Trends and Inequalities in Maternal and Newborn Health Services for Unplanned Settlements of Lusaka City, Zambia.

Living conditions and other factors in urban unplanned settlements present unique challenges for improving maternal and newborn health (MNH), yet MNH inequalities associated with such challenges are not well understood. This study examined trends and inequalities in coverage of MNH services in the last 20 years in unplanned and planned settlements of Lusaka City, Zambia. Geospatial information was used to map Lusaka's settlements and health facilities. Zambia Demographic Health Surveys (ZDHS 2001, 2007, 2013/2014, and 2018) were used to compare antenatal care (ANC), institutional delivery, and Cesarean section (C-section) coverage, and neonatal mortality rates between the poorer 60% and richer 40% households. Health Management Information System (HMIS) data from 2018 to 2021 were used to compute service volumes and coverage rates for ANC1 and ANC4, and institutional delivery and C-sections by facility level and type in planned and unplanned settlements. Although the correlation is not exact, our data analysis showed close alignment; and thus, we opted to use the 60% poorer and 40% richer groups as a proxy for households in unplanned versus planned settlements. Unplanned settlements were serviced by primary centers or first-level hospitals. ZDHS findings show that by 2018, at least one ANC visit and institutional delivery became nearly universal throughout Lusaka, but early and four or more ANC visits, C-sections, and neonatal mortality rates remained worse among poorer than richer women in ZDHS. In HMIS, ANC and institutional delivery volumes were highest in public facilities, especially in unplanned settlements. The volume of C-sections was much greater within facilities in planned than unplanned settlements. Our study exposed persistent gaps in timing and use of ANC and emergency obstetric care between unplanned and planned communities. Closing such gaps requires strengthening outreach early and consistently in pregnancy and increasing emergency obstetric care capacities and referrals to improve access to important MNH services for women and newborns in Lusaka's unplanned settlements.

Improving health literacy through group antenatal care: results from a cluster randomized controlled trial in Ghana.

BACKGROUND: Although the majority of Ghanaian women receive antenatal care (ANC), many exhibit low health literacy by misinterpreting and incorrectly operationalizing ANC messages, leading to poor maternal and newborn health outcomes. Prior research in low-resource settings has found group antenatal care (G-ANC) feasible for women and providers. This study aims to determine the effect of G-ANC on increasing maternal health literacy. We hypothesized that pregnant women randomized into G-ANC would exhibit a greater increase in maternal health literacy than women in routine, individual ANC. METHODS: A 5-year cluster randomized controlled trial was conducted in 14 rural and peri-urban health facilities in the Eastern Region of Ghana. Facilities were paired based on patient volume and average gestational age at ANC enrollment and then randomized into intervention (G-ANC) vs. control (routine, individual ANC); 1761 pregnant women were recruited. Data collection occurred at baseline (T0) and post-birth (T2) using the Maternal Health Literacy scale, a 12-item composite scale to assess maternal health literacy. Logistic regression compared changes in health literacy from T0 to T2. RESULTS: Overall, women in both the intervention and control groups improved their health literacy scores over time (p < 0.0001). Women in the intervention group scored significantly higher on 3 individual items and on overall composite scores (p < 0.0001) and were more likely to attend 8 or more ANC visits. CONCLUSION: While health literacy scores improved for all women attending ANC, women randomized into G-ANC exhibited greater improvement in overall health literacy post-birth compared to those receiving routine individual care. Life-saving information provided during ANC must be presented in an understandable format to prevent women and newborns from dying of preventable causes. TRIAL REGISTRY: Ethical approval for the study was obtained from the Institutional Review Boards of the University of Michigan (HUM#00161464) and the Ghana Health Service (GHS-ERC: 016/04/19).

Changes in health facility readiness for obstetric and neonatal care services in Nepal: an analysis of cross-sectional health facility survey data in 2015 and 2021.

BACKGROUND: Nepal is committed to achieving the Sustainable Development Goal (SDG) 2030 target 3.1 of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. Along with increasing access to health facility (HF)-based delivery services, improving HF readiness is critically important. The majority of births in Nepal are normal low-risk births and most of them take place in public HFs, as does the majority of maternal deaths. This study aims to assess changes in HF readiness in Nepal between 2015 and 2021, notably, if HF readiness for providing high-quality services for normal low-risk deliveries improved; if the functionality of basic emergency obstetric and neonatal care (BEmONC) services increased; and if infection prevention and control improved. METHODS: Cross-sectional data from two nationally representative HF-based surveys in 2015 and 2021 were analyzed. This included 457 HFs in 2015 and 804 HFs in 2021, providing normal low-risk delivery services. Indices for HF readiness for normal low-risk delivery services, BEmONC service functionality, and infection prevention and control were computed. Independent sample T-test was used to measure changes over time. The results were stratified by public versus private HFs. RESULTS: Despite a statistically significant increase in the overall HF readiness index for normal low-risk delivery services, from 37.9% in 2015 to 43.7%, in 2021, HF readiness in 2021 remained inadequate. The availability of trained providers, essential medicines for mothers, and basic equipment and supplies was high, while that of essential medicines for newborns was moderate; availability of delivery care guidelines was low. BEmONC service functionality did not improve and remained below five percent facility coverage at both time points. In private HFs, readiness for good quality obstetrical care was higher than in public HFs at both time points. The infection prevention and control index improved over time; however, facility coverage in 2021 remained below ten percent. CONCLUSIONS: The slow progress and sub-optimal readiness for normal, low-risk deliveries and infection prevention and control, along with declining and low BEmONC service functionality in 2021 is reflective of poor quality of care and provides some proximate explanation for the moderately high maternal mortality and the stagnation of neonatal mortality in Nepal. To reach the SDG 2030 target of reducing maternal deaths, Nepal must hasten its efforts to strengthen supply chain systems to enhance the availability and utilization of essential medicines, equipment, and supplies, along with guidelines, to bolster the human resource capacity, and to implement mechanisms to monitor quality of care. In general, the capacity of local governments to deliver basic healthcare services needs to be increased.

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.

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

BACKGROUND: 60% of women in Papua New Guinea (PNG) give birth unsupervised and outside of a health facility, contributing to high national maternal and perinatal mortality rates. We evaluated a practical, hospital-based on-the-job training program implemented by local health authorities in PNG between 2013 and 2019 aimed at addressing this challenge by upskilling community health workers (CHWs) to provide quality maternal and newborn care in rural health facilities. METHODS: Two provinces, the Eastern Highlands and Simbu Provinces, were included in the study. In the Eastern Highlands Province, a baseline and end point skills assessment and post-training interviews 12 months after completion of the 2018 training were used to evaluate impacts on CHW knowledge, skills, and self-reported satisfaction with training. Quality and timeliness of referrals was assessed through data from the Eastern Highlands Province referral hospital registers. In Simbu Province, impacts of training on facility births, stillbirths and referrals were evaluated pre- and post-training retrospectively using routine health facility reporting data from 2012 to 2019, and negative binomial regression analysis adjusted for potential confounders and correlation of outcomes within facilities. RESULTS: The average knowledge score increased significantly, from 69.8% (95% CI:66.3-73.2%) at baseline, to 87.8% (95% CI:82.9-92.6%) following training for the 8 CHWs participating in Eastern Highlands Province training. CHWs reported increased confidence in their skills and ability to use referral networks. There were significant increases in referrals to the Eastern Highlands provincial hospital arriving in the second stage of labour but no significant difference in the 5 min Apgar score for children, pre and post training. Data on 11,345 births in participating facilities in Simbu Province showed that the number of births in participating rural health facilities more than doubled compared to prior to training, with the impact increasing over time after training (0-12 months after training: IRR 1.59, 95% CI: 1.04-2.44, p-value 0.033, > 12 months after training: IRR 2.46, 95% CI:1.37-4.41, p-value 0.003). There was no significant change in stillbirth or referral rates. CONCLUSIONS: Our findings showed positive impacts of the upskilling program on CHW knowledge and practice of participants, facility births rates, and appropriateness of referrals, demonstrating its promise as a feasible intervention to improve uptake of maternal and newborn care services in rural and remote, low-resource settings within the resourcing available to local authorities. Larger-scale evaluations of a size adequately powered to ascertain impact of the intervention on stillbirth rates are warranted.

Prioritization of maternal and newborn health policies and their implementation in the eastern conflict affected areas of the Democratic Republic of Congo: a political economy analysis.

BACKGROUND: Maternal and neonatal mortality remains a major concern in the Democratic Republic of Congo (DRC), and the country's protracted crisis context exacerbates the problem. This political economy analysis examines the maternal and newborn health (MNH) prioritization in the DRC, focussing specifically on the conflict-affected regions of North and South Kivu. The aim is to understand the factors that facilitate or hinder the prioritization of MNH policy development and implementation by the Congolese government and other key actors at national level and in the provinces of North and South Kivu. METHODS: Using a health policy triangle framework, data collection consisted of in-depth interviews with key actors at different levels of the health system, combined with a desk review. Qualitative data were analysed using inductive and then deductive approaches, exploring the content, process, actor dynamics, contextual factors and gender-related factors influencing MNH policy development and implementation. RESULTS: The study highlighted the challenges of prioritizing policies in the face of competing health and security emergencies, limited resources and governance issues. The universal health coverage policy seems to offer hope for improving access to MNH services. Results also revealed the importance of international partnerships and global financial mechanisms in the development of MNH strategies. They reveal huge gender disparities in the MNH sector at all levels, and the need to consider cultural factors that can positively or negatively impact the success of MNH policies in crisis zones. CONCLUSIONS: MNH is a high priority in DRC, yet implementation faces hurdles due to financial constraints, political influences, conflicts and gender disparities. Addressing these challenges requires tailored community-based strategies, political engagement, support for health personnel and empowerment of women in crisis areas for better MNH outcomes.

To leave no one behind: Assessing utilization of maternal newborn and child health services by all the 13 particularly vulnerable tribal groups (PVTGs) of Odisha, India.

BACKGROUND: Indigenous tribal people experience lower coverage of maternal, newborn and child healthcare (MNCH) services worldwide, including in India. Meanwhile, Indian tribal people comprise a special sub-population who are even more isolated, marginalized and underserved, designated as particularly vulnerable tribal groups (PVTGs). However, there is an extreme paucity of evidence on how this most vulnerable sub-population utilizes health services. Therefore, we aimed to estimate MNCH service utilization by all the 13 PVTGs of the eastern Indian state of Odisha and compare that with state and national rates. METHODS: A total of 1186 eligible mothers who gave birth to a live child in last 5 years, were interviewed using a validated questionnaire. The weighted MNCH service utilization rates were estimated for antenatal care (ANC), intranatal care (INC), postnatal care (PNC) and immunization (for 12-23-month-old children). The same rates were estimated for state (n = 7144) and nationally representative samples (n = 176 843) from National Family Health Survey-5. RESULTS: The ANC service utilization among PVTGs were considerably higher than national average except for early pregnancy registration (PVTGs 67% versus national 79.9%), and 5 ANC components (80.8% versus 82.3%). However, their institutional delivery rates (77.9%) were lower than averages for Odisha (93.1%) and India (90.1%). The PNC and immunization rates were substantially higher than the national averages. Furthermore, the main reasons behind greater home delivery in the PVTGs were accessibility issues (29.9%) and cultural barriers (23.1%). CONCLUSION: Ours was the first study of MNCH service utilization by PVTGs of an Indian state. It is very pleasantly surprising to note that the most vulnerable subpopulation of India, the PVTGs, have achieved comparable or often greater utilization rates than the national average, which may be attributable to overall significantly better performance by the Odisha state. However, PVTGs have underperformed in terms of timely pregnancy registration and institutional delivery, which should be urgently addressed.

The (temporary) Covid-19 baby bust in Mexico.

In this paper, we investigate whether fertility and newborn health changed during the Covid-19 pandemic in Mexico. We use national administrative data and an event-study design to examine the impact of the Covid-19 pandemic on fertility and newborn health characteristics. Our findings suggest that Mexico's fertility declined temporarily as measured by conceptions that likely occurred during the stay-at-home order. Initially, the general fertility rate fell by 11-12 per cent but quickly rebounded and returned close to its original levels by the end of 2021. Newborn health also deteriorated during the pandemic. Instances of low birthweight and prematurity substantially increased, with both remaining elevated over the entire pandemic period.

Provider Perceptions on Bereavement Following Newborn Death: A Qualitative Study from Ethiopia and Ghana.

OBJECTIVE: The objective of this study was to explore how clinicians in low- and middle-income countries engage and support parents following newborn death. STUDY DESIGN: Qualitative interviews of 40 neonatal clinicians with diverse training were conducted in Addis Ababa, Ethiopia, and Kumasi, Ghana. Transcribed interviews were analyzed and coded through the constant comparative method. RESULTS: Three discrete themes around bereavement communication emerged. (1) Concern for the degree of grief experienced by mothers and apprehension to further contribute to it. This led to modified communication to shield her from emotional trauma. (2) Acknowledgment of cultural factors impacting neonatal loss. Clinicians reported that loss of a newborn is viewed differently than loss of an older child and is associated with a diminished degree of public grief; however, despite cultural expectations dictating private grief, interview subjects noted that mothers do suffer emotional pain when a newborn dies. (3) Barriers impeding communication and psychosocial support for families, often relating to language differences and resource limitations. CONCLUSIONS: Neonatal mortality remains the leading global cause of mortality under age 5, with the majority of these deaths occurring in low- and middle-income countries, yet scant literature exists on approaches to communication around end-of-life and bereavement care for neonates in these settings. We found that medical providers in Ghana and Ethiopia described structural and cultural challenges that they navigate following the death of a newborn when communicating and supporting bereaved parents.

Multidomain and multilevel strategies to improve equity in maternal and newborn health services in Nepal: perspectives of health managers and policymakers.

BACKGROUND: Nepal has committed to achieving universal coverage of quality maternal and newborn health (MNH) services by 2030. Achieving this, however, requires urgently addressing the widening inequity gradient in MNH care utilisation. This qualitative study examined the multidomain systemic and organisational challenges, operating in multi-level health systems, that influence equitable access to MNH services in Nepal. METHODS: Twenty-eight in-depth interviews were conducted with health policymakers and program managers to understand supply-side perspectives of drivers of inequity in MNH services. Braun and Clarke's thematic approach was employed in analysing the data. Themes were generated and explained using a multidomain (structural, intermediary, and health system) and multi-level (micro, meso and macro) analytical framework. RESULTS: Participants identified underlying factors that intersect at the micro, meso and macro levels of the health system to create inequity in MNH services. Key challenges identified at the macro (federal) level included corruption and poor accountability, weak digital governance and institutionalisation of policies, politicisation of the health workforce, poor regulation of private MNH services, weak health management, and lack of integration of health in all policies. At the meso (provincial) level, identified factors included weak decentralisation, inadequate evidence-based planning, lack of contextualizing health services for the population, and non-health sector policies. Challenges at the micro (local) level were poor quality health care, inadequate empowerment in household decision making and lack of community participation. Structural drivers operated mostly at macro-level political factors; intermediary challenges were within the non-health sector but influenced supply and demand sides of health systems. CONCLUSIONS: Multidomain systemic and organisational challenges, operating in multi-level health systems, influence the provision of equitable health services in Nepal. Policy reforms and institutional arrangements that align with the country's federalised health system are needed to narrow the gap. Such reform efforts should include policy and strategic reforms at the federal level, contextualisation of macro-policies at the provincial level, and context-specific health service delivery at the local level. Macro-level policies should be guided by political commitment and strong accountability, including a policy framework for regulating private health services. The decentralisation of power, resources, and institutions at the provincial level is essential for technical support to the local health systems. Integrating health in all policies and implementation is critical in addressing contextual social determinants of health.

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.

Quality of maternal and newborn health care at private hospitals in Iraq: a cross-sectional study.

BACKGROUND: Approximately 25% of facility births take place in private health facilities. Recent national studies of maternal and newborn health (MNH) service availability and quality have focused solely on the status of public sector facilities, leaving a striking gap in information on the quality of maternal and newborn care services. METHODS: A rapid cross-sectional assessment was conducted in November 2022 to assess the quality of MNH services at private hospitals in Iraq. Multi-stage sampling was used to select 15% of the country's 164 private hospitals. Assessment tools included a facility assessment checklist, a structured health worker interview tool, and a structured client exit interview tool. Data collection was conducted using KoboToolbox software on Android tablets, and analysis conducted using SPSS v28. RESULTS: All hospitals visited provided MNH services and had skilled personnel present or on-call 24 h/day, 7 days/week. Most births (88%) documented between January and June 2022 were cesarean births. Findings indicate that nearly all hospitals have the human resources, equipment, medicines and supplies necessary for quality antenatal, intrapartum and early essential newborn care, and many are also equipped with special units and resources needed to care for small and sick babies. However, while resources are in place for basic and advanced care, there are gaps in knowledge and practice of high-impact interventions that require few or no resources to perform, including skin-to-skin thermal care and support for early initiation of breastfeeding. Person-centered maternity care scores suggest that private hospitals offer a positive experience of care for all clients, however there is room for improvement in provider-client communication. CONCLUSIONS: This assessment highlights the need for deeper dives into factors that underly decisions about how and where to give birth, and both understanding and practice of early essential newborn care and pre-discharge examinations and counseling at private healthcare facilities in Iraq. Engaging private health facility staff in efforts to monitor and improve the quality of maternal and newborn care, with a focus on early essential newborn care and provider-client communication for all clients, will ensure that women and newborns benefit from the best care possible with available resources.

Length of stay and determinants of early discharge after facility-based childbirth in Cameroon: analysis of the 2018 Demographic and Health Survey.

BACKGROUND: A minimum length of stay following facility birth is a prerequisite for women and newborns to receive the recommended monitoring and package of postnatal care. The first postnatal care guidelines in Cameroon were issued in 1998 but adherence to minimum length of stay has not been assessed thus far. The objective of this study was to estimate the average length of stay and identify determinants of early discharge after facility birth. METHODS: We analyzed the Cameroon 2018 Demographic and Health Survey. We included 4,567 women who had a live birth in a heath facility between 2013 and 2018. We calculated their median length of stay in hours by mode of birth and the proportion discharged early (length of stay < 24 h after vaginal birth or < 5 days after caesarean section). We assessed the association between sociodemographic, context-related, facility-related, obstetric and need-related factors and early discharge using bivariate and multivariable logistic regression. RESULTS: The median length of stay (inter quartile range) was 36 (9-84) hours after vaginal birth (n = 4,290) and 252 (132-300) hours after caesarean section (n = 277). We found that 28.8% of all women who gave birth in health facilities were discharged too early (29.7% of women with vaginal birth and 15.1% after a caesarean section). Factors which significantly predicted early discharge in multivariable regression were: maternal age < 20 years (compared to 20-29 years, aOR: 1.44; 95%CI 1.13-1.82), unemployment (aOR: 0.78; 95%CI: 0.63-0.96), non-Christian religions (aOR: 1.65; 95CI: 1.21-2.24), and region of residence-Northern zone aOR:9.95 (95%CI:6.53-15.17) and Forest zone aOR:2.51 (95%CI:1.79-3.53) compared to the country's capital cities (Douala or Yaounde). None of the obstetric characteristics was associated with early discharge. CONCLUSIONS: More than 1 in 4 women who gave birth in facilities in Cameroon were discharged too early; this mostly affected women following vaginal birth. The reasons leading to lack of adherence to postnatal care guidelines should be better understood and addressed to reduce preventable complications and provide better support to women and newborns during this critical period.

Effect of mentorship and a mHealth application in updating provider skills and knowledge in maternal and newborn care in two informal settlements of Nairobi.

BACKGROUND: Children and women in urban informal settlements have fewer choices to access quality maternal and newborn health care. Many facilities serving these communities are under-resourced and staffed by fewer providers with limited access to skills updates. We sought to increase provider capacity by equipping them with skills to provide general and emergency obstetric and newborn care in 24 facilities serving two informal settlements in Nairobi. We present evidence of the combined effect of mentorship using facility-based mentors who demonstrate skills, support skills drills training, and provide practical feedback to mentees and a self-guided online learning platform with easily accessible EmONC information on providers' smart phones. METHODS: We used mixed methods research with before and after cross-sectional provider surveys conducted at baseline and end line. During end line, 18 in-depth interviews were conducted with mentors and mentees who were exposed, and providers not exposed to the intervention to explore effectiveness and experience of the intervention on quality maternal health services. RESULTS: Results illustrated marked improvement from ability to identify antepartum hemorrhage (APH), postpartum hemorrhage (PPH), manage retained placenta, ability to identify and manage obstructed labour, Pre-Eclampsia and Eclampsia (PE/E), puerperal sepsis, and actions taken to manage conditions when they present. Overall, out of 95 elements examined there were statistically significant improvements of both individual scores and overall scores from 29/95 at baseline (30.5%) to 44.3/95 (46.6%) during end line representing a 16- percentage point increase (p > 0.001). These improvements were evident in public health facilities representing a 17.3% point increase (from 30.9% at baseline to 48.2% at end line, p > 0.001). Similarly, providers working in private facilities exhibited a 15.8% point increase in knowledge from 29.7% at baseline to 45.5% at end line (p = 0.0001). CONCLUSION: This study adds to the literature on building capacity of providers delivering Maternal and Newborn Health (MNH) services to women in informal settlements. The complex challenges of delivering MNH services in informal urban settings where communities have limited access require a comprehensive approach including ensuring access to supplies and basic equipment. Nevertheless, the combined effects of the self-guided online platform and mentorship reinforces EmONC knowledge and skills. This combined approach is more likely to improve provider competency, and skills as well as improving maternal and newborn health outcomes.

Service delivery interventions to improve maternal and newborn health in low- and middle-income countries: scoping review of quality improvement, implementation research and health system strengthening approaches.

INTRODUCTION: This review explores the characteristics of service delivery-related interventions to improve maternal and newborn health (MNH) in low-and middle-income countries (LMICs) over the last two decades, comparing three common framings of these interventions, namely, quality improvement (QI), implementation science/research (IS/IR), and health system strengthening (HSS). METHODS: The review followed the staged scoping review methodology proposed by Levac et al. (2010). We developed and piloted a systematic search strategy, limited to English language peer-reviewed articles published on LMICs between 2000 and March 2022. Analysis was conducted in two-quantitative and qualitative-phases. In the quantitative phase, we counted the year of publication, country(-ies) of origin, and the presence of the terms 'quality improvement', 'health system strengthening' or 'implementation science'/ 'implementation research' in titles, abstracts and key words. From this analysis, a subset of papers referred to as 'archetypes' (terms appearing in two or more of titles, abstract and key words) was analysed qualitatively, to draw out key concepts/theories and underlying mechanisms of change associated with each approach. RESULTS: The searches from different databases resulted in a total of 3,323 hits. After removal of duplicates and screening, a total of 231 relevant articles remained for data extraction. These were distributed across the globe; more than half (n = 134) were published since 2017. Fifty-five (55) articles representing archetypes of the approach (30 QI, 16 IS/IR, 9 HSS) were analysed qualitatively. As anticipated, we identified distinct patterns in each approach. QI archetypes tended towards defined process interventions (most typically, plan-do-study-act cycles); IS/IR archetypes reported a wide variety of interventions, but had in common evaluation methodologies and explanatory theories; and HSS archetypes adopted systemic perspectives. Despite their distinctiveness, there was also overlap and fluidity between approaches, with papers often referencing more than one approach. Recognising the complexity of improving MNH services, there was an increased orientation towards participatory, context-specific designs in all three approaches. CONCLUSIONS: Programmes to improve MNH outcomes will benefit from a better appreciation of the distinctiveness and relatedness of different approaches to service delivery strengthening, how these have evolved and how they can be combined.

Community perspectives and experiences of quality maternal and newborn care in East New Britain, Papua New Guinea.

BACKGROUND: Quality maternal and newborn care is essential for improving the health of mothers and babies. Low- and middle-income countries, such as Papua New Guinea (PNG), face many barriers to achieving quality care for all. Efforts to improve the quality of maternal and newborn care must involve community in the design, implementation, and evaluation of initiatives to ensure that interventions are appropriate and relevant for the target community. We aimed to describe community members' perspectives and experiences of maternal and newborn care, and their ideas for improvement in one province, East New Britain, in PNG. METHODS: We undertook a qualitative descriptive study in partnership with and alongside five local health facilities, health care workers and community members, using a Partnership Defined Quality Approach. We conducted ten focus group discussions with 68 community members (identified through church, market and other community-based groups) in East New Britain PNG to explore perspectives and experiences of maternal and newborn care, identify enablers and barriers to quality care and interventions to improve care. Discussions were transcribed verbatim. A mixed inductive and deductive analysis was conducted including application of the World Health Organisation (WHO) Quality Maternal and Newborn Care framework. RESULTS: Using the WHO framework, we present the findings in accordance with the five experience of care domains. We found that the community reported multiple challenges in accessing care and facilities were described as under-staffed and under resourced. Community members emphasised the importance of good communication and competent, caring and respectful healthcare workers. Both women and men expressed a strong desire for companionship during labor and birth. Several changes were suggested by the community that could immediately improve the quality of care. CONCLUSIONS: Community perspectives and experiences are critical for informing effective and sustainable interventions to improve the quality of maternal and newborn care and increasing facility-based births in PNG. A greater understanding of the care experience as a key component of quality care is needed and any quality improvement initiatives must include the user experience as a key outcome measure.

Improving the care provided to, and experienced by, women and their families during pregnancy and childbirth is important for improving the health of mothers and babies. Community members should be involved in thinking about appropriate ways to improve care. Papua New Guinea (PNG) is a country in the Pacific which faces multiple challenges to improving care during pregnancy and birth. We aimed to understand what community members think about care provided and experienced during labour and birth in East New Britain, a rural province of PNG. We worked with five health facilities, health workers and community members in East New Britain to develop a qualitative research project. We carried out 10 focus group discussions with community members in East New Britain to understand what the provision and experience of care was like during labour and birth, and ways that it could be improved. We found that community members identified multiple challenges in getting to facilities and many facilities were found to have not enough supplies, equipment, or staff. Community members wanted staff that were good at their work but also caring and respectful. Women wanted to have support people present during labour and birth and many men wanted to be present too. Our results show that it is important to understand what the community thinks about the quality of care during labour and birth and this information is helpful to design effective activities to improve the care provided and experienced.

Perspectives of stakeholders regarding the value of maternal and newborn health interventions and practices supported by UNICEF and other partners in the West Nile region of Uganda: a qualitative study.

INTRODUCTION: Uganda has high maternal, neonatal, and under-five mortality rates. This study documents stakeholder perspectives on best practices in a maternal and newborn health (MNH) quality-improvement programme implemented in the West Nile region of Uganda to improve delivery and utilisation of MNH services. METHODS: This exploratory cross-sectional qualitative study, conducted at the end of 2021, captured the perspectives of stakeholders representing the different levels of the healthcare system. Data were collected in four districts through: interviews with key informants working at all levels of the health system; focus group discussions with parents and caretakers and with community health workers; and interviews with individual community members whose lives had been impacted by the MNH programme. The initial content analysis was followed by a deductive synthesis pitched according to the different levels of the health system and the health-systems building blocks. RESULTS: The findings are summarised according to the health-systems building blocks and an account is given of three of the interventions most valued by participants: (1) data use for evidence-based decision making (with regard to human resources, essential reproductive health commodities, and financing); (2) establishment of special newborn care units and high-dependency maternity units at district hospitals and training of the health workforce (also with reference to other infrastructural improvements such as the provision of water, sanitation and hygiene facilities at health facilities); and (3) community referral of pregnant women through a commercial motorcycle voucher referral system. CONCLUSION: The MNH programme in the West Nile region adopted a holistic and system-wide approach to addressing the key bottlenecks in the planning, delivery, and monitoring of quality MNH services. There was general stakeholder appreciation across the board that the interventions had the potential to improve quality of care and newborn and maternal health outcomes. However, as the funding was largely donor-driven, questions about government ownership and sustainability in the context of limited resources remain.

Stakeholders' perspectives on the acceptability and feasibility of maternity waiting homes: a qualitative synthesis.

BACKGROUND: Maternity waiting homes (MHWs) are recommended to help bridge the geographical gap to accessing maternity services. This study aimed to provide an analysis of stakeholders' perspectives (women, families, communities and health workers) on the acceptability and feasibility of MWHs. METHODS: A qualitative evidence synthesis was conducted. Studies that were published between January 1990 and July 2020, containing qualitative data on the perspectives of the stakeholder groups were included. A combination of inductive and deductive coding and thematic synthesis was used to capture the main perspectives in a thematic framework. RESULTS: Out of 4,532 papers that were found in the initial search, a total of 38 studies were included for the thematic analysis. Six themes emerged: (1) individual factors, such as perceived benefits, awareness and knowledge of the MWH; (2) interpersonal factors and domestic responsibilities, such as household and childcare responsibilities, decision-making processes and social support; (3) MWH characteristics, such as basic services and food provision, state of MWH infrastructure; (4) financial and geographical accessibility, such as transport availability, costs for MWH attendance and loss of income opportunity; (5) perceived quality of care in the MWH and the adjacent health facility, including regular check-ups by health workers and respectful care; and (6) Organization and advocacy, for example funding, community engagement, governmental involvement. The decision-making process of women and their families for using an MWH involves balancing out the gains and losses, associated with all six themes. CONCLUSION: This systematic synthesis of qualitative literature provides in-depth insights of interrelating factors that influence acceptability and feasibility of MWHs according to different stakeholders. The findings highlight the potential of MWHs as important links in the maternal and neonatal health (MNH) care delivery system. The complexity and scope of these determinants of utilization underlines the need for MWH implementation strategy to be guided by context. Better documentation of MWH implementation, is needed to understand which type of MWH is most effective in which setting, and to ensure that those who most need the MWH will use it and receive quality services. These results can be of interest for stakeholders, implementers of health interventions, and governmental parties that are responsible for MNH policy development to implement acceptable and feasible MWHs that provide the greatest benefits for its users. Trial registration Systematic review registration number: PROSPERO 2020, CRD42020192219.

New Antenatal Model in Africa and India (NAMAI) study: implementation research to improve antenatal care using WHO recommendations.

BACKGROUND: In 2020, an estimated 287 000 women died globally from pregnancy-related causes and 2 million babies were stillborn. Many of these outcomes can be prevented by quality healthcare during pregnancy and childbirth. Within the continuum of maternal health, antenatal care (ANC) is a key moment in terms of contact with the health system, yet it remains an underutilized platform. This paper describes the protocol for a study conducted in collaboration with Ministries of Health and country research partners that aims to employ implementation science to systematically introduce and test the applicability of the adapted WHO ANC package in selected sites across four countries. METHODS: Study design is a mixed methods stepped-wedge cluster randomized implementation trial with a nested cohort component (in India and Burkina Faso). The intervention is composed of two layers: (i) the country- (or state)-specific ANC package, including evidence-based interventions to improve maternal and newborn health outcomes, and (ii) the co-interventions (or implementation strategies) to help delivery and uptake of the adapted ANC package. Using COM-B model, co-interventions support behaviour change among health workers and pregnant women by (1) training health workers on the adapted ANC package and ultrasound (except in India), (2) providing supplies, (3) conducting mentoring and supervision and (4) implementing community mobilization strategies. In Rwanda and Zambia, a fifth strategy includes a digital health intervention. Qualitative data will be gathered from health workers, women and their families, to gauge acceptability of the adapted ANC package and its components, as well as experience of care. The implementation of the adapted ANC package of interventions, and their related costs, will be documented to understand to what extent the co-interventions were performed as intended, allowing for iteration. DISCUSSION: Results from this study aim to build the global evidence base on how to implement quality ANC across different settings and inform pathways to scale, which will ultimately lead to stronger health systems with better maternal and perinatal outcomes. On the basis of the study results, governments will be able to adopt and plan for national scale-up, aiming to improve ANC nationally. This evidence will inform global guidance. TRIAL REGISTRATION NUMBER: ISRCTN, ISRCTN16610902. Registered 27 May 2022. https://www.isrctn.com/ISRCTN16610902.

'Everything's adaptable': A qualitative study of how nurses make decisions in sustained home-visiting care with mothers and children experiencing adversity.

AIMS: To explore nurse decision-making processes in the delivery of sustained home-visiting care for mothers of young children who are experiencing adversity. DESIGN: Qualitative descriptive research design using focus group interviews. METHODS: Thirty-two home-visiting nurses participated in four focus group interviews exploring their decision-making in the care they provide to families. The data were analysed using a reflexive thematic analysis approach. RESULTS: Four steps of a recurring stepwise decision-making process were identified: (1) information gathering; (2) exploring; (3) implementing; (4) checking. The facilitators and barriers to effective decision-making processes were also identified and included elements relating to good relationship skills, a good attitude, high quality training and mentoring and resources. CONCLUSION: The findings indicate that a recurring stepwise process of decision-making requires both analytical and intuitive approaches. The intuition required by home-visiting nurses is to sense unvoiced client needs and identify the right time and way to intervene. The nurses were engaged in adapting the care in response to the client's unique needs while ensuring the fidelity of the programme scope and standards. We recommend creating an enabling working environment with cross-disciplinary team members and having well-developed structures, particularly the feedback systems such as clinical supervision and case reviews. Enhanced skills to establish trusting relationships with clients can help home-visiting nurses make effective decisions with mothers and families, particularly in the face of significant risk. IMPACT: This study explored nurse decision-making processes in the context of sustained home-visiting care, which has been largely unexplored in the research literature. Understanding the effective decision-making processes, particularly when nurses customize or individualize the care in response to the client's unique needs, assists with the development of strategies for precision home-visiting care. The identification of facilitators and barriers informs approaches designed to support nurses in effective decision-making.