Did aid to the Ebola crisis divert aid for reproductive, maternal, and newborn health? An analysis of donor-reported data in Sierra Leone

BACKGROUND

Infectious disease outbreaks like Ebola and Covid-19 are increasing in frequency. They may harm reproductive, maternal and newborn health (RMNH) directly and indirectly. Sierra Leone experienced a sharp deterioration of RMNH during the 2014-16 Ebola epidemic. One possible explanation is that donor funding may have been diverted away from RMNH to the Ebola response.

METHODS

We analysed donor-reported data from the Organisation for Economic Cooperation and Development (OECD)'s Creditor Reported System (CRS) data for Sierra Leone before, during and after the 2014-16 Ebola epidemic to understand whether aid flows for Ebola displaced aid for RMNH. We estimated aid for Ebola using key term searches and manual review of CRS records. We estimated aid for RMNH by applying the Muskoka-2 algorithm to the CRS and analysing CRS purpose codes.

RESULTS

We find substantial increases in aid to Sierra Leone (from $484 million in 2013 to $1 billion at the height of the epidemic in 2015), most of which was earmarked for the Ebola response. Overall, Ebola aid was additional to RMNH funding. RMNH aid was sustained during the epidemic (at $42 m per year) and peaked immediately after (at $77 m in 2016). There is some evidence of a small displacement of RMNH aid from the UK during the period when its Ebola funding increased.

CONCLUSIONS

Modest changes to RMNH donor aid patterns are insufficient to explain the severe decline in RMNH indicators recorded during the outbreak. Our findings therefore suggest the need for substantial increases in routine aid to ensure that basic RMNH services and infrastructure are strong before an epidemic occurs, as well as increased aid for RMNH during epidemics like Ebola and Covid-19, if reproductive, maternal and newborn healthcare is to be maintained at pre-epidemic levels.

Pregnant and postpartum women's experiences of the indirect impacts of the COVID-19 pandemic in high-income countries: a qualitative evidence synthesis

BACKGROUND

Pregnant and postpartum women's experiences of the COVID-19 pandemic, as well as the emotional and psychosocial impact of COVID-19 on perinatal health, has been well-documented across high-income countries. Increased anxiety and fear, isolation, as well as a disrupted pregnancy and postnatal period are widely described in many studies. The aim of this study was to explore, describe and synthesise studies that addressed the experiences of pregnant and postpartum women in high-income countries during the first two years of the pandemic.

METHODS

A qualitative evidence synthesis of studies relating to women's experiences in high-income countries during the pandemic were included. Two reviewers extracted the data using a thematic synthesis approach and NVivo 20 software. The GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) was used to assess confidence in review findings.

RESULTS

Sixty-eight studies were eligible and subjected to a sampling framework to ensure data richness. In total, 36 sampled studies contributed to the development of themes, sub-themes and review findings. There were six over-arching themes: (1) dealing with public health restrictions; (2) navigating changing health policies; (3) adapting to alternative ways of receiving social support; (4) dealing with impacts on their own mental health; (5) managing the new and changing information; and (6) being resilient and optimistic. Seventeen review findings were developed under these themes with high to moderate confidence according to the GRADE-CERQual assessment.

CONCLUSIONS

The findings from this synthesis offer different strategies for practice and policy makers to better support women, babies and their families in future emergency responses. These strategies include optimising care delivery, enhancing communication, and supporting social and mental wellbeing.

The effect of the WHO Safe Childbirth Checklist on essential delivery practices and birth outcomes: Evidence from a pair-wise matched randomized controlled trial in Pakistan

We study the effect of the Safe Childbirth Checklist (SCC) - a tool developed by the WHO to improve the quality of delivery care - on a range of provider- and patient-level outcomes. We conducted a clustered pair-wise matched randomized controlled trial among 166 health providers in two districts of Pakistan. This included primary and secondary health facilities as well as non-facility based rural health workers. We do not find positive effects on health outcomes, but on the adherence to some essential delivery practices, mostly to those conducted during the patient's admission to the delivery ward. We also find increased rates of referrals to higher-level facilities.

Maternal and newborn healthcare utilization in Kampala urban slums: perspectives of women, their spouses, and healthcare providers

BACKGROUND

It is assumed that the health conditions of urban women are superior to their rural counterparts. However, evidence from Asia and Africa, show that poor urban women and their families have worse access to antenatal care and facility childbirth compared to the rural women. The maternal, newborn, and child mortality rates as high as or higher than those in rural areas. In Uganda, maternal and newborn health data reflect similar trend. The aim of the study was to understand factors that influence use of maternal and newborn healthcare in two urban slums of Kampala, Uganda.

METHODS

A qualitative study was conducted in urban slums of Kampala, Uganda and conducted 60 in-depth interviews with women who had given birth in the 12 months prior to data collection and traditional birth attendants, 23 key informant interviews with healthcare providers, coordinator of emergency ambulances/emergency medical technicians and the Kampala Capital City Authority health team, and 15 focus group discussions with partners of women who gave birth 12 months prior to data collection and community leaders. Data were thematically coded and analyzed using NVivo version 10 software.

RESULTS

The main determinants that influenced access to and use of maternal and newborn health care in the slum communities included knowledge about when to seek care, decision-making power, financial ability, prior experience with the healthcare system, and the quality of care provided. Private facilities were perceived to be of higher quality, however women primarily sought care at public health facilities due to financial constraints. Reports of disrespectful treatment, neglect, and financial bribes by providers were common and linked to negative childbirth experiences. The lack of adequate infrastructure and basic medical equipment and medicine impacted patient experiences and provider ability to deliver quality care.

CONCLUSIONS

Despite availability of healthcare, urban women and their families are burdened by the financial costs of health care. Disrespectful and abusive treatment at hands of healthcare providers is common translating to negative healthcare experiences for women. There is a need to invest in quality of care through financial assistance programs, infrastructure improvements, and higher standards of provider accountability are needed.

Using process-oriented groups reflections with health care providers to improve childbirth care in the Democratic Republic of Congo - An implementation study

OBJECTIVE

The ability to systematically reflect on care during labour and birth needs to be developed among health care providers. This study investigates the experiences of health care providers who have participated in process-oriented group reflections. The activity of group reflections was one of the three pillars of a training intervention seeking to implement evidence-based care routines during labour and birth that could contribute to reduced mortality and improved maternal and newborn health in the Democratic Republic of Congo (DRC).

METHODS

Using a qualitative approach, we interviewed 131 health care providers, in focus groups (n = 19) and individually (n = 2). Analysis of transcribed interviews was conducted using qualitative content analysis according to Elo and Kyngäs.

RESULTS

Group reflections added essential knowledge to the other components of the three-pillar training intervention. Through sharing and analysing care situations health care providers got increased self-awareness, tools to achieve structured and safe care routines, and to practice teamworking.

CONCLUSION

Using a structured model of process-oriented group reflection for health care providers on care during labour and birth proved to be a vital aspect of the training intervention, as it added knowledge to the skills gained through theoretical and simulation-based education. The three-pillar training intervention improved care routines that supported healthy births and management of complications. We recommend that structured and secure group reflections be included in similar training activities in the DRC and elsewhere, and assessed in further studies.

Diverse pre-service midwifery education pathways in Cambodia and Malawi: A qualitative study utilising a midwifery education pathway conceptual framework

OBJECTIVES

Educated and skilled midwives are required to improve maternal and newborn health and reduce stillbirths. There are three main approaches to the pre-service education of midwives: direct entry, post-nursing and integrated programmes combining nursing and midwifery. Within these, there can be multiple programmes of differing lengths and qualifications, with many countries offering numerous pathways. This study explores the history, rationale, benefits and disadvantages of multiple pre-service midwifery education in Malawi and Cambodia. The objectives are to investigate the differences in education, roles and deployment as well as how key informants perceive that the various pathways influence workforce, health care, and wider health systems outcomes in each country.

DESIGN

Qualitative data were collected during semi-structured interviews and analysed using a pre-developed conceptual framework for understanding the development and outcomes of midwifery education programmes. The framework was created before data collection.

SETTING

The setting is one Asian and one African country: Cambodia and Malawi.

PARTICIPANTS

Twenty-one key informants with knowledge of maternal health care at the national level from different Government and non-governmental backgrounds.

RESULTS

Approaches to midwifery education have historical origins. Different pathways have developed iteratively and are influenced by a need to fill vacancies, raise standards and professionalise midwifery. Cambodia has mostly focused on direct-entry midwifery while Malawi has a strong emphasis on dual-qualified nurse-midwives. Informants reported that associate midwifery cadres were often trained in a more limited set of competencies, but in reality were often required to carry out similar roles to professional midwives, often without supervision. While some respondents welcomed the flexibility offered by multiple cadres, a lack of coordination and harmonisation was reported in both countries.

KEY CONCLUSIONS

The development of midwifery education in Cambodia and Malawi is complex and somewhat fragmented. While some midwifery cadres have been trained to fulfil a more limited role with fewer competencies, in practice they often have to perform a more comprehensive range of competencies.

IMPLICATIONS FOR PRACTICE

Education of midwives in the full range of globally established competencies, and leadership and coordination between Ministries of Health, midwife educators and professional bodies are all needed to ensure midwives can have the greatest impact on maternal and newborn health and wellbeing.

What predicts delayed first antenatal care contact among primiparous women? Findings from a cross-sectional study in Nigeria

BACKGROUND

Delayed first antenatal care contact refers to first antenatal care contact occurring above twelfth weeks of gestation. Studies in Nigeria and in other countries have examined the prevalence and predictors of delayed first antenatal care contact. Nevertheless, existing studies have rarely examined the predictors among primiparous women. In addition, the evidence of higher health risks associated with primigravida emphasizes the need to focus on primiparous women. This study, therefore, examined the predictors of delayed first antenatal care contact among primiparous women in Nigeria.

METHODS

The study was a descriptive cross-sectional design that analyzed data extracted from the 2018 Nigeria Demographic and Health Survey. The study analyzed a weighted sample of 3,523 primiparous women. The outcome variable was delayed first antenatal care contact. explanatory variables were grouped into predisposing, enabling, and need factors. The predisposing factors were maternal age, education, media exposure, religion, household size, The knowledge of the fertile period, and women's autonomy. The enabling factors were household wealth, employment status, health insurance, partner's education, financial inclusion, and barriers to accessing healthcare. The need factors were pregnancy wantedness and spousal violence during pregnancy. Data were analyzed using Stata 14. Two multivariable logistic regression models were fitted. Statistical significance was set at p < 0.05.

RESULTS

Nearly two-thirds (65.0%) of primiparous women delayed first antenatal care contact. Maternal age, maternal education, media exposure, religion, household membership, and knowledge of the fertile period were predisposing factors that significantly influenced the likelihood of delayed first antenatal care contact. Also, household wealth, employment status, health insurance, partner's education, perception of distance to the health facility, and financial inclusion were enabling factors that had significant effects on delayed first antenatal care contact. Pregnancy wantedness was the only need factor that significantly influenced the likelihood of delayed first antenatal care contact.

CONCLUSION

The majority of primiparous women in Nigeria delayed first antenatal care contact and the delay was predicted by varied predisposing, enabling, and need factors. Therefore, a public health education program that targets women of reproductive age especially primiparous women is needed to enhance early antenatal care contact in the country.

High coverage but low quality of maternal and newborn health services in the coverage cascade: who is benefitted and left behind in accessing better quality health services in Nepal?

BACKGROUND

Antenatal care (ANC) visits, institutional delivery, and postnatal care (PNC) visits are vital to improve the health of mothers and newborns. Despite improved access to these routine maternal and newborn health (MNH) services in Nepal, little is known about the cascade of health service coverage, particularly contact coverage, intervention-specific coverage, and quality-adjusted coverage of MNH services. This study examined the cascade of MNH services coverage, as well as social determinants associated with uptake of quality MNH services in Nepal.

METHODS

We conducted a secondary analysis of data derived from the Nepal Demographic and Health Survey (NDHS) 2016, taking 1978 women aged 15-49 years who had a live birth in the 2 years preceding the survey. Three outcome variables were (i) four or more (4⁺) ANC visits, (ii) institutional delivery, and (iii) first PNC visit for mothers and newborns within 48 h of childbirth. We applied a cascade of health services coverage, including contact coverage, intervention-specific and quality-adjusted coverage, using a list of specific intervention components for each outcome variable. Several social determinants of health were included as independent variables to identify determinants of uptake of quality MNH services. We generated a quality score for each outcome variable and dichotomised the scores into two categories of "poor" and "optimal" quality, considering > 0.8 as a cut-off point. Binomial logistic regression was conducted and odds ratios (OR) were reported with 95% confidence intervals (CIs) at the significance level of p < 0.05 (two-tailed).

RESULTS

Contact coverage was higher than intervention-specific coverage and quality-adjusted coverage across all MNH services. Women with advantaged ethnicities or who had access to bank accounts had higher odds of receiving optimal quality MNH services, while women who speak the Maithili language and who had high birth order (≥ 4) had lower odds of receiving optimal quality ANC services. Women who received better quality ANC services had higher odds of receiving optimal quality institutional delivery. Women received poor quality PNC services if they were from remote provinces, had higher birth order and perceived problems when not having access to female providers.

CONCLUSIONS

Women experiencing ethnic and social disadvantages, and from remote provinces received poor quality MNH services. The quality-adjusted coverage can be estimated using household survey data, such as demographic and health surveys, especially in countries with limited routine data. Policies and programs should focus on increasing quality of MNH services and targeting disadvantaged populations and those living in remote areas. Ensuring access to female health providers and improving the quality of earlier maternity visits could improve the quality of health care during the pregnancy-delivery-postnatal period.

The determinants of staff retention after Emergency Obstetrics and Newborn Care training in Kenya: a cross-sectional study

Introduction

Kenya’s maternal mortality ratio is relatively high at 342/100,000 live births. Confidential enquiry into maternal deaths showed that 90% of the maternal deaths received substandard care with health workforce related factors identified in 75% of 2015/2016 maternal deaths. Competent Skilled Health Personnel (SHP) providing emergency obstetric and newborn care (EmONC) in an enabling environment reduces the risk of adverse maternal and newborn outcomes. The study objective was to identify factors that determine the retention of SHP 1 – 5 years after EmONC training in Kenya.

Methods

A cross-sectional review of EmONC SHP in five counties (Kilifi, Taita Taveta, Garissa, Vihiga and Uasin Gishu) was conducted between January–February 2020. Data was extracted from a training database. Verification of current health facilities where trained SHP were deployed and reasons for non-retention were collected. Descriptive data analysis, transfer rate by county and logistic regression for SHP retention determinants was performed.

Results

A total of 927 SHP were trained from 2014–2019. Most SHP trained were nurse/midwives (677, 73%) followed by clinical officers (151, 16%) and doctors (99, 11%). Half (500, 54%) of trained SHP were retained in the same facility. Average trained staff transfer rate was 43%, with Uasin Gishu lowest at 24% and Garissa highest at 50%. Considering a subset of trained staff from level 4/5 facilities with distinct hospital departments, only a third (36%) of them are still working in relevant maternity/newborn/gynaecology departments. There was a statistically significant difference in transfer rate by gender in Garissa, Vihiga and the combined 5 counties (p < 0.05). Interval from training in years (1 year, AOR = 4.2 (2.1–8.4); cadre (nurse/midwives, AOR = 2.5 (1.4–4.5); and county (Uasin Gishu AOR = 9.5 (4.6- 19.5), Kilifi AOR = 4.0 (2.1–7.7) and Taita Taveta AOR = 1.9 (1.1–3.5), p < 0.05, were significant determinants of staff retention in the maternity departments.

Conclusion

Retention of EmONC trained SHP in the relevant maternity departments was low at 36 percent. SHP were more likely to be retained by 1-year after training compared to the subsequent years and this varied from county to county. County policies and guidelines on SHP deployment, transfers and retention should be strengthened to optimise the benefits of EmONC training.

Quality newborn care in East New Britain, Papua New Guinea: measuring early newborn care practices and identifying opportunities for improvement

BACKGROUND

Renewed attention and investment is needed to improve the quality of care during the early newborn period to address preventable newborn deaths and stillbirths in Papua New Guinea (PNG). We aimed to assess early newborn care practices and identify opportunities for improvement in one province (East New Britain) in PNG.

METHODS

A mixed-methods study was undertaken in five rural health facilities in the province using a combination of facility audits, labour observations and qualitative interviews with women and maternity providers. Data collection took place between September 2019 and February 2020. Quantitative data were analysed descriptively, whilst qualitative data were analysed using content analysis. Data were triangulated by data source.

RESULTS

Five facility audits, 30 labour observations (in four of the facilities), and interviews with 13 women and eight health providers were conducted to examine early newborn care practices. We found a perinatal mortality rate of 32.2 perinatal deaths per 1000 total births and several barriers to quality newborn care, including an insufficient workforce, critical infrastructure and utility constraints, and limited availability of essential newborn medicines and equipment. Most newborns received at least one essential newborn care practice in the first hour of life, such as immediate and thorough drying (97%).

CONCLUSIONS

We observed high rates of essential newborn care practices including immediate skin-to-skin and delayed cord clamping. We also identified multiple barriers to improving the quality of newborn care in East New Britain, PNG. These findings can inform the development of effective interventions to improve the quality of newborn care. Further, this study demonstrates that multi-faceted programs that include increased investment in the health workforce, education and training, and availability of essential equipment, medicines, and supplies are required to improve newborn outcomes.

Maternal and newborn health for the urban poor: the need for a new mental model and implementation strategies to accelerate progress

Background

Urbanization challenges the assumptions that have traditionally influenced maternal and newborn health (MNH) programs. This landscaping outlines how current mental models for MNH programs have fallen short for urban slum populations and identifies implications for the global community. We employed a three-pronged approach, including a literature review, key informant interviews with global- and national-level experts, and a case study in Bangladesh.

Main body

Our findings highlight that the current mental model for MNH is inadequate to address the needs of the urban poor. Implementation challenges have arisen from using traditional methods that are not well adapted to traits inherent in slum settings. A re-thinking of implementation strategies will also need to consider a paucity of available routine data, lack of formal coordination between stakeholders and providers, and challenging municipal government structures. Innovative approaches, including with communications, outreach, and technology, will be necessary to move beyond traditional rural-centric approaches to MNH. As populations continue to urbanize, common slum dynamics will challenge conventional strategies for health service delivery. In addition, the COVID-19 pandemic has exposed weaknesses in a system that requires intersectoral collaborations to deliver quality care.

Conclusion

Programs will need to be iterative and adaptive, reflective of sociodemographic features. Integrating the social determinants of health into evaluations, using participatory human-centered design processes, and innovative public-private partnerships may prove beneficial in slum settings. But a willingness to rethink the roles of all actors within the delivery system overall may be needed most.

Impact of reliable light and electricity on job satisfaction among maternity health workers in Uganda: A cluster randomized trial

BACKGROUND

Maintaining a motivated health workforce is critical to health system effectiveness and quality of care. Scant evidence exists on whether interventions aimed to strengthen health infrastructure in low-resource settings affect health workers. This study evaluated the impact of an intervention providing solar light and electricity to rural maternity facilities in Uganda on health workers' job satisfaction.

METHODS

We used a mixed-methods design embedded in a cluster randomized trial to evaluate whether and how the We Care Solar Suitcase intervention, a solar electric system providing lighting and power, affected health workers in rural Ugandan maternity facilities with unreliable light. Facilities were randomly assigned to receive the intervention or not without blinding in a cluster-randomized controlled trial. Outcomes were assessed through two rounds of surveys with health workers. We used regression analyses to examine the intervention's impact on job satisfaction. We used an inductive approach to analyze qualitative data to understand the study context and interpret quantitative findings.

RESULTS

We interviewed 85 health workers across 30 facilities, the majority of whom were midwives or nurses. Qualitative reports indicated that unreliable light made it difficult to provide care, worsened facility conditions, and harmed health workers and patients. Before the intervention, only 4% of health workers were satisfied with their access to light and electricity. After the installation, satisfaction with light increased by 76 percentage points [95% confidence interval (CI): 61-92 percentage points], although satisfaction with electricity did not change. Experience of negative impacts of lack of overhead light also significantly decreased and the intervention modestly increased job satisfaction. Qualitative evidence illustrated how the intervention may have strengthened health workers' sense of job security and confidence in providing high-quality care while pointing towards implementation challenges and other barriers health workers faced.

CONCLUSIONS

Reliable access to light and electricity directly affects health workers' ability to provide maternal and neonatal care and modestly improves job satisfaction. Policy makers should invest in health infrastructure as part of multifaceted policy strategies to strengthen human resources for health and to improve maternal and newborn health services. Trial registration socialscienceregistry.org: AEARCTR-0003078. Registered June 12, 2018, https://www.socialscienceregistry.org/trials/3078 Additionally registered on: ClinicalTrials.gov: NCT03589625, Registered July 18, 2018, https://clinicaltrials.gov/ct2/show/NCT03589625 ).

The effect of co-payments on the take-up of prenatal tests

Noninvasive prenatal screening tests help identify genetic disorders in a fetus, but their take-up remains low in several countries. Using a regression discontinuity design, we test the causal effect of a policy that eliminated co-payments for noninvasive screening tests in Italy. We identify the treatment effects by a discontinuity in women's eligibility for a free test based on their conception date. We find that the policy increases the probability of women's undergoing noninvasive screening tests by 5.5 percentage points, and the effect varies by socioeconomic status. We do not find evidence of substitution effects with more expensive and riskier invasive diagnostic tests. In addition, the increase in take-up does not affect pregnancy termination or newborn health. We find some evidence of positive effects on mothers' health behaviors during pregnancy as measured by reductions in mothers' weight gain and hospital admissions during pregnancy, but these are statistically significant only at the 10 percent level.

A randomized group antenatal care pilot showed increased partner communication and partner HIV testing during pregnancy in Malawi and Tanzania

BACKGROUND

HIV testing at antenatal care (ANC) is critical to achieving zero new infections in sub-Saharan Africa. Although most women are tested at ANC, they remain at risk for HIV exposure and transmission to their infant when their partners are not tested. This study evaluates how an HIV-enhanced and Centering-based group ANC model-Group ANC+ that uses interactive learning to practice partner communication is associated with improvements in partner HIV testing during pregnancy.

METHODS

A randomized pilot study conducted in Malawi and Tanzania found multiple positive outcomes for pregnant women (n = 218) assigned to Group ANC+ versus individual ANC. This analysis adds previously unpublished results for two late pregnancy outcomes: communication with partner about three reproductive health topics (safer sex, HIV testing, and family planning) and partner HIV testing since the first antenatal care visit. Multivariate logistic regression models were used to assess the effect of type of ANC on partner communication and partner testing. We also conducted a mediation analysis to assess whether partner communication mediated the effect of type of care on partner HIV testing.

RESULTS

Nearly 70% of women in Group ANC+ reported communicating about reproductive health with their partner, compared to 45% of women in individual ANC. After controlling for significant covariates, women in group ANC were twice as likely as those in individual ANC to report that their partner got an HIV test (OR 1.99; 95% CI: 1.08, 3.66). The positive effect of the Group ANC + model on partner HIV testing was fully mediated by increased partner communication.

CONCLUSIONS

HIV prevention was included in group ANC health promotion without compromising services and coverage of standard ANC topics, demonstrating that local high-priority health promotion needs can be integrated into ANC using a Group ANC+. These findings provide evidence that greater partner communication can promote healthy reproductive behaviors, including HIV prevention. Additional research is needed to understand the processes by which group ANC allowed women to discuss sensitive topics with partners and how these communications led to partner HIV testing.

How do women, men, and health providers perceive interventions to influence men's engagement in maternal and newborn health? A qualitative evidence synthesis

Globally, there is growing awareness of the important contributions men can make as key stakeholders in maternal and newborn health (MNH), and increased investment in interventions designed to influence men's engagement to improve MNH outcomes. Interventions typically target men, women, couples or health providers, yet how these stakeholders perceive and experience interventions is not well understood and the fact that women may experience these interventions as disempowering has been identified as a major concern. This review aims to synthesise how women, men, and providers perceive and experience interventions designed to influence men's engagement in MNH, in order to identify perceived benefits and risks of participating in interventions, and other key factors affecting uptake of and adherence to interventions. We conducted a qualitative evidence synthesis based on a systematic search of the literature, analysing a purposive sample of 66 out of 144 included studies to enable rich synthesis. Women, men and providers report that interventions enable more and better care for women, newborns and men, and strengthen family relationships between the newborn, father and mother. At the same time, stakeholders report that poorly designed or implemented interventions carry risks of harm, including constraining some women's access to MNH services and compounding negative impacts of existing gender inequalities. Limited health system capacity to deliver men-friendly MNH services, and pervasive gender inequality, can limit the accessibility and acceptability of interventions. Sociodemographic factors, household needs, and peer networks can influence how men choose to support MNH, and may affect demand for and adherence to interventions. Overall, perceived benefits of interventions designed to influence men's engagement in MNH are compelling, reported risks of harm are likely manageable through careful implementation, and there is clear evidence of demand from women and men, and some providers, for increased opportunities and support for men to engage in MNH.

Using the WHO safe childbirth checklist to improve essential care delivery as part of the district-wide maternal and newborn health quality improvement initiative, a time series study

Background

Care bundles are a set of three to five evidence-informed practices which, when performed collectively and reliably, may improve health system performance and patient care. To date, many studies conducted to improve the quality of essential birth care practices (EBPs) have focused primarily on provider- level and have fallen short of the predicted impact on care quality, indicating that a systems approach is needed to improve the delivery of reliable quality care.

This study evaluates the effect of integrating the use of the World Health Organization Safe Childbirth Checklist (WHO-SCC) into a district-wide system improvement collaborative program designed to improve and sustain the delivery of EBPs as measured by “clinical bundle” adherence over-time.

Methods

The WHO-SCC was introduced in the context of a district-wide Maternal and Newborn Health (MNH) collaborative quality of care improvement program in four agrarian Ethiopia regions. Three “clinical bundles” were created from the WHO-SCC: On Admission, Before Pushing, and Soon After Birth bundles. The outcome of each bundle was measured using all- or- none adherence. Adherence was assessed monthly by reviewing charts of live births.

A time-series analysis was employed to assess the effectiveness of system-level interventions on clinical bundle adherence. STATA version 13.1 was used to analyze the trend of each bundle adherence overtime.

Autocorrelation was checked to assess if the assumption of independence in observations collected overtime was valid. Prais-Winsten was used to minimize the effect of autocorrelation.

Findings

Quality improvement interventions targeting the three clinical bundles resulted in improved adherence over time across the four MNH collaborative. In Tankua Abergele collaborative (Tigray Region), the overall mean adherence to “On Admission” bundle was 86% with β = 1.39 (95% CI; 0.47–2.32; P <  0.005) on average monthly.

Similarly, the overall mean adherence to the “Before Pushing” bundle in Dugna Fango collaborative; Southern Nations, Nationalities and People’s (SNNP) region was 80% with β = 2.3 (95% CI; 0.89–3.74; P <  0.005) on average monthly.

Conclusion

Using WHO-SCC paired with a system-wide quality improvement approach improved and sustained quality of EBPs delivery. Further studies should be conducted to evaluate the impact on patient-level outcomes.

Intersectional (in) equities in contact coverage of maternal and newborn health services in Nepal: insights from a nationwide cross-sectional household survey

Background

Persistent inequities in coverage of maternal and newborn health (MNH) services continue to pose a major challenge to the health-care system in Nepal. This paper uses a novel composite indicator of intersectional (dis) advantages to examine how different (in) equity markers intersect to create (in) equities in contact coverage of MNH services across the continuum of care (CoC) in Nepal.

Methods

A secondary analysis was conducted among 1978 women aged 15–49 years who had a live birth in the two years preceding the survey. Data were derived from the Nepal Demographic and Health Survey (NDHS) 2016. The three outcome variables included were 1) at least four antenatal care (4ANC) visits, 2) institutional delivery, and 3) postnatal care (PNC) consult for newborns and mothers within 48 h of childbirth. Independent variables were wealth status, education, ethnicity, languages, residence, and marginalisation status. Intersectional (dis) advantages were created using three socioeconomic variables (wealth status, level of education and ethnicity of women). Binomial logistic regression analysis was employed to identify the patterns of (in) equities in contact coverage of MNH services across the CoC.

Results

The contact coverage of 4ANC visits, institutional delivery, and PNC visit was 72, 64, and 51% respectively. Relative to women with triple disadvantage, the odds of contact coverage of 4ANC visits was more than five-fold higher (Adjusted Odds Ratio (aOR) = 5.51; 95% CI: 2.85, 10.64) among women with triple forms of advantages (literate and advantaged ethnicity and higher wealth status). Women with triple advantages were seven-fold more likely to give birth in a health institution (aOR = 7.32; 95% CI: 3.66, 14.63). They were also four times more likely (aOR = 4.18; 95% CI: 2.40, 7.28) to receive PNC visit compared to their triple disadvantaged counterparts.

Conclusions

The contact coverage of routine MNH visits was low among women with social disadvantages and lowest among women with multiple forms of socioeconomic disadvantages. Tracking health service coverage among women with multiple forms of (dis) advantage can provide crucial information for designing contextual and targeted approaches to actions towards universal coverage of MNH services and improving health equity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11142-8.

Can transparency and accountability programs improve health? Experimental evidence from Indonesia and Tanzania

We assess the impact of a transparency and accountability program designed to improve maternal and newborn health (MNH) outcomes in Indonesia and Tanzania. Co-designed with local partner organizations to be community-led and non-prescriptive, the program sought to encourage community participation to address local barriers in access to high quality care for pregnant women and infants. We evaluate the impact of this program through randomized controlled trials (RCTs), involving 100 treatment and 100 control communities in each country. We find that on average, this program did not have a statistically significant impact on the use or content of maternal and newborn health services, nor on perceptions of civic efficacy or civic participation among recent mothers in the communities where it was offered. These findings hold in both countries and in a set of prespecified subgroups. To identify reasons for the lack of impacts, we use a mixed-method approach combining interviews, observations, surveys, focus groups, and ethnographic studies that together provide an in-depth assessment of the complex causal paths linking participation in the program to improvements in MNH outcomes. Although participation in program meetings was substantial and sustained in most communities, and most attempted at least some of what they had planned, only a minority achieved tangible improvements, and fewer still saw more than one such success. In our assessment, the main explanation for the lack of impact is that few communities were able to traverse the complex causal paths from planning actions to accomplishing tangible improvements in their access to quality health care.

Birth companionship in a government health system: a pilot study in Kigoma, Tanzania

Background

Having a companion of choice throughout childbirth is an important component of good quality and respectful maternity care for women and has become standard in many countries. However, there are only a few examples of birth companionship being implemented in government health systems in low-income countries. To learn if birth companionship was feasible, acceptable and led to improved quality of care in these settings, we implemented a pilot project using 9 intervention and 6 comparison sites (all government health facilities) in a rural region of Tanzania.

Methods

The pilot was developed and implemented in Kigoma, Tanzania between July 2016 and December 2018. Women delivering at intervention sites were given the choice of having a birth companion with them during childbirth. We evaluated the pilot with: (a) project data; (b) focus group discussions; (c) structured and semi-structured interviews; and (d) service statistics.

Results

More than 80% of women delivering at intervention sites had a birth companion who provided support during childbirth, including comforting women and staying by their side. Most women interviewed at intervention sites were very satisfied with having a companion during childbirth (96–99%). Most women at the intervention sites also reported that the presence of a companion improved their labor, delivery and postpartum experience (82–97%). Health providers also found companions very helpful because they assisted with their workload, alerted the provider about changes in the woman’s status, and provided emotional support to the woman. When comparing intervention and comparison sites, providers at intervention sites were significantly more likely to: respond to women who called for help (p = 0.003), interact in a friendly way (p < 0.001), greet women respectfully (p < 0.001), and try to make them more comfortable (p = 0.003). Higher proportions of women who gave birth at intervention sites reported being “very satisfied” with the care they received (p < 0.001), and that the staff were “very kind” (p < 0.001) and “very encouraging” (p < 0.001).

Conclusion

Birth companionship was feasible and well accepted by health providers, government officials and most importantly, women who delivered at intervention facilities. The introduction of birth companionship improved women’s experience of birth and the maternity ward environment overall.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03746-0.

Antenatal Care Utilization and Obstetric and Newborn Outcomes Among Pregnant Refugees Attending a Specialized Refugee Clinic

The objective of the study is to characterize the antenatal care utilization and obstetric and newborn outcomes among refugee women at a specialized refugee clinic and determine whether these outcomes varied between refugees (government-assisted or privately-sponsored) and asylum seekers. This retrospective cohort study included women receiving antenatal care at a specialized refugee clinic between 2011 and 2016. Time from arrival to first clinic visit, Adequacy of Prenatal Care Utilization Index, and obstetric and newborn outcomes were examined, stratified by refugee category. Amongst 179 women, median time from arrival to first clinic visit was longer for asylum seekers (2.8 months, IQR 12.9) compared to government-assisted and privately-sponsored refugees (0.4 months, IQR 0.7, and 1.6 months, IQR 3.2, respectively; p < 0.01). A larger proportion of asylum seeking women received inadequate antenatal care. No difference was found in obstetric and newborn outcomes. Differences in antenatal care utilization between refugee categories suggest that barriers may remain for asylum seekers; however, obstetric and newborn outcomes were comparable amongst refugee categories.

Understanding the roles of community health workers in improving perinatal health equity in rural Uttar Pradesh, India: a qualitative study

BACKGROUND

Despite substantial reductions in perinatal deaths (stillbirths and early neonatal deaths), India's perinatal mortality rates remain high, both nationally and in individual states. Rates are highest among disadvantaged socio-economic groups. To address this, India's National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to counsel and support women by visiting them at home before and after childbirth. We conducted a qualitative study to explore the roles of ASHAs' home visits in improving equity in perinatal health between socio-economic position groups in rural Uttar Pradesh (UP), India.

METHODS

We conducted social mapping in four villages of two districts in UP, followed by three focus group discussions in each village (12 in total) with ASHAs and women who had recently given birth belonging to 'higher' and 'lower' socio-economic position groups (n = 134 participants). We analysed the data in NVivo and Dedoose using a thematic framework approach.

RESULTS

Home visits enabled ASHAs to build trusting relationships with women, offer information about health services, schemes and preventive care, and provide practical support for accessing maternity care. This helped many women and families prepare for birth and motivated them to deliver in health facilities. In particular, ASHAs encouraged women who were poorer, less educated or from lower caste groups to give birth in public Community Health Centres (CHCs). However, women who gave birth at CHCs often experienced insufficient emergency obstetric care, mistreatment from staff, indirect costs, lack of medicines, and referrals to higher-level facilities when complications occurred. Referrals often led to delays and higher fees that placed the greatest burden on families who were considered of lower socio-economic position or living in remote areas, and increased their risk of experiencing perinatal loss.

CONCLUSIONS

The study found that ASHAs built relationships, counselled and supported many pregnant women of lower socio-economic positions. Ongoing inequities in health facility births and perinatal mortality were perpetuated by overlapping contextual issues beyond the ASHAs' purview. Supporting ASHAs' integration with community organisations and health system strategies more broadly is needed to address these issues and optimise pathways between equity in intervention coverage, processes and perinatal health outcomes.

The relationship between inequitable gender norms and provider attitudes and quality of care in maternal health services in Rwanda: a mixed methods study

Background

Rwanda has made great progress in improving reproductive, maternal, and newborn health (RMNH) care; however, barriers to ensuring timely and full RMNH service utilization persist, including women’s limited decision-making power and poor-quality care. This study sought to better understand whether and how gender and power dynamics between providers and clients affect their perceptions and experiences of quality care during antenatal care, labor and childbirth.

Methods

This mixed methods study included a self-administered survey with 151 RMNH providers with questions on attitudes about gender roles, RMNH care, provider-client relations, labor and childbirth, which took place between January to February 2018. Two separate factor analyses were conducted on provider responses to create a Gender Attitudes Scale and an RMNH Quality of Care Scale. Three focus group discussions (FGDs) conducted in February 2019 with RMNH providers, female and male clients, explored attitudes about gender norms, provision and quality of RMNH care, provider-client interactions and power dynamics, and men’s involvement. Data were analyzed thematically.

Results

Inequitable gender norms and attitudes – among both RMNH care providers and clients – impact the quality of RMNH care. The qualitative results illustrate how gender norms and attitudes influence the provision of care and provider-client interactions, in addition to the impact of men’s involvement on the quality of care. Complementing this finding, the survey found a relationship between health providers’ gender attitudes and their attitudes towards quality RMNH care: gender equitable attitudes were associated with greater support for respectful, quality RMNH care.

Conclusions

Our findings suggest that gender attitudes and power dynamics between providers and their clients, and between female clients and their partners, can negatively impact the utilization and provision of quality RMNH care. There is a need for capacity building efforts to challenge health providers’ inequitable gender attitudes and practices and equip them to be aware of gender and power dynamics between themselves and their clients. These efforts can be made alongside community interventions to transform harmful gender norms, including those that increase women’s agency and autonomy over their bodies and their health care, promote uptake of health services, and improve couple power dynamics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03592-0.

eRegCom-Quality Improvement Dashboard for healthcare providers and Targeted Client Communication to pregnant women using data from an electronic health registry to improve attendance and quality of antenatal care: study protocol for a multi-arm cluster randomized trial

BACKGROUND

This trial evaluates interventions that utilize data entered at point-of-care in the Palestinian maternal and child eRegistry to generate Quality Improvement Dashboards (QID) for healthcare providers and Targeted Client Communication (TCC) via short message service (SMS) to clients. The aim is to assess the effectiveness of the automated communication strategies from the eRegistry on improving attendance and quality of care for pregnant women.

METHODS

This four-arm cluster randomized controlled trial will be conducted in the West Bank and the Gaza Strip, Palestine, and includes 138 clusters (primary healthcare clinics) enrolling from 45 to 3000 pregnancies per year. The intervention tools are the QID and the TCC via SMS, automated from the eRegistry built on the District Health Information Software 2 (DHIS2) Tracker. The primary outcomes are appropriate screening and management of anemia, hypertension, and diabetes during pregnancy and timely attendance to antenatal care. Primary analysis, at the individual level taking the design effect of the clustering into account, will be done as intention-to-treat.

DISCUSSION

This trial, embedded in the implementation of the eRegistry in Palestine, will inform the use of digital health interventions as a health systems strengthening approach.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN10520687 . Registered on 18 October 2018.

Birth attendants' hand hygiene compliance in healthcare facilities in low and middle-income countries: a systematic review

Background

With an increasing number of women delivering in healthcare facilities in Low and Middle Income Countries (LMICs), healthcare workers’ hand hygiene compliance on labour wards is pivotal to preventing infections. Currently there are no estimates of how often birth attendants comply with hand hygiene, or of the factors influencing compliance in healthcare facilities in LMICs.

Methods

We conducted a systematic review to investigate the a) level of compliance, b) determinants of compliance and c) interventions to improve hand hygiene during labour and delivery among birth attendants in healthcare facilities of LMICs. We also aimed to assess the quality of the included studies and to report the intra-cluster correlation for studies conducted in multiple facilities.

Results

We obtained 797 results across four databases and reviewed 71 full texts. Of these, fifteen met our inclusion criteria. Overall, the quality of the included studies was particularly compromised by poorly described sampling methods and definitions. Hand hygiene compliance varied substantially across studies from 0 to 100%; however, the heterogeneity in definitions of hand hygiene did not allow us to combine or compare these meaningfully. The five studies with larger sample sizes and clearer definitions estimated compliance before aseptic procedures opportunities, to be low (range: 1–38%). Three studies described two multi-component interventions, both were shown to be feasible.

Conclusions

Hand hygiene compliance was low for studies with larger sample sizes and clear definitions. This poses a substantial challenge to infection prevention during birth in LMICs facilities. We also found that the quality of many studies was suboptimal. Future studies of hand hygiene compliance on the labour ward should be designed with better sampling frames, assess inter-observer agreement, use measures to improve the quality of data collection, and report their hand hygiene definitions clearly.

Setting up a maternal and newborn registry applying electronic platform: an experience from the Bangladesh site of the global network for women's and children's health

BACKGROUND

The Global Network for Women's and Children's Health Research (Global Network, GN) has established the Maternal Newborn Health Registry (MNHR) to assess MNH outcomes over time. Bangladesh is the newest country in the GN and has implemented a full electronic MNH registry system, from married women surveillance to pregnancy enrollment and subsequent follow ups.

METHOD

Like other GN sites, the Bangladesh MNHR is a prospective, population-based observational study that tracks pregnancies and MNH outcomes. The MNHR site is in the Ghatail and Kalihati sub-districts of the Tangail district. The study area consists of 12 registry clusters each of ~ 18,000-19,000 population. All pregnant women identified through a two-monthly house-to-house surveillance are enrolled in the registry upon consenting and followed up on scheduled visits until 42 days after pregnancy outcome. A comprehensive automated registry data capture system has been developed that allows for married women surveillance, pregnancy enrollment, and data collection during follow-up visits using a web-linked tablet-PC-based system.

RESULT

During March-May 2019, a total of 56,064 households located were listed in the Bangladesh MNH registry site. Of the total 221,462 population covered, 49,269 were currently married women in reproductive age (CMWRA). About 13% CMWRA were less susceptible to pregnancy. Large variability was observed in selected contraceptive usage across clusters. Overall, 5% of the listed CMWRAs were reported as currently pregnant.

CONCLUSION

In comparison to paper-pen capturing system electronic data capturing system (EDC) has advantages of less error-prone data collection, real-time data collection progress monitoring, data quality check and sharing. But the implementation of EDC in a resource-poor setting depends on technical infrastructure, skilled staff, software development, community acceptance and a data security system. Our experience of pregnancy registration, intervention coverage, and outcome tracking provides important contextualized considerations for both design and implementation of individual-level health information capturing and sharing systems.

Maternal and newborn healthcare practices: assessment of the uptake of lifesaving services in Hoima District, Uganda

BACKGROUND

The current maternal mortality ratio in Uganda is 336 maternal deaths per 100,000 live births. Infant mortality is 43 deaths per 1000 live births, with 42% of the mortality occurring during the neonatal period. This might be related to a weak health system in the country. This study aimed at assessing the uptake of lifesaving services during pregnancy and childbirth in Hoima District, Uganda.

METHODS

The study used a cross-sectional quantitative design among 691 women with a child under 5 years. Households were randomly sampled from a list of all the villages in the district with the ENA for SMART software using the EPI methodology. Pre-coded questionnaires uploaded in the Open Data Kit were used for data collection. The data was cleaned and analysed using MS Excel and SPSS software. Descriptive results are presented.

RESULTS

Of the 55.1% women attending at least four antenatal care (ANC) visits, only 24.3% had the first ANC within the first trimester. Moreover, ANC services generally was of poor quality, with only 0.4% meeting all the requirements for quality of ANC service. The highest contributors to this poor quality included poor uptake of iron-folic acid (adherence 28.8%), the six-required birth preparedness and complication readiness items (13.2%), and recognition of the seven danger signs of pregnancy (3.0%). Adherence to the seven essential newborn care actions was very low (0.5%), mainly caused by three practices: initiating breastfeeding within 1 h (59.9%), lack of postnatal care within 24 h (20.1%), and failure to recognize the 6 danger signs of the newborn (2.4%). Only 11.1% of the males participated in all maternal and newborn care requirements, by encouraging women to seek healthcare (39.9%), accompanying them to healthcare (36.9%), and HIV counselling and support services (26.2%).

CONCLUSION

The study reveals poor maternal and newborn practices throughout the continuum of care, from ANC and skilled birth attendance to newborn care during childbirth. With such poor results, it is not surprising that Hoima is sixth of 10 districts that have the highest numbers of deaths due to maternal mortality in Uganda.

Measuring the availability and geographical accessibility of maternal health services across sub-Saharan Africa

BACKGROUND

With universal health coverage a key component of the 2030 Sustainable Development Goals, targeted monitoring is crucial for reducing inequalities in the provision of services. However, monitoring largely occurs at the national level, masking sub-national variation. Here, we estimate indicators for measuring the availability and geographical accessibility of services, at national and sub-national levels across sub-Saharan Africa, to show how data at varying spatial scales and input data can considerably impact monitoring outcomes.

METHODS

Availability was estimated using the World Health Organization guidelines for monitoring emergency obstetric care, defined as the number of hospitals per 500,000 population. Geographical accessibility was estimated using the Lancet Commission on Global Surgery, defined as the proportion of pregnancies within 2 h of the nearest hospital. These were calculated using geo-located hospital data for sub-Saharan Africa, with their associated travel times, along with small area estimates of population and pregnancies. The results of the availability analysis were then compared to the results of the accessibility analysis, to highlight differences between the availability and geographical accessibility of services.

RESULTS

Despite most countries meeting the targets at the national level, we identified substantial sub-national variation, with 58% of the countries having at least one administrative unit not meeting the availability target at province level and 95% at district level. Similarly, 56% of the countries were found to have at least one province not meeting the accessibility target, increasing to 74% at the district level. When comparing both availability and accessibility within countries, most countries were found to meet both targets; however sub-nationally, many countries fail to meet one or the other.

CONCLUSION

While many of the countries met the targets at the national level, we found large within-country variation. Monitoring under the current guidelines, using national averages, can mask these areas of need, with potential consequences for vulnerable women and children. It is imperative therefore that indicators for monitoring the availability and geographical accessibility of health care reflect this need, if targets for universal health coverage are to be met by 2030.

Professional advice for primary healthcare workers in Ethiopia: a social network analysis

BACKGROUND

In an era of increasingly competitive funding, governments and donors will be looking for creative ways to extend and maximise resources. One such means can include building upon professional advice networks to more efficiently introduce, scale up, or change programmes and healthcare provider practices. This cross-sectional, mixed-methods, observational study compared professional advice networks of healthcare workers in eight primary healthcare units across four regions of Ethiopia. Primary healthcare units include a health centre and typically five satellite health posts.

METHODS

One hundred sixty staff at eight primary healthcare units were interviewed using a structured tool. Quantitative data captured the frequency of healthcare worker advice seeking and giving on providing antenatal, childbirth, postnatal and newborn care. Network and actor-level metrics were calculated including density (ratio of ties between actors to all possible ties), centrality (number of ties incident to an actor), distance (average number of steps between actors) and size (number of actors within the network). Following quantitative network analyses, 20 qualitative interviews were conducted with network study participants from four primary healthcare units. Qualitative interviews aimed to interpret and explain network properties observed. Data were entered, analysed or visualised using Excel 6.0, UCINET 6.0, Netdraw, Adobe InDesign and MaxQDA10 software packages.

RESULTS

The following average network level metrics were observed: density .26 (SD.11), degree centrality .45 (SD.08), distance 1.94 (SD.26), number of ties 95.63 (SD 35.46), size of network 20.25 (SD 3.65). Advice networks for antenatal or maternity care were more utilised than advice networks for post-natal or newborn care. Advice networks were typically limited to primary healthcare unit staff, but not necessarily to supervisors. In seeking advice, a colleague's level of training and knowledge were valued over experience. Advice exchange primarily took place in person or over the phone rather than over email or online fora. There were few barriers to seeking advice.

CONCLUSION

Informal, inter-and intra-cadre advice networks existed. Fellow primary healthcare unit staff were preferred, particularly midwives, but networks were not limited to the primary healthcare unit. Additional research is needed to associate network properties with outcomes and pilot network interventions with central actors.

Confronting the culture of care: a call to end disrespect, discrimination, and detainment of women and newborns in health facilities everywhere

Quality and respect are increasingly recognized as critical aspects of the provision of health care, and poor quality may be an essential driver of low health care utilization, especially for maternal and neonatal care. Beyond differential access to care, unequal levels of quality exacerbate inequity, and those who need services most, including displaced, migrant, and conflict-affected populations, may be receiving poorer quality care, or may be deterred from seeking care at all.Examples from around the world show that mothers and their children are often judged and mistreated for presenting to facilities without clean or "modern" clothing, without soap or clean sheets to use in the hospital, or without gifts like sweets or candies for providers. Underfunded facilities may rely on income from those seeking care, but denying and shaming the poor further discriminates against vulnerable women and newborns, by placing additional financial burden on those already marginalized.The culture of care needs to shift to create welcoming environments for all care-seekers, regardless of socio-economic status. No one should fear mistreatment, denial of services, or detainment due to lack of gifts or payments. There is an urgent need to ensure that health care centers are safe, friendly, respectful, and hospitable spaces for women, their newborns, and their families.

An effectiveness-implementation hybrid type 1 trial assessing the impact of group versus individual antenatal care on maternal and infant outcomes in Malawi

BACKGROUND

Sub-Saharan Africa has the world's highest rates of maternal and perinatal mortality and accounts for two-thirds of new HIV infections and 25% of preterm births. Antenatal care, as the entry point into the health system for many women, offers an opportunity to provide life-saving monitoring, health promotion, and health system linkages. Change is urgently needed, because potential benefits of antenatal care are not realized when pregnant women experience long wait times and short visits with inconsistent provisioning of essential services and minimal health promotion, especially for HIV prevention. This study answers WHO's call for the rigorous study of group antenatal care as a transformative model that provides a positive pregnancy experience and improves outcomes.

METHODS

Using a hybrid type 1 effectiveness-implementation design, we test the effectiveness of group antenatal care by comparing it to individual care across 6 clinics in Blantyre District, Malawi. Our first aim is to evaluate the effectiveness of group antenatal care through 6 months postpartum. We hypothesize that women in group care and their infants will have less morbidity and mortality and more positive HIV prevention outcomes. We will test hypotheses using multi-level hierarchical models using data from repeated surveys (four time points) and health records. Guided by the consolidated framework for implementation research, our second aim is to identify contextual factors related to clinic-level degree of implementation success. Analyses use within and across-case matrices.

DISCUSSION

This high-impact study addresses three global health priorities, including maternal and infant mortality, HIV prevention, and improved quality of antenatal care. Results will provide rigorous evidence documenting the effectiveness and scalability of group antenatal care. If results are negative, governments will avoid spending on less effective care. If our study shows positive health impacts in Malawi, the results will provide strong evidence and valuable lessons learned for widespread scale-up in other low-resource settings. Positive maternal, neonatal, and HIV-related outcomes will save lives, impact the quality of antenatal care, and influence health policy as governments make decisions about whether to adopt this innovative healthcare model.

TRIAL REGISTRATION

ClinicalTrials.gov registration number NCT03673709. Registered on September 17, 2018.

Quality of maternal and newborn healthcare services in two public hospitals of Bangladesh: identifying gaps and provisions for improvement

BACKGROUND

Healthcare service delivery systems need to ensure standard quality of care (QoC) for achieving expected health outcomes. Although Bangladesh has a good healthcare service delivery system, there are major concerns about the quality of maternal and newborn health (MNH) care services, which is imperative for achievements in health. The study aimed to measure the QoC for different MNH services in two selected public health facilities of Bangladesh. This study also documented the specific areas of each care which needs intervention.

METHODS

The study was conducted in two district-level public health facilities-a district hospital (DH) and a mother and child welfare centre (MCWC). A total of 228 cases of MNH services were observed by using contextualized checklist 'Standards-based Management and Recognition (S-BMR)' for 8 selected MNH care services. For scoring, performed activities were calculated as percentages of the total recommended activities and categorized as high (> 80%), moderate (50 to 80%), and low (< 50%).

RESULTS

Overall QoC scores were moderate for each DH (54.8%), and MCWC (56.1%). In DH, the QoC score was high for blood transfusion (80.3%); moderate for maternal complications management (77.0%), caesarean section (CS) (65.6%), infection prevention (64.3%), sick newborn care (54.1%), and normal vaginal delivery (NVD) (52.6%); and low for antenatal care (ANC) (25.6%) and postnatal care (PNC) (19.0%). In MCWC, the QoC scores were high for infection prevention (83.0%); moderate for CS (76.5%) and NVD (59.8%); and low for ANC (36.9%) and PNC (24.5%).

CONCLUSIONS

In the study facilities, the QoC for MNH services is found to be unsatisfactory, particularly for ANC and PNC. Urgent initiative needs to be taken by introducing contextualized quality monitoring tools at health facilities, along with training of the care providers and introducing a quality monitoring system.

Understanding mistreatment during institutional delivery in Northeast Nigeria: a mixed-method study

BACKGROUND

Improving quality of care including the clinical aspects and the experience of care has been advocated for improved coverage and better childbirth outcomes.

OBJECTIVE

This study aimed to explore the quality of care relating to the prevalence and manifestations of mistreatment during institutional birth in Gombe State, northeast Nigeria, an area of low institutional delivery coverage.

METHODS

The frequency of dimensions of mistreatment experienced by women delivering in 10 health facilities of Gombe State were quantitatively captured during exit interviews with 342 women in July-August 2017. Manifestations of mistreatment were qualitatively explored through in-depth interviews and focus groups with 63 women living in communities with high and low coverage of institutional deliveries.

RESULTS

The quantitative data showed that at least one dimension of mistreatment was reported by 66% (95% confidence interval (CI) 45-82%) of women exiting a health facility after delivery. Mistreatment related to health system conditions and constraints were reported in 50% (95% CI 31-70%) of deliveries. In the qualitative data women expressed frustration at being urged to deliver at the health facility only to be physically or verbally mistreated, blamed for poor birth outcomes, discriminated against because of their background, left to deliver without assistance or with inadequate support, travelling long distances to the facility only to find staff unavailable, or being charged unjustified amount of money for delivery.

CONCLUSIONS

Mistreatment during institutional delivery in Gombe State is highly prevalent and predominantly relates to mistreatment arising from both health system constraints as well as health worker behaviours, limiting efforts to increase coverage of institutional delivery. To address mistreatment during institutional births, strategies that emphasise a broader health systems approach, tackle multiple causes, integrate a detailed understanding of the local context and have buy-in from grassroots-level stakeholders are recommended.

Expanding access to maternal, newborn and primary healthcare services through private-community-government partnership clinic models in rural Kenya: the Ubuntu-Afya kiosk model

Background

Fifteen counties contribute 98.7% of the maternal and newborn morbidity and mortality in Kenya. The dismal maternal and newborn (MNH) outcomes in these settings are mostly attributable to limited access to skilled MNH services. Public health services are stretched and limited in reach, and many social programmes are not sustainably designed. We implemented a network of 16 self-sustaining community medical centres (Ubuntu-Afya Kiosks) in Homa Bay County, to facilitate access to MNH and other primary health services. We investigated the effect of these centres on MNH access indicators over a 2-year period of initial implementation.

Methods

We conducted a baseline and end-line survey in June 2016 and May 2018 respectively, in 10 community health units (CHU) served by Ubuntu-Afya Kiosks. We targeted women of child bearing age, ensuring equal sample across the 10 CHUs. The surveys were powered to detect a 10% increase in the proportion of women who deliver under a skilled birth attendant from a perceived baseline of 55%. Background characteristics of the respondents were compared using Fisher’s exact test for the categorical data. STATA ‘svy’ commands were used to calculate confidence intervals for the proportions taking into account the clustering within CHU.

Results

The coverage of antenatal care during previous pregnancy was 99% at end-line compared to 81% at baseline. Seventy one percent of mothers attended at least four antenatal care visits, compared to 64% at baseline. The proportion of women who delivered under a skilled birth attendant during previous pregnancy was higher at end-line (90%) compared to baseline (85%). There was an increase in the proportion of women who had their newborns examined within 2 day of delivery from 74 to 92% at end-line. A considerable proportion of the respondents visited private clinics at end-line (31%) compared to 3% at baseline.

Conclusions

Ubuntu-Afya Kiosks were associated with enhanced access to MNH care, with significant improvements observed in newborn examination within 2 days after delivery. More women sought care from private clinics at end-line compared to baseline, indicating potential for private sector in supporting health service delivery gaps in under-served settings.

Improving the quality of maternal and newborn health outcomes through a clinical mentorship program in the Democratic Republic of the Congo: study protocol

Background

The Democratic Republic of the Congo (DRC) boasts one of the highest rates of institutional deliveries in sub-Saharan Africa (80%), with eight out of every ten births also assisted by a skilled provider. However, the maternal and neonatal mortality are still among the highest in the world, which demonstrates the poor in-facility quality of maternal and newborn care. The objective of this ongoing project is to design, implement, and evaluate a clinical mentorship program in 72 health facilities in two rural provinces of Kwango and Kwilu, DRC.

Methods

This is an ongoing quasi-experimental study. In the 72 facilities, 48 facilities were assigned to the group where the clinical mentorship program is being implemented (intervention group), and 24 facilities were assigned to the group where the clinical mentorship program is not being implemented (control group). The groups were selected and assigned based on administrative criteria, taking into account the number of deliveries in each facility, the coverage of health zones, accessibility, and ease of implementation of a clinical mentorship program. The main activities are organizing and training a national team of mentors (including senior midwives, obstetricians, and pediatricians) in clinical mentoring, deploying them to mentor all health providers (mentees) performing maternal and newborn health (MNH) services, and providing in-service training in routine and Emergency Obstetrical and Newborn Care (EmONC) to the mentees in health facilities over an 18-month period. Baseline and endline assessments are carried out to evaluate the effectiveness of the clinical mentorship program on the quality of MNH care and the effective coverage of key interventions to reduce maternal and neonatal mortality. Findings will be disseminated nationwide and internationally, as scientific evidence is scarce. A national strategy, guidelines, and tools for clinical mentorship in MNH will be developed for replication in other provinces, thus benefitting the entire country.

Discussion

This is the largest project on clinical mentorship aimed to improving the quality of MNH care in Africa. This program is expected to generate one of the first pieces of scientific evidence on the effectiveness of a clinical mentorship program in MNH on a scientifically designed and sustainable model.

Conditional cash transfers to improve use of health facilities by mothers and newborns in conflict affected countries, a prospective population based intervention study from Afghanistan

BACKGROUND

The effects of conditional cash transfer (CCT) programs on maternal and child health (MCH) service use in conflicted affected countries such as Afghanistan are not known.

METHODS

We conducted a non-randomised population based intervention study in six Afghanistan districts from December 2016 to December 2017. Six control districts were purposively matched. Women were eligible to be included in the baseline and endline evaluation surveys if they had given birth to one or more children in the last 12 months. The intervention was a CCT program including information, education, communication (IEC) program about CCT to community members and financial incentives to community health workers (CHWs) and families if mothers delivered their child at a health facility. Control districts received standard care. The primary objective was to assess the effect of CCT on use of health facilities for delivery. Secondary objectives were to assess the effect of CCT on antenatal care (ANC), postnatal care (PNC) and CHW motivation to perform home visits. Outcomes were analysed at 12 months using multivariable difference-in-difference linear regression models adjusted for clustering and socio demographic variables.

RESULTS

Overall, facility delivery increased in intervention villages by 14.3% and control villages by 8.4% (adjusted mean difference [AMD] 3.3%; 95% confidence interval [- 0.14 to 0.21], p value 0.685). There was no effect in the poorest quintile (AMD 0.8% [- 0.30 to 0.32], p value 0.953). ANC (AMD 45.0% [0.18 to 0.72] p value 0.004) and PNC (AMD 31.8% [- 0.05 to 0.68] p value 0.080) increased in the intervention compared to the control group. CHW home visiting changed little in intervention villages (- 3.0%) but decreased by - 23.9% in control villages (AMD 12.2% [- 0.27 to 0.51], p value 0.508). CCT exposure was 27.3% (342/1254) overall and 10.2% (17/166) in the poorest quintile.

CONCLUSIONS

Our study demonstrated that a CCT program provided to women aged 16-49 years can be implemented in a highly conservative conflict affected population. CCT should be scaled up for the poorest women in Afghanistan.

Harmonizing scientific rigor with political urgency: policy learnings for identifying accelerators for scale-up from the safe childbirth checklist programme in Rajasthan, India

BACKGROUND

Quick scaling-up of innovative and promising interventions in health systems of low and middle-income countries to rapidly achieve population level benefits is a key challenge. While there is consensus on the need for rigorous scientific evidence on effectiveness of interventions before considering scale-up, there can be significant time lag for the want of gold-standard evidence. The Safe Childbirth Checklist (SCC) programme in India, demonstrated how an innovation was robustly evaluated and scaled up nationally, within a short span of time. In this narrative review, we describe the strategies discussed in various published scale-up frameworks and map them against the strategies adopted by the SCC programme to identify accelerators which facilitated its rapid scale up.

METHODS

The narrative review - done from May to June 2017 - involved keyword searches of electronic databases of PubMed, Ovid Medline and Google Scholar. It included the key words 'pilot', 'health innovations', 'scale-up', 'replication', 'expansion', 'increased coverage', 'conceptual models for scale-up', 'frame-works for scale-up', 'evidence for scale-up' in the title of publications,. This search was limited to publications in English after the year 1995. We used snowball sampling approach (by referring to bibliographies of shortlisted publications) to identify additional publications related to scale-up. We then screened the identified publications independently and relevant publications that discussed attributes for a conceptual model for scale-up of public health interventions in low and middle-income countries were shortlisted. We then mapped the strategies we used in SCC program scale up against those described in the shortlisted frameworks to identify seven accelerators which facilitated rapid scale up.

RESULTS

The identified accelerators were: testing the intervention in real world, resource constrained settings; using an appropriate and time sensitive research design; testing the intervention at substantial scale and in diverse settings; using an adaptive and iterative prototyping approach for implementation; sharing data and evidence with key stakeholders on an ongoing basis; targeting bridge resources through strategic engagement of stakeholders and timely integration of scale-up plans with annual planning and budgeting cycles and systems.

CONCLUSION

These accelerators will complement current frameworks and provide guidance to future scale-up initiatives in India and elsewhere.

"The more children you have, the more praise you get from the community": exploring the role of sociocultural context and perceptions of care on maternal and newborn health among Somali refugees in UNHCR supported camps in Kenya

Background

Maternal and neonatal survival are key components of population health and may be particularly vulnerable in humanitarian contexts of civil unrest and displacement. Understanding what factors contribute to poor health outcomes throughout the reproductive life cycle and across the continuum of care is crucial for improving health programming in acute and protracted refugee settings.

Methods

We undertook a mixed-methods baseline assessment of factors related to maternal and neonatal health among refugees living in the Dadaab refugee complex in eastern Kenya. The qualitative component included 23 focus group discussions with 207 community members and 22 key informant interviews with relevant UN and non-governmental organization staff, community leaders, health managers, and front-line health care providers. We analysed qualitative data for content and themes using inductive and deductive techniques.

Results

Taking a life course perspective, we found that the strong desire for large families and the primary social role of the woman as child bearer impacted maternal and neonatal health in the camps through preferences for early marriage, low demand for contraception, and avoidance of caesarean sections. Participants described how a strong fear of death, disability, and reduced fecundity from caesarean sections results in avoidance of the surgery, late presentation to the health facility in labour, and difficulty gaining timely informed consent. Mistrust of health service providers also played a role in this dynamic. In terms of newborn care practices, while breastfeeding is culturally supported and women increasingly accept feeding colostrum to the newborn, mixed feeding practices and application of foreign substances to the umbilicus continue to present risks to newborn health in this community.

Conclusions

The findings from our study showcase the role that specific sociocultural beliefs and practices and perceptions of health care services have on maternal and neonatal health. An in-depth understanding of how these factors impact the utilization of biomedical health services provides valuable information for targeted improvements in health service provision that are tailored to the local context.

Effect of a community health worker mHealth monitoring system on uptake of maternal and newborn health services in Rwanda

Background

In an effort to improve access to proven maternal and newborn health interventions, Rwanda implemented a mobile phone (mHealth) monitoring system called RapidSMS. RapidSMS was scaled up across Rwanda in 2013. The objective of this study was to evaluate the impact of RapidSMS on the utilization of maternal and newborn health services in Rwanda.

Methods

Using data from the 2014/15 Rwanda demographic and health survey, we identified a cohort of women aged 15–49 years who had a live birth that occurred between 2010 and 2014. Using interrupted time series design, we estimated the impact of RapidSMS on uptake of maternal and newborn health services including antenatal care (ANC), health facility delivery and vaccination coverage.

Results

Overall, the coverage rate at baseline for ANC (at least one visit), health facility delivery and vaccination was very high (> 90%). The baseline rate was 50.30% for first ANC visit during the first trimester and 40.57% for at least four ANC visits. We found no evidence that implementing RapidSMS was associated with an immediate increase in ANC (level change: -1.00% (95% CI: -2.30 to 0.29) for ANC visit at least once, -1.69% (95% CI: -9.94 to 6.55) for ANC (at least 4 visits), -3.80% (95% CI: -13.66 to 6.05) for first ANC visit during the first trimester), health facility delivery (level change: -1.79, 95% CI: -6.16 to 2.58), and vaccination coverage (level change: 0.58% (95%CI: -0.38 to 1.55) for BCG, -0.75% (95% CI: -6.18 to 4.67) for polio 0). Moreover, there was no significant trend change across the outcomes studied.

Conclusion

Based on survey data, the implementation of RapidSMS did not appear to increase uptake of the maternal and newborn health services we studied in Rwanda. In most instances, this was because the existing level of the indicators we studied was very high (ceiling effect), leaving little room for potential improvement. RapidSMS may work in contexts where improvement remains to be made, but not for indicators that are already very high. As such, further research is required to understand why RapidSMS had no impact on indicators where there was enough room for improvement.

Temporal trends in spatial inequalities of maternal and newborn health services among four east African countries, 1999-2015

BACKGROUND

Sub-Saharan Africa continues to account for the highest regional maternal mortality ratio (MMR) in the world, at just under 550 maternal deaths per 100,000 live births in 2015, compared to a global rate of 216 deaths. Spatial inequalities in access to life-saving maternal and newborn health (MNH) services persist within sub-Saharan Africa, however, with varied improvement over the past two decades. While previous research within the East African Community (EAC) region has examined utilisation of MNH care as an emergent property of geographic accessibility, no research has examined how these spatial inequalities have evolved over time at similar spatial scales.

METHODS

Here, we analysed temporal trends of spatial inequalities in utilisation of antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) among four East African countries. Specifically, we used Bayesian spatial statistics to generate district-level estimates of these services for several time points using Demographic and Health Surveys data in Kenya, Tanzania, Rwanda, and Uganda. We examined temporal trends of both absolute and relative indices over time, including the absolute difference between estimates, as well as change in performance ratios of the best-to-worst performing districts per country.

RESULTS

Across all countries, we found the greatest spatial equality in ANC, while SBA and PNC tended to have greater spatial variability. In particular, Rwanda represented the only country to consistently increase coverage and reduce spatial inequalities across all services. Conversely, Tanzania had noticeable reductions in ANC coverage throughout most of the country, with some areas experiencing as much as a 55% reduction. Encouragingly, however, we found that performance gaps between districts have generally decreased or remained stably low across all countries, suggesting countries are making improvements to reduce spatial inequalities in these services.

CONCLUSIONS

We found that while the region is generally making progress in reducing spatial gaps across districts, improvement in PNC coverage has stagnated, and should be monitored closely over the coming decades. This study is the first to report temporal trends in district-level estimates in MNH services across the EAC region, and these findings establish an important baseline of evidence for the Sustainable Development Goal era.

"We need good nutrition but we have no money to buy food": sociocultural context, care experiences, and newborn health in two UNHCR-supported camps in South Sudan

BACKGROUND

Determinants of newborn health and survival exist across the reproductive life cycle, with many sociocultural and contextual factors influencing outcomes beyond the availability of, and access to, quality health services. In order to better understand key needs and opportunities to improve newborn health in refugee camp settings, we conducted a multi-methods qualitative study of the status of maternal and newborn health in refugee camps in Upper Nile state, South Sudan.

METHODS

In 2016, we conducted 18 key informant interviews with health service managers and front-line providers and 13 focus group discussions in two Sudanese refugee camps in Maban County, South Sudan. Our focus group discussions comprised 147 refugee participants including groups of mothers, fathers, grandmothers, traditional birth attendants, community health workers, and midwives. We analysed our data for content and themes using inductive and deductive techniques.

RESULTS

We found both positive practices and barriers to newborn health in the camps throughout the reproductive lifecycle. Environmental and contextual factors such as poor nutrition, lack of livelihood opportunities, and insecurity presented barriers to both general health and self-care during pregnancy. We found that the receipt of material incentives is one of the leading drivers of utilization of antenatal care and facility-based childbirth services. Barriers to facility-based childbirth included poor transportation specifically during the night; insecurity; being accustomed to home delivery; and fears of an unfamiliar birth environment, caesarean section, and encountering male health care providers during childbirth. Use of potentially harmful traditional practices with the newborn are commonplace including mixed feeding, use of herbal infusions to treat newborn illnesses, and the application of ash and oil to the newborn's umbilicus.

CONCLUSIONS

Numerous sociocultural and contextual factors impact newborn health in this setting. Improving nutritional support during pregnancy, strengthening community-based transportation for women in labour, allowing a birth companion to be present during delivery, addressing harmful home-based newborn care practices such as mixed feeding and application of foreign substances to the umbilicus, and optimizing the networks of community health workers and traditional birth attendants are potential ways to improve newborn health outcomes.

Working with community health workers to improve maternal and newborn health outcomes: implementation and scale-up lessons from eastern Uganda

Background: Preventable maternal and newborn deaths can be averted through simple evidence-based interventions, such as the use of community health workers (CHWs), also known in Uganda as village health teams. However, the CHW strategy faces implementation challenges regarding training packages, supervision, and motivation.

Objectives: This paper explores knowledge levels of CHWs, describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy.

Methods: The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The aim of the visits was to promote birth preparedness and utilization of maternal and newborn health (MNH) services. Mixed methods of data collection were employed. Quantitative data were analyzed using Stata version 13.0 to determine the level and predictors of CHW knowledge of MNH. Qualitative data from 10 key informants and 15 CHW interviews were thematically analyzed to assess the implementation experiences.

Results: CHWs’ knowledge of MNH improved from 41.3% to 77.4% after training, and to 79.9% 1 year post-training. However, knowledge of newborn danger signs declined from 85.5% after training to 58.9% 1 year later. The main predictors of CHW knowledge were age (≥ 35 years) and post-primary level of education. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57.3%. Notably, CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and thus maintained low dropout rates at 3.6%. Challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of means of transportation such as bicycles.

Conclusions: CHWs are an important resource in community-based health information and improving demand for MNH services. However, the CHW training and supervision models require strengthening for improved performance. Local solutions regarding CHW motivation are necessary for sustainability.

'The development sector is a graveyard of pilot projects!' Six critical actions for externally funded implementers to foster scale-up of maternal and newborn health innovations in low and middle-income countries

BACKGROUND

Donors often fund projects that develop innovative practices in low and middle-income countries, hoping recipient governments will adopt and scale them within existing systems and programmes. Such innovations frequently end when project funding ends, limiting longer term potential in countries with weak health systems and pressing health needs. This paper aims to identify critical actions for externally funded project implementers to enable scale-up of maternal and newborn child health innovations originally funded by the Bill & Melinda Gates Foundation ('the foundation'), or influenced by innovations that were originally funded by the foundation in three low-income settings: Ethiopia, the state of Uttar Pradesh in India and northeast Nigeria. We define scale-up as the adoption of donor-funded innovations beyond their original project settings and time periods.

METHODS

We conducted 71 in-depth, semi-structured interviews with representatives from government, donors and other development partner agencies, donor-funded implementers including frontline providers, research organisations and professional associations. We explored three case study maternal and newborn innovations. Selection criteria were: a) innovations originally funded by the Bill & Melinda Gates Foundation ('the foundation'), or influenced by innovations that were originally funded by the foundation; b) innovations for which a decision to scale-up had been made, allowing us to reflect on the factors influencing those decisions; c) innovations with increased geographical reach, benefitting a greater number of people, beyond districts where foundation-funded implementers were active. Our data were analysed based on a common analytic framework to aid cross-country comparisons.

RESULTS

Based on study respondents' accounts, we identified six critical steps that donor-funded implementers had taken to enable the adoption of maternal and newborn health innovations at scale: designing innovations for scale; generating evidence to influence and inform scale-up; harnessing the support of powerful individuals; being prepared for scale-up and responsive to change; ensuring continuity by being part of the transition to scale; and embracing the aid effectiveness principles of country ownership, alignment and harmonisation.

CONCLUSIONS

Six critical actions identified in this study were associated with adopting and scaling maternal and newborn health innovations. However, scale-up is unpredictable and depends on factors outside implementers' control.

Impact of universal home visits on maternal and infant outcomes in Bauchi state, Nigeria: protocol of a cluster randomized controlled trial

BACKGROUND

Maternal mortality in Nigeria is one of the highest in the world. Access to antenatal care is limited and the quality of services is poor in much of the country. Previous research in Bauchi State found associations between maternal morbidity and domestic violence, heavy work in pregnancy, lack of knowledge about danger signs, and lack of spousal communication about pregnancy and childbirth. This cluster randomized controlled stepped-wedge trial will test the impact of universal home visits to pregnant women and their partners, and the added value of video edutainment.

METHODS

The trial will take place in six wards of Toro Local Government Area in Bauchi State, Nigeria, randomly allocated into three waves of two wards each. Home visits will begin in wave 1 wards immediately; in wave 2 wards after one year; and in wave 3 wards after a further year. In each wave, one ward, randomly allocated, will receive video edutainment during the home visits. Female home visitors will contact all households in their catchment areas of about 300 households, register all pregnant women, and visit them every two months during pregnancy, after delivery and one year later. They will use android handsets to collect information on pregnancy progress, send this to a central server, and discuss with the women the evidence about household factors associated with higher maternal risks, using video clips in the edutainment wards. Male home visitors will contact the partners of the pregnant women and discuss with them the same evidence. We will compare outcomes between wave 1 and wave 2 wards at about one year, between wave 2 and wave 3 wards at about two years, and finally between wards with and without added edutainment. Primary outcomes will be complications in pregnancy and delivery, and child health at one year. Secondary outcomes include knowledge and attitudes, use of health services, knowledge of danger signs, and household care of pregnant women.

DISCUSSION

Demonstrating an impact of home visits and understanding potential mechanisms could have important implications for reducing maternal morbidity and mortality in other settings with poor access to quality antenatal care services.

TRIAL REGISTRATION

Registration number: ISRCTN82954580 . Registry: ISRCTN. Date of registration: 11 August 2017. Retrospectively registered.

Knowledge and involvement of husbands in maternal and newborn health in rural Bangladesh

BACKGROUND

Access to skilled health services during pregnancy, childbirth and postnatal period for obstetric care is one of the strongest determinants of maternal and newborn health (MNH) outcomes. In many countries, husbands are key decision-makers in households, effectively determining women's access to health services. We examined husbands' knowledge and involvement regarding MNH issues in rural Bangladesh, and how their involvement is related to women receiving MNH services from trained providers.

METHODS

We conducted a cross-sectional survey in two rural sub-districts of Bangladesh in 2014 adopting a stratified cluster sampling technique. Women with a recent birth history and their husbands were interviewed separately with a structured questionnaire. A total of 317 wife-husband dyads were interviewed. The associations between husbands accompanying their wives as explanatory variables and utilization of skilled services as outcome variables were assessed using multiple logistic regression analyses.

RESULTS

In terms of MNH knowledge, two-thirds of husbands were aware that women have special rights related to pregnancy and childbirth and one-quarter could mention three or more pregnancy-, birth- and postpartum-related danger signs. With regard to MNH practice, approximately three-quarters of husbands discussed birth preparedness and complication readiness with their wives. Only 12% and 21% were involved in identifying a potential blood donor and arranging transportation, respectively. Among women who attended antenatal care (ANC), 47% were accompanied by their husbands. Around half of the husbands were present at the birthplace during birth. Of the 22% women who received postpartum care (PNC), 67% were accompanied by their husbands. Husbands accompanying their wives was positively associated with women receiving ANC from a medically trained provider (AOR 4.5, p < .01), birth at a health facility (AOR 1.5, p < .05), receiving PNC from a medically trained provider (AOR 48.8, p < .01) and seeking care from medically trained providers for obstetric complications (AOR 3.0, p < 0.5).

CONCLUSION

Husbands accompanying women when receiving health services is positively correlated with women's use of skilled MNH services. Special initiatives should be taken for encouraging husbands to accompany their wives while availing MNH services. These initiatives should aim to increase men's awareness regarding MNH issues, but should not be limited to this.

Use of an electronic Partograph: feasibility and acceptability study in Zanzibar, Tanzania

BACKGROUND

The ePartogram is a tablet-based application developed to improve care for women in labor by addressing documented challenges in partograph use. The application is designed to provide real-time decision support, improve data entry, and increase access to information for appropriate labor management. This study's primary objective was to evaluate the feasibility and acceptability of ePartogram use in resource-constrained clinical settings.

METHODS

The ePartogram was introduced at three facilities in Zanzibar, Tanzania. Following 3 days of training, skilled birth attendants (SBAs) were observed for 2 weeks using the ePartogram to monitor laboring women. During each observed shift, data collectors used a structured observation form to document SBA comfort, confidence, and ability to use the ePartogram. Results were analyzed by shift. Short interviews, conducted with SBAs (n = 82) after each of their first five ePartogram-monitored labors, detected differences over time. After the observation period, in-depth interviews were conducted (n = 15). A thematic analysis of interview transcripts was completed.

RESULTS

Observations of 23 SBAs using the ePartogram to monitor 103 women over 84 shifts showed that the majority of SBAs (87-91%) completed each of four fundamental ePartogram tasks-registering a client, entering first and subsequent measurements, and navigating between screens-with ease or increasing ease on their first shift; this increased to 100% by the fifth shift. Nearly all SBAs (93%) demonstrated confidence and all SBAs demonstrated comfort in using the ePartogram by the fifth shift. SBAs expressed positive impressions of the ePartogram and found it efficient and easy to use, beginning with first client use. SBAs noted the helpfulness of auditory reminders (indicating that measurements were due) and visual alerts (signaling abnormal measurements). SBAs expressed confidence in their ability to interpret and act on these reminders and alerts.

CONCLUSIONS

It is feasible and acceptable for SBAs to use the ePartogram to support labor management and care. With structured training and support during initial use, SBAs quickly became competent and confident in ePartogram use. Qualitative findings revealed that SBAs felt the ePartogram improved timeliness of care and supported decision-making. These findings point to the ePartogram's potential to improve quality of care in resource-constrained labor and delivery settings.

The effect of implementation strength of basic emergency obstetric and newborn care (BEmONC) on facility deliveries and the met need for BEmONC at the primary health care level in Ethiopia

BACKGROUND

Basic emergency obstetric and newborn care (BEmONC) is a primary health care level initiative promoted in low- and middle-income countries to reduce maternal and newborn mortality. Tailored support, including BEmONC training to providers, mentoring and monitoring through supportive supervision, provision of equipment and supplies, strengthening referral linkages, and improving infection-prevention practice, was provided in a package of interventions to 134 health centers, covering 91 rural districts of Ethiopia to ensure timely BEmONC care. In recent years, there has been a growing interest in measuring program implementation strength to evaluate public health gains. To assess the effectiveness of the BEmONC initiative, this study measures its implementation strength and examines the effect of its variability across intervention health centers on the rate of facility deliveries and the met need for BEmONC.

METHODS

Before and after data from 134 intervention health centers were collected in April 2013 and July 2015. A BEmONC implementation strength index was constructed from seven input and five process indicators measured through observation, record review, and provider interview; while facility delivery rate and the met need for expected obstetric complications were measured from service statistics and patient records. We estimated the dose-response relationships between outcome and explanatory variables of interest using regression methods.

RESULTS

The BEmONC implementation strength index score, which ranged between zero and 10, increased statistically significantly from 4.3 at baseline to 6.7 at follow-up (p < .05). Correspondingly, the health center delivery rate significantly increased from 24% to 56% (p < .05). There was a dose-response relationship between the explanatory and outcome variables. For every unit increase in BEmONC implementation strength score there was a corresponding average of 4.5 percentage points (95% confidence interval: 2.1-6.9) increase in facility-based deliveries; while a higher score for BEmONC implementation strength of a health facility at follow-up was associated with a higher met need.

CONCLUSION

The BEmONC initiative was effective in improving institutional deliveries and may have also improved the met need for BEmONC services. The BEmONC implementation strength index can be potentially used to monitor the implementation of BEmONC interventions.

Approaches towards improving the quality of maternal and newborn health services in South Asia: challenges and opportunities for healthcare systems

BACKGROUND

South Asia is experiencing a dismal state of maternal and newborn health (MNH) as the region has been falling behind in reducing the levels of maternal and neonatal mortality. Most of the efforts are focused on enhancing coverage of MNH services; however, quality remains a serious concern if the region is to achieve expected outcomes in terms of standardised MNH services within healthcare delivery systems. This research consists of a review of South Asian quality improvement (QI) approaches/interventions, specifically implemented for MNH improvement.

METHODS

A literature review of QI approaches/interventions was conducted using the PRISMA guidelines. Online databases, including PubMed, the Cochrane Library and Google Scholar, were searched. Primary studies published between 1998 and 2013 were considered. Studies were initially screened and selected based upon the selection criteria for data extraction. A thematic synthesis/analysis was performed to organise, group and interpret the key findings according to prominent themes.

RESULTS

Thirty studies from six South Asian countries were included in the review. Findings from these selected studies were grouped under eight broad, cross-cutting themes, which emerged from a deductive approach, representing the most commonly employed QI approaches for improving MNH services within different geographical settings. These consist of capacity building of healthcare providers on clinical quality, clinical audits and feedback, financial incentives to beneficiaries, pay-for-performance, supportive supervision, community engagement, collaborative efforts and multidimensional interventions.

CONCLUSIONS

Employing and documenting QI approaches is essential in order to measure the potential of an intervention, considering its cost-effectiveness, feasibility and acceptability to communities. This research concluded that QI approaches are very diverse and cross-cutting, because they are subject to the varied requirements of regional health systems. This high level of variability leads to implementation and knowledge-management challenges for MNH programme planners and managers in the countries of the South Asia region.

eRegQual-an electronic health registry with interactive checklists and clinical decision support for improving quality of antenatal care: study protocol for a cluster randomized trial

Background

Health worker compliance with established best-practice clinical and public health guidelines may be enhanced by customized checklists of care and clinical decision support driven by point-of-care data entry into an electronic health registry. The public health system of Palestine is currently implementing a national electronic registry (eRegistry) for maternal and child health. This trial is embedded in the national implementation and aims to assess the effectiveness of the eRegistry’s interactive checklists and clinical decision support, compared with the existing paper based records, on improving the quality of care for pregnant women.

Methods

This two-arm cluster randomized controlled trial is conducted in the West Bank, Palestine, and includes 120 clusters (primary healthcare clinics) with an average annual enrollment of 60 pregnancies. The intervention tool is the eRegistry’s interactive checklists and clinical decision support implemented within the District Health Information System 2 (DHIS2) Tracker software, developed and customized for the Palestinian context. The primary outcomes reflect the processes of essential interventions, namely timely and appropriate screening and management of: 1) anemia in pregnancy; 2) hypertension in pregnancy; 3) abnormal fetal growth; 4) and diabetes mellitus in pregnancy. The composite primary health outcome encompasses five conditions representing risk for the mother or baby that could have been detected or prevented by high-quality antenatal care: moderate or severe anemia at admission for labor; severe hypertension at admission for labor; malpresentation at delivery undetected during pregnancy; small for gestational age baby at delivery undetected during pregnancy; and large for gestational age baby at delivery. Primary analysis at the individual level taking the design effect of the clustering into account will be performed as intention-to-treat.

Discussion

This trial, embedded in the national implementation of the eRegistry in Palestine, allows the assessment of process and health outcomes in a large-scale pragmatic setting. Findings will inform the use of interactive checklists and clinical decision support driven by point-of-care data entry into an eRegistry as a health systems-strengthening approach.

Trial registration

ISRCTN trial registration number, ISRCTN18008445. Registered on 6 April 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2386-5) contains supplementary material, which is available to authorized users.

Participatory monitoring and evaluation approaches that influence decision-making: lessons from a maternal and newborn study in Eastern Uganda

Background

The use of participatory monitoring and evaluation (M&E) approaches is important for guiding local decision-making, promoting the implementation of effective interventions and addressing emerging issues in the course of implementation. In this article, we explore how participatory M&E approaches helped to identify key design and implementation issues and how they influenced stakeholders’ decision-making in eastern Uganda.

Method

The data for this paper is drawn from a retrospective reflection of various M&E approaches used in a maternal and newborn health project that was implemented in three districts in eastern Uganda. The methods included qualitative and quantitative M&E techniques such as  key informant interviews, formal surveys and supportive supervision, as well as participatory approaches, notably participatory impact pathway analysis.

Results

At the design stage, the M&E approaches were useful for identifying key local problems and feasible local solutions and informing the activities that were subsequently implemented. During the implementation phase, the M&E approaches provided evidence that informed decision-making and helped identify emerging issues, such as weak implementation by some village health teams, health facility constraints such as poor use of standard guidelines, lack of placenta disposal pits, inadequate fuel for the ambulance at some facilities, and poor care for low birth weight infants. Sharing this information with key stakeholders prompted them to take appropriate actions. For example, the sub-county leadership constructed placenta disposal pits, the district health officer provided fuel for ambulances, and health workers received refresher training and mentorship on how to care for newborns.

Conclusion

Diverse sources of information and perspectives can help researchers and decision-makers understand and adapt evidence to contexts for more effective interventions. Supporting districts to have crosscutting, routine information generating and sharing platforms that bring together stakeholders from different sectors is therefore crucial for the successful implementation of complex development interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12961-017-0274-9) contains supplementary material, which is available to authorized users.

Effects of demand-side incentives in improving the utilisation of delivery services in Oyam District in northern Uganda: a quasi-experimental study

BACKGROUND

We evaluated the effects and financial costs of two interventions with respect to utilisation of institutional deliveries and other maternal health services in Oyam District in Uganda.

METHODS

We conducted a quasi-experimental study involving intervention and comparable/control sub-counties in Oyam District for 12 months (January-December 2014). Participants were women receiving antenatal care, delivery and postnatal care services. We evaluated two interventions: the provision of (1) transport vouchers to women receiving antenatal care and delivering at two health centres (level II) in Acaba sub-county, and (2) baby kits to women who delivered at Ngai Health Centre (level III) in Ngai sub-county. The study outcomes included service coverage of institutional deliveries, four antenatal care visits, postnatal care, and the percentage of women 'bypassing' maternal health services inside their resident sub-counties. We calculated the effect of each intervention on study outcomes using the difference in differences analysis. We calculated the cost per institutional delivery and the cost per unit increment in institutional deliveries for each intervention.

RESULTS

Overall, transport vouchers had greater effects on all four outcomes, whereas baby kits mainly influenced institutional deliveries. The absolute increase in institutional deliveries attributable to vouchers was 42.9%; the equivalent for baby kits was 30.0%. Additionally, transport vouchers increased the coverage of four antenatal care visits and postnatal care service coverage by 60.0% and 49.2%, respectively. 'Bypassing' was mainly related to transport vouchers and ranged from 7.2% for postnatal care to 11.9% for deliveries. The financial cost of institutional delivery was US$9.4 per transport voucher provided, and US$10.5 per baby kit. The incremental cost per unit increment in institutional deliveries in the transport-voucher system was US$15.9; the equivalent for the baby kit was US$30.6.

CONCLUSION

The transport voucher scheme effectively increased utilisation of maternal health services whereas the baby-kit scheme was only effective in increasing institutional deliveries. The transport vouchers were less costly than the baby kits in the promotion of institutional deliveries. Such incentives can be sustainable if the Ministry of Health integrates them in the health system.