correlates of (dis)continuity of MCVs across the antenatal-postnatal period.

Methods

We conducted further analysis of the 2016 Nepal Demographic and Health Survey. A total of 1,978 women aged 15–49 years, who had live birth two years preceding the survey, were included in the analysis. The outcome variable was (dis)continuity of routine MCVs (at least four ANC visits, institutional delivery, and PNC visit) across the pathway of antennal through to postnatal period. Independent variables included several social determinants of health under structural, intermediary, and health system domains. Multinomial logistic regression was conducted to identify the correlates of routine MCVs. Relative risk ratios (RR) were reported with 95% confidence intervals at a significance level of p<0.05.

Results

Approximately 41% of women completed all routine MCVs with a high proportion of discontinuation around childbirth. Women of disadvantaged ethnicities, from low wealth status, who were illiterate had higher RR of discontinuation of MCVs (compared to completion of all MCVs). Similarly, women who speak Bhojpuri, from remote provinces (Karnali and Sudurpaschim), who had a high birth order (≥4), who were involved in the agricultural sector, and who had unwanted last birth had a higher RR of discontinuation of MCVs. Women discontinued routine MCVs if they had poor awareness of health mother-groups and perceived the problem of not having female providers.

Conclusions

Routine monitoring using composite coverage indicators is required to track the levels of (dis)continuity of routine MCVs at the maternity care continuum. Strategies such as raising awareness on the importance of maternity care, care provision from female health workers could potentially improve the completion of MCVs. In addition, policy and programmes for continuity of maternity care are needed to focus on women with socioeconomic and ethnic disadvantages and from remote provinces.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00791-4.

Mapping the quality of basic and comprehensive emergency obstetric care services in Haiti

OBJECTIVE

To investigate geographical inequalities and changes in the quality of emergency obstetric care services available in Haiti over time.

METHODS

We utilized data from the Service Provision Assessment survey of all health facilities in Haiti in 2013 and 2017.We developed a quality index for basic emergency obstetric care (BEmOC) and comprehensive emergency obstetric care (CEmOC) based on the items in the signal functions of an emergency obstetric care framework, using a structure, process and outcome framework. We measured the quality index of all facilities in 2013 and 2017. We also assessed geographical trends and changes in quality between 2013 and 2017 using geospatial analysis.

RESULT

Our analysis showed that basic structure items such as connection to electricity grid, manual vacuum extractors, vacuum aspirators and dilation and curettage kits were widely unavailable at healthcare facilities. There was a significant improvement in indicators of structure (P < 0.001) and BEmOC (P = 0.03) in primary facilities; however, there was no significant change in the quality of CEmOC in primary facilities (P = 0.18). Similarly, there was no significant change in any of the structure or process indicators at secondary care facilities.

CONCLUSION

The availability of BEmOC at several Haitian facilities remains poor; however, there was significant improvement at primary care facilities, with little to no change in overall quality at secondary health facilities.

Global stakeholder perspectives of home birth: a systematic scoping review

Home birth is experienced by people very differently worldwide. These experiences likely differ by the type of stakeholder involved (women, their support persons, birth attendants, policy-makers), the experience itself (low-risk birth, transfer to hospital, previous deliveries), and by the health system within which home birth occurs (e.g., high-resource versus low- and middle-resource countries). Research evidence of stakeholders' perspectives of home birth could usefully inform personal and policy decisions about choosing and providing home birth, but the current literature is fragmented and its breadth is not fully understood.We conducted a systematic scoping review to understand how the research literature on stakeholders' perspectives of home birth is characterized in terms of populations, settings and identified issues, and what potential gaps exist in the research evidence. A range of electronic, web-based and key informant sources of evidence were searched. Located references were assessed, data extracted, and descriptively analyzed using robust methods.Our analysis included 460 full reports. Findings from 210 reports of studies in high-resource countries suggested that research with fathers and same-sex partners, midwives, and vulnerable populations and perspectives of freebirth and transfer to hospital could be synthesized. Gaps in primary research exist with respect to family members, policy makers, and those living in rural and remote locations. A further 250 reports of studies in low- and middle-resource countries suggested evidence for syntheses related to fathers and other family members, policy makers, and other health care providers and examination of issues related to emergency transfer to hospital, rural and remote home birth, and those who birth out of hospital, often at home, despite receiving antenatal care intended to increase healthcare-seeking behavior. Gaps in primary research suggest an examination is needed of perspectives in countries with higher maternal mortality and among first-time mothers and young mothers.Our scoping review identified a considerable body of research evidence on stakeholder perspectives of home birth. These could inform the complex factors influencing personal decisions and health system planning around home birth in both high- and low- and middle-resource countries. Future primary research is warranted on specific stakeholders worldwide and with vulnerable populations in areas of high maternal mortality.

Patterns, travel to care and factors influencing obstetric referral: Evidence from Nigeria's most urbanised state

The criticality of referral makes it imperative to study its patterns and factors influencing it at a health systems level. This study of referral in Lagos, Nigeria is based on health records of 4181 pregnant women who presented with obstetric emergencies at one of the 24 comprehensive emergency obstetric care (EmOC) facilities in the state between November 2018 and October 2019 complemented with distance and time data extracted from Google Maps. Univariate, bivariate, and multivariate analyses were conducted. About a quarter of pregnant women who presented with obstetric emergencies were referred. Most referrals were from primary health centres (41.9 %), private (23.5 %) and public (16.2 %) hospitals. Apart from the expected low-level to high-level referral pattern, there were other patterns observed including non-formal, multiple, and post-delivery referrals. Travel time and distance to facilities that could provide needed care increased two-fold on account of referrals compared to scenarios of going directly to the final facility, mostly travelling to these facilities by private cars/taxis (72.8 %). Prolonged/obstructed labour was the commonest obstetric indication for referral, with majority of referred pregnant women delivered via caesarean section (52.9 %). After adjustment, being married, not being registered for antenatal care at facility of care, presenting at night or with a foetus in distress increased the odds of referral. However, parity, presentation in the months following the commissioning of a new comprehensive EmOC facility or with abortion reduced the likelihood of being referred. Our findings underscore the need for health systems strengthening interventions that support women during referral and the importance of antenatal care and early booking to aid identification of potential pregnancy complications whilst establishing robust birth preparedness plans that can minimise the need for referral in the event of emergencies. Indeed, there are context-specific influences that need to be addressed if effective referral systems are to be designed.

An assessment of geographical access and factors influencing travel time to emergency obstetric care in the urban state of Lagos, Nigeria

Previous efforts to estimate the travel time to comprehensive emergency obstetric care (CEmOC) in low- and middle-income countries (LMICs) have either been based on spatial models or self-reported travel time, both with known inaccuracies. The study objectives were to estimate more realistic travel times for pregnant women in emergency situations using Google Maps, determine system-level factors that influence travel time and use these estimates to assess CEmOC geographical accessibility and coverage in Lagos state, Nigeria. Data on demographics, obstetric history and travel to CEmOC facilities of pregnant women with an obstetric emergency, who presented between 1st November 2018 and 31st December 2019 at a public CEmOC facility were collected from hospital records. Estimated travel times were individually extracted from Google Maps for the period of the day of travel. Bivariate and multivariate analyses were used to test associations between travel and health system-related factors with reaching the facility >60 minutes. Mean travel times were compared and geographical coverage mapped to identify ‘hotspots’ of predominantly >60 minutes travel to facilities. For the 4005 pregnant women with traceable journeys, travel time ranges were 2–240 minutes (without referral) and 7–320 minutes (with referral). Total travel time was within the 60 and 120 minute benchmark for 80 and 96% of women, respectively. The period of the day of travel and having been referred were significantly associated with travelling >60 minutes. Many pregnant women living in the central cities and remote towns typically travelled to CEmOC facilities around them. We identified four hotspots from which pregnant women travelled >60 minutes to facilities. Mean travel time and distance to reach tertiary referral hospitals were significantly higher than the secondary facilities. Our findings suggest that actions taken to address gaps need to be contextualized. Our approach provides a useful guide for stakeholders seeking to comprehensively explore geographical inequities in CEmOC access within urban/peri-urban LMIC settings.

Review of midwifery education in Uganda: Toward a framework for integrated learning and midwifery model of care

OBJECTIVE

To examine the current approach to midwifery education and deployment in Uganda against the backdrop of the evidence presented in the Lancet Series on Midwifery and the International Confederation of Midwives Global Standards for Midwifery Education. To make a distinction between 'Midwifery Model of Care' and training in maternal health nursing and highlight the need for midwifery education that is in alignment with international standards and reflexive to the realities of the Ugandan clinical context.

SETTING/PARTICIPANTS

A review of Ugandan nursing and midwifery education structure, curricula and current workforce configurations. A review of government reports and published literature regarding nursing and midwifery education.

FINDINGS

The pathways for nursing and midwifery education in Uganda are too numerous and without clear pathways for educational advancement. The scope of practice for new graduates is not realistic to the context midwives will practice in. Overall, nursing and midwifery education curricula does not prepare graduates to International Confederation of Midwives Standards and lacks training and mentorship in the 'Midwifery Model of Care' making graduates closer to 'maternity nurses' than midwives.

KEY CONCLUSIONS

The Ugandan midwifery education curricula and model needs to bring education standards into alignment with International Confederation of Midwives such that midwives are equipped to practice using the Quality Maternal Newborn Care Framework. Until this is accomplished maternal and newborn mortality rates will remain high, Uganda will continue to lose one of it's greatest resources, it's human capital, and the Sustainable Development Goal 3 will remain out of reach.

Measuring facility readiness to provide childbirth care: a comparison of indices using data from a health facility survey in Ethiopia

BACKGROUND

Actionable information about the readiness of health facilities is needed to inform quality improvement efforts in maternity care, but there is no consensus on the best approach to measure readiness. Many countries use the WHO's Service Availability and Readiness Assessment (SARA) or the Demographic and Health Survey (DHS) Programme's Service Provision Assessment to measure facility readiness. This study compares measures of childbirth service readiness based on SARA and DHS guidance to an index based on WHO's quality of maternal and newborn care standards.

METHODS

We used cross-sectional data from Performance Monitoring for Action Ethiopia's 2019 survey of 406 health facilities providing childbirth services. We calculated childbirth service readiness scores using items based on SARA, DHS and WHO standards. For each, we used three aggregation methods for generating indices: simple addition, domain-weighted addition and principal components analysis. We compared central tendency, spread and item variation between the readiness indices; concordance between health facility scores and rankings; and correlations between readiness scores and delivery volume.

RESULTS

Indices showed moderate agreement with one another, and all had a small but significant positive correlation with monthly delivery volume. Ties were more frequent for indices with fewer items. More than two-thirds of items in the relatively shorter SARA and DHS indices were widely (>90%) available in hospitals, and half of the SARA items were widely (>90%) available in health centres/clinics. Items based on the WHO standards showed greater variation and captured unique aspects of readiness (eg, quality improvement processes, actionable information systems) not included in either the SARA or DHS indices.

CONCLUSION

SARA and DHS indices rely on a small set of widely available items to assess facility readiness to provide childbirth care. Expanded selection of items based on the WHO standards can better differentiate between levels of service readiness.

Exploring women's decisions of where to give birth in the Peruvian Amazon; why do women continue to give birth at home? A qualitative study

Background

Despite improvements in maternal mortality globally, hundreds of women continue to die daily. The World Health Organisation therefore advises all women in low-and-middle income countries to give birth in healthcare facilities. Barriers to seeking intrapartum care have been described in Thaddeus and Maine’s Three Delays Model, however these decisions are complex and often unique to different settings. Loreto, a rural province in Peru has one of the highest homebirth rates in the country at 31.8%. The aim of this study was to explore facilitators and barriers to facility births and explore women’s experiences of intrapartum care in Amazonian Peru.

Methods

Through purposive sampling, postnatal women were recruited for semi-structured interviews (n = 25). Interviews were transcribed verbatim and thematically analysed. A combination of deductive and inductive coding was used. Analytical triangulation was undertaken, and data saturation was used to determine when no further interviews were necessary.

Results

Five themes were generated from the data: 1) Financial barriers; 2) Accessing care; 3) Fear of healthcare facilities; 4) Importance of seeking care and 5) Comfort and traditions of home. Generally, participants realised the importance of seeking skilled care however barriers persisted, across all areas of the Three Delays Model. Barriers identified included fear of healthcare facilities and interventions, direct and indirect costs, continuation of daily activities, distance and availability of transport. Women who delivered in healthcare facilities had mixed experiences, many reporting good attention, however a selection experienced poor treatment including abusive behaviour.

Conclusion

Despite free care, women continue to face barriers seeking obstetric care in Amazonian Peru, including fear of hospitals, cost and availability of transport. However, women accessing care do not always receive positive care experiences highlighting implications for changes in accessibility and provision of care. Minimising these barriers is critical to improve maternal and neonatal outcomes in rural Peru.

Critical comparative analysis of data sources toward understanding referral during pregnancy and childbirth: three perspectives from Nigeria

BACKGROUND

The highest risk of maternal and perinatal deaths occurs during and shortly after childbirth and is preventable if functional referral systems enable women to reach appropriate health services when obstetric complications occur. Rising numbers of deliveries in health facilities, including in high mortality settings like Nigeria, require formalised coordination across the health system to ensure that women and newborns get to the right level of care, at the right time. This study describes and critically assesses the extent to which referral and its components can be captured using three different data sources from Nigeria, examining issues of data quality, validity, and usefulness for improving and monitoring obstetric care systems.

METHODS

The study included three data sources on referral for childbirth care in Nigeria: a nationally representative household survey, patient records from multiple facilities in a state, and patient records from the apex referral facility in a city. We conducted descriptive analyses of the extent to which referral status and components were captured across the three sources. We also iteratively developed a visual conceptual framework to guide our critical comparative analysis.

RESULTS

We found large differences in the proportion of women referred, and this reflected the different denominators and timings of the referral in each data source. Between 16 and 34% of referrals in the three sources originated in government hospitals, and lateral referrals (origin and destination facility of the same level) were observed in all three data sources. We found large gaps in the coverage of key components of referral as well as data gaps where this information was not routinely captured in facility-based sources.

CONCLUSIONS

Our analyses illustrated different perspectives from the national- to facility-level in the capture of the extent and components of obstetric referral. By triangulating across multiple data sources, we revealed the strengths and gaps within each approach in building a more complete picture of obstetric referral. We see our visual framework as assisting further research efforts to ensure all referral pathways are captured in order to better monitor and improve referral systems for women and newborns.

A retrospective study of the impact of health worker strikes on maternal and child health care utilization in western Kenya

BACKGROUND

There have been dozens of strikes by health workers in Kenya in the past decade, but there are few studies of their impact on maternal and child health services and outcomes. We conducted a retrospective survey study to assess the impact of nationwide strikes by health workers in 2017 on utilization of maternal and child health services in western Kenya.

METHODS

We utilized a parent study to enroll women who were pregnant in 2017 when there were prolonged strikes by health workers ("strike group") and women who were pregnant in 2018 when there were no major strikes ("control group"). Trained research assistants administered a close-ended survey to retrospectively collect demographic and pregnancy-related health utilization and outcomes data. Data were collected between March and July 2019. The primary outcomes of interest were antenatal care (ANC) visits, delivery location, and early child immunizations. Generalized estimating equations were used to estimate risk ratios between the strike and control groups, adjusting for socioeconomic status, health insurance status, and clustering. Adjusted risk ratios (ARR) were calculated with 95% confidence intervals (95%CI).

RESULTS

Of 1341 women recruited in the parent study in 2017 (strike group), we re-consented 843 women (63%) to participate. Of 924 women recruited in the control arm of the parent study in 2018 (control group), we re-consented 728 women (79%). Women in the strike group were 17% less likely to attend at least four ANC visits during their pregnancy (ARR 0.83, 95%CI 0.74, 0.94) and 16% less likely to deliver in a health facility (ARR 0.84, 95%CI 0.76, 0.92) compared to women in the control group. Whether a child received their first oral polio vaccine did not differ significantly between groups, but children of women in the strike group received their vaccine significantly longer after birth (13 days versus 7 days, p = 0.002).

CONCLUSION

We found that women who were pregnant during nationwide strikes by health workers in 2017 were less likely to receive WHO-recommended maternal child health services. Strategies to maintain these services during strikes are urgently needed.

The effect of distance on maternal institutional delivery choice: Evidence from Malawi

In many low- and middle-income countries, geographical accessibility continues to be a barrier to health care utilization. In this paper, we aim to better understand the full relationship between distance to providers and utilization of maternal delivery services. We address three methodological challenges: non-linear effects between distance and utilization; unobserved heterogeneity through non-random distance "assignment"; and heterogeneous effects of distance. Linking Malawi Demographic Health Survey household data to Service Provision Assessment facility data, we consider distance as a continuous treatment variable, estimating a Dose-Response Function based on generalized propensity scores, allowing exploration of non-linearities in the effect of an increment in distance at different distance exposures. Using an instrumental variables approach, we examine the potential for unobserved differences between women residing at different distances to health facilities. Our results suggest distance significantly reduces the probability of having a facility delivery, with evidence of non-linearities in the effect. The negative relationship is shown to be particularly strong for women with poor health knowledge and lower socio-economic status, with important implications for equity. We also find evidence of potential unobserved confounding, suggesting that methods that ignore such confounding may underestimate the effect of distance on the utilization of health services.

Distance to available services for newborns at facilities in Malawi: A secondary analysis of survey and health facility data

Background

Malawi has halved the neonatal mortality rate between 1990–2018, however, is not on track to achieve the Sustainable Development Goal 12 per 1,000 live births. Despite a high facility birth rate (91%), mother-newborn dyads may not remain in facilities long enough to receive recommended care and quality of care improvements are needed to reach global targets. Physical access and distance to health facilities remain barriers to quality postnatal care.

Methods

Using data We used individual data from the 2015–16 Malawi Demographic and Health Survey and facility data from the 2013–14 Malawi Service Provision Assessment, linking households to all health facilities within specified distances and travel times. We calculated service readiness scores for facilities to measure their capacity to provide birth/newborn care services. We fitted multi-level regression models to evaluate the association between the service readiness and appropriate newborn care (receiving at least five of six interventions).

Results

Households with recent births (n = 6010) linked to a median of two birth facilities within 5–10 km and one facility within a two-hour walk. The maximum service environment scores for linked facilities median was 77.5 for facilities within 5–10 km and 75.5 for facilities within a two-hour walk. While linking to one or more facilities within 5-10km or a two-hour walk was not associated with appropriate newborn care, higher levels of service readiness in nearby facilities was associated with an increased risk of appropriate newborn care.

Conclusions

Women’s choice of nearby facilities and quality facilities is limited. High quality newborn care is sub-optimal despite high coverage of facility birth and some newborn care interventions. While we did not find proximity to more facilities was associated with increased risk of appropriate care, high levels of service readiness was, showing facility birth and improved access to well-prepared facilities are important for improving newborn care.

Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap

Large disparities in maternal and neonatal mortality exist between low- and high-income countries. Mothers and babies continue to die at high rates in many countries despite substantial increases in facility birth. One reason for this may be the current design of health systems in most low-income countries where, unlike in high-income countries, a substantial proportion of births occur in primary care facilities that cannot offer definitive care for complications. We argue that the current inequity in care for childbirth is a global double standard that limits progress on maternal and newborn survival. We propose that health systems need to be redesigned to shift all deliveries to hospitals or other advanced care facilities to bring care in line with global best practice. Health system redesign will require investing in high-quality hospitals with excellent midwifery and obstetric care, boosting quality of primary care clinics for antenatal, postnatal, and newborn care, decreasing access and financial barriers, and mobilizing populations to demand high-quality care. Redesign is a structural reform that is contingent on political leadership that envisions a health system designed to deliver high-quality, respectful care to all women giving birth. Getting redesign right will require focused investments, local design and adaptation, and robust evaluation.

Decentralization and Regionalization: Redesigning Health Systems for High Quality Maternity Care Comment on "Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries"

The question of how to optimally design health systems in low- and middle-income countries (LMICs) for high quality care and survival requires context-specific evidence on which level of the health system is best positioned to deliver services. Given documented poor quality of care for surgical conditions in LMICs, evidence to support intentional health system design is urgently needed. Iverson and colleagues address this very important question. This commentary explores their findings with particular attention to how they apply to maternity care. Though surgical maternity care is a common healthcare need, maternal complications are often unpredictable and require immediate surgical attention in order to avert serious morbidity or mortality. A discussion of decentralization for maternity services must grapple with this tension and differentiate between facilities that can provide emergency surgical care and those that can not.

Clinical practice guidelines for recurrent miscarriage in high-income countries: a systematic review

Recurrent miscarriage affects 1-2% of women of reproductive age, depending on the definition used. A systematic review was conducted to identify, appraise and describe clinical practice guidelines (CPG) published since 2000 for the investigation, management, and/or follow-up of recurrent miscarriage within high-income countries. Six major databases, eight guideline repositories and the websites of 11 professional organizations were searched to identify potentially eligible studies. The quality of eligible CPG was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool. A narrative synthesis was conducted to describe, compare and contrast the CPG and recommendations therein. Thirty-two CPG were included, from which 373 recommendations concerning first-trimester recurrent miscarriage were identified across four sub-categories: structure of care (42 recommendations, nine CPG), investigations (134 recommendations, 23 CPG), treatment (153 recommendations, 24 CPG), and counselling and supportive care (46 recommendations, nine CPG). Most CPG scored 'poor' on applicability (84%) and editorial independence (69%); and to a lesser extent stakeholder involvement (38%) and rigour of development (31%). Varying levels of consensus were found across CPG, with some conflicting recommendations. Greater efforts are required to improve the quality of evidence underpinning CPG, the rigour of their development and the inclusion of multi-disciplinary perspectives, including those with lived experience of recurrent miscarriage.

Maternal Delivery at Home: Issues in India

INTRODUCTION

Maternal delivery at home without skilled care at birth is a major public health issue. The current study aimed to assess the various contributing and eliminating factors of maternal delivery at home in India. The reasons for not delivering at healthcare facilities were also explored.

METHODS

The study used the National Family Health Surveys (NFHS)-4 (2015-2016) data from states and union territories of India for analysis. A national representative sample of 699,686 women of reproductive age group (15-49 years) was used. Cross-tabulation and multivariate logistic regression analyses were performed.

RESULTS

The prevalence of home delivery in India was 22%, among which 34% of women believed that institutional delivery was not a necessity. Financial constraints, lack of proper transportation facilities, non-accessibility of healthcare institutions and not getting permission from family members were the main reasons cited by the women for delivering at home. The proportion of home deliveries was much higher among women from more disadvantaged socioeconomic areas than women from less disadvantaged socioeconomic areas. Domestic violence and partner control were essential factors contributing to the prevalence of home delivery. However, the women who owned mobile phones and used a short message service (SMS) facility delivered at home less often.

CONCLUSION

Policymakers should focus more on the women living in disadvantaged socioeconomic areas and other marginalised populations with less education and low economic levels to provide them with optimum delivery care utilisation. Strengthening of public healthcare facilities and more effective use of skilled birth attendents and their networking are essential steps. Electronic and economic empowerment of women should be emphasised to bring about a significant reduction in the proportion of home deliveries in India.

Travel time and perinatal mortality after emergency caesarean sections: an evaluation of the 2-hour proximity indicator in Sierra Leone

INTRODUCTION

Longer travel times are associated with increased adverse maternal and perinatal outcomes. Geospatial modelling has been increasingly used to estimate geographic proximity in emergency obstetric care. In this study, we aimed to assess the correlation between modelled and patient-reported travel times and to evaluate its clinical relevance.

METHODS

Women who delivered by caesarean section in nine hospitals were followed up with home visits at 1 month and 1 year. Travel times between the location before the delivery and the facility where caesarean section was performed were estimated, based on two models (model I Ouma et al; model II Munoz et al). Patient-reported and modelled travel times were compared applying a univariable linear regression analysis, and the relation between travel time and perinatal mortality was assessed.

RESULTS

The median reported travel time was 60 min, compared with 13 and 34 min estimated by the two models, respectively. The 2-hour access threshold correlated with a patient-reported travel time of 5.7 hours for model I and 1.8 hours for model II. Longer travel times were associated with transport by boat and ambulance, visiting one or two facilities before reaching the final facility, lower education and poverty. Lower perinatal mortality was found both in the group with a reported travel time of 2 hours or less (193 vs 308 per 1000 births, p<0.001) and a modelled travel time of 2 hours or less (model I: 209 vs 344 per 1000 births, p=0.003; model II: 181 vs 319 per 1000 births, p<0.001).

CONCLUSION

The standard model, used to estimate geographical proximity, consistently underestimated the travel time. However, the conservative travel time model corresponded better to patient-reported travel times. The 2-hour threshold as determined by the Lancet Commission on Global Surgery, is clinically relevant with respect to reducing perinatal death, not a clear cut-off.

Seeing the Forest for the Trees: A Set of Descriptive Case Studies Presented with the Networks of Care Framework

Durable solutions for daunting problems in global health can be elusive. The global health literature tends to present aggregated data and highlight clinical outcomes but fails to describe the systems that buttress the interventions. The common idiom about "missing the forest for the trees" is apropos: by focusing on individual examples, we may miss the bigger picture. How implementation of policies and innovations plays out on the front lines of service delivery often goes uncommunicated. The Networks of Care scoping study takes a different approach, looking at diverse programs to seek out common patterns. Using the four domains of the Networks of Care framework to structure descriptions of six operational programs reveals commonalities in their designs and shows the utility of the framework's components. The commonalities increase our conviction that the framework can be used as a practical approach to strengthen service-level health systems. The case studies are followed by a commentary about the potential synergy of Networks of Care with Universal Health Coverage efforts, to deliver on the core promises to increase access and quality of care for all, especially the persistently underserved. These case studies help define a practical toolkit to promote enduring positive changes, forging a path for the Networks of Care framework to move anecdotes of individual successes to health policy and broader implementation, enabling global health practitioners at all levels to keep the big picture in focus while working toward ensuring healthy lives and well-being for all.

A protocol for a systematic review of clinical practice guidelines for recurrent miscarriage

Recurrent miscarriage (RM) was recently re-defined by the European Society of Human Reproduction and Embryology (ESHRE) as the loss of two or more consecutive pregnancies. Before this, and indeed still in some countries, RM was defined as three or more consecutive pregnancy losses. While the incidence of RM depends on the definition employed and population studied, it is generally accepted to affect 1-6% of women of reproductive age. Clinical practice guidelines (CPGs) for RM have been published by some professional organisations. While there are CPGs on miscarriage in Ireland, there are none concerning RM specifically. The aim of this systematic review is to identify, appraise and describe published CPGs for the management, investigation and/or follow-up of RM within high-income countries. Electronic databases (MEDLINE (Ovid ^®; 1946), Embase ^® (Elsevier; 1980), CINAHL Complete (EBSCOhost; 1994), Web of Science™ (Thomson Reuters), Scopus (Elsevier; 2004), and Open Grey (INIST-CNRS; 2011)), selected guideline repositories, and the websites of professional societies will be searched to identify CPGs, published within the last 20 years, for potential inclusion. Two reviewers will review abstracts and full texts independently against the eligibility criteria. Characteristics and recommendations of included CPGs will be extracted by one reviewer and double-checked by another. Two reviewers will use the Appraisal of Guidelines for Research and Evaluation version 2 (AGREE II) instrument independently to assess the quality of the included CPGs. Narrative synthesis will be conducted to appraise and compare CPGs and their recommendations or guidance therein. The identification, appraisal and description of published CPGs in other high-income countries will be a valuable first step in informing efforts to promote the optimisation and standardisation of RM care.

A protocol for a systematic review of clinical practice guidelines for recurrent miscarriage

Recurrent miscarriage (RM) was recently re-defined by the European Society of Human Reproduction and Embryology (ESHRE) as the loss of two or more consecutive pregnancies. Before this, and indeed still in some countries, RM was defined as three or more consecutive pregnancy losses. While the incidence of RM depends on the definition employed and population studied, it is generally accepted to affect 1-6% of women of reproductive age. Clinical practice guidelines (CPGs) for RM have been published by some professional organisations. While there are CPGs on miscarriage in Ireland, there are none concerning RM specifically. The aim of this systematic review is to identify, appraise and describe published CPGs for the management, investigation and/or follow-up of RM within high-income countries. Electronic databases (MEDLINE (Ovid ®; 1946), Embase ® (Elsevier; 1980), CINAHL Complete (EBSCOhost; 1994), Web of Science™ (Thomson Reuters), Scopus (Elsevier; 2004), and Open Grey (INIST-CNRS; 2011)), selected guideline repositories, and the websites of professional societies will be searched to identify CPGs, published within the last 20 years, for potential inclusion. Two reviewers will review abstracts and full texts independently against the eligibility criteria. Characteristics and recommendations of included CPGs will be extracted by one reviewer and double-checked by another. Two reviewers will use the Appraisal of Guidelines for Research and Evaluation version 2 (AGREE II) instrument independently to assess the quality of the included CPGs. Narrative synthesis will be conducted to appraise and compare CPGs and their recommendations or guidance therein. The identification, appraisal and description of published CPGs in other high-income countries will be a valuable first step in informing efforts to promote the optimisation and standardisation of RM care.

Assessment of Bypass of the Nearest Primary Health Care Facility Among Women in Ghana

IMPORTANCE

Recent reports have highlighted that expanding access to health care is ineffective at meeting the goal of universal health coverage if the care offered does not meet a minimum level of quality. Health care facilities nearest to patient's homes that are perceived to offer inadequate or inappropriate care are frequently bypassed in favor of more distant private or tertiary-level hospital facilities that are perceived to offer higher-quality care.

OBJECTIVE

To estimate the frequency with which women in Ghana bypass the nearest primary health care facility and describe patient experiences, costs, and other factors associated with this choice.

DESIGN, SETTING, AND PARTICIPANTS

This nationally representative survey study was conducted in 2017 and included 4203 households to identify women in Ghana aged 15 to 49 years (ie, reproductive age) who sought primary care within the last 6 months. Women who sought care within the past 6 months were included in the study. Data were analyzed from 2018 to 2019.

EXPOSURES

Bypass was defined as a woman's report that she sought care at a health facility other than the nearest facility.

MAIN OUTCOMES AND MEASURES

Sociodemographic characteristics, reasons why women sought care, reasons why women bypassed their nearest facility, ratings for responsiveness of care, patient experience, and out-of-pocket costs. All numbers and percentages were survey-weighted to account for survey design.

RESULTS

A total of 4289 women met initial eligibility criteria, and 4207 women (98.1%) completed the interview. A total of 1993 women reported having sough health care in the past 6 months, and after excluding those who were ineligible and survey weighting, the total sample included 1946 women. Among these, 629 women (32.3%) reported bypassing their nearest facilities for primary care. Women who bypassed their nearest facilities, compared with women who did not, were more likely to visit a private facility (152 women [24.5%] vs 202 women [15.6%]) and borrow money to pay for their care (151 women [24.0%] vs 234 women [17.8%]). After adjusting for covariates, women who bypassed reported paying a mean of 107.2 (95% CI, 79.1-135.4) Ghanaian Cedis (US $18.50 [95% CI, $13.65-$23.36]) for their care, compared with a mean of 58.6 (95% CI, 28.1-89.2) Ghanaian Cedis (US $10.11 [95% CI, $4.85-15.35]) for women who did not bypass (P = .006). Women who bypassed cited clinician competence (136 women [34.3%]) and availability of supplies (93 women [23.4%]) as the most important factors in choosing a health facility.

CONCLUSIONS AND RELEVANCE

The findings of this survey study suggest that bypassing the nearest health care facility was common among women in Ghana and that available services at lower levels of primary care are not meeting the needs of a large proportion of women. Among the benefits women perceived from bypassing were clinician competence and availability of supplies. These data provide insights to policy makers regarding potential gaps in service delivery and may help to guide primary health care improvement efforts.