Improving post-partum family planning services provided by female community health volunteers in Nepal: a mixed methods study.

BACKGROUND: Family planning services in the post-partum period, termed post-partum family planning (PPFP) is critical to cover the unmet need for contraception, especially when institutional delivery rates have increased. However, the intention to choose PPFP methods such as post-partum intrauterine devices (PPIUD) remains low in countries such as Nepal. Community health workers such as Female Community Health Volunteers (FCHVs) could play an important role in improving the service coverage of PPFP in Nepal. However, their knowledge of PPFP and community-based services related to PPFP remain unclear. This study aims to assess the effect on community-based PPFP services by improving FCHV's knowledge through orientation on PPFP. METHODS: We conducted this mixed-methods study in Morang District in Nepal. The intervention involved orientation of FCHVs on PPFP methods. We collected quantitative data from three sources; via a survey of FCHVs that assessed their knowledge before and after the intervention, from their monthly reporting forms on counseling coverage of women at different stages of pregnancy from the communities, and by interviewing mothers in their immediate post-partum period in two selected hospitals. We also conducted six focus group discussions with the FCHVs to understand their perception of PPFP and the intervention. We performed descriptive and multivariable analyses for quantitative results and thematic analysis for qualitative data. RESULTS: In total, 230 FCHVs participated in the intervention and their knowledge of PPFP improved significantly after it. The intervention was the only factor significantly associated with their improved knowledge (adjusted odds ratio = 24, P < 0.001) in the multivariable analysis. FCHVs were able to counsel 83.3% of 1872 mothers at different stages of pregnancy in the communities. In the two hospitals, the proportion of mothers in their immediate post-partum period whom reported they were counseled by FCHVs during their pregnancy increased. It improved from 7% before the intervention to 18.1% (P < 0.001) after the intervention. The qualitative findings suggested that the intervention improved their knowledge in providing PPFP counseling. CONCLUSION: The orientation improved the FCHV's knowledge of PPFP and their community-based counseling. Follow-up studies are needed to assess the longer term effect of the FCHV's role in improving community-based PPFP services.

Factors affecting the behavior outcomes on post-partum intrauterine contraceptive device uptake and continuation in Nepal: a qualitative study.

BACKGROUND: The use of post-partum family planning (PPFP) methods such as post-partum intrauterine device (PPIUD) in general remains low despite its benefits for the women. The reasons or factors affecting the uptake and continuation of such PPFP methods in developing countries such as Nepal remains unclear. This qualitative research aims to explore the factors affecting PPIUD uptake and continuation related behaviors among post-partum mothers within 6 weeks of childbirth in Nepal. METHODS: This qualitative study was conducted through 43 in-depth interviews among post-partum mothers who delivered in 3 selected hospitals in Nepal. Data were analyzed through content analysis using the theory of planned behavior (TPB) as the theoretical framework. RESULTS: The themes and categories were structured around the three major components of the TPB on attitude, subjective norms, and behavioral control. Majority of the women in this study, irrespective of their behavioral outcome expressed a positive attitude towards PPIUD use. However, the women who expressed an unfavorable attitude towards PPIUD influenced their behavior to not choose or discontinue PPIUD. Subjective norms such as the family, peer, and societal influences against PPIUD negatively affected the women's intention and behavior related to PPIUD. Whereas, the positive influence of the health providers positively affected their behavior. Regarding the behavior control, women who had their own control over decisions tended to use PPIUD. However, external factors such as their husband's preference or medical conditions also played a prominent role in preventing many to use PPIUD despite their positive intentions. CONCLUSION: As suggested in TPB, this study shows that multiple factors that are interlinked affected the behaviors related to uptake and continuation of PPIUD. The attitude helped in s`haping intention but did not always lead to the behavioral outcome of PPIUD uptake and continuation. Subjective norms had a strong influence on both intention and behavior. Behavior control belief also had an important role in the outcome with respect to PPIUD uptake and continuation. Thus, a more layered, multidimensional and interlinked intervention is necessary to bring positive behavior changes related to PPIUD.

Integrating postpartum contraceptive counseling and IUD insertion services into maternity care in Nepal: results from stepped-wedge randomized controlled trial.

BACKGROUND: In Nepal, 54% of women have an unmet need for family planning within the 2 years following a birth. Provision of a long-acting and reversible contraceptive method at the time of birth in health facilities could improve access to postpartum family planning for women who want to space or limit their births. This paper examines the impact of an intervention that introduced postpartum contraceptive counseling in antenatal care and immediate postpartum intra-uterine device (PPIUD) insertion services following institutional delivery, with the intent to eventually integrate PPIUD counseling and insertion services as part of routine maternity care in Nepal. METHODS: This study took place in six large tertiary hospitals. All women who gave birth in these hospitals in the 18-month period between September 2015 and March 2017 were asked to participate. A total of 75,587 women (99.6% consent rate) gave consent to be interviewed while in postnatal ward after delivery and before discharge from hospital. We use a stepped-wedge cluster randomized design with randomization of the intervention timing at the hospital level. The baseline data collection began prior to the intervention in all hospitals and the intervention was introduced into the hospitals in two steps, with first group of three hospitals implementing the intervention 3 months after the baseline had begun, and second group of three hospitals implementing the intervention 9 months after the baseline had begun. We estimate the overall effect using a linear regression with a wild bootstrap to estimate valid standard errors given the cluster randomized design. We also estimate the effect of being counseled on PPIUD uptake. RESULTS: Our Intent-to-Treat analysis shows that being exposed to the intervention increased PPIUD counseling among women by 25 percentage points (pp) [95% CI: 14-40 pp], and PPIUD uptake by four percentage points [95% CI: 3-6 pp]. Our adherence-adjusted estimate shows that, on average, being counseled due to the intervention increased PPIUD uptake by about 17 percentage points [95% CI: 14-40 pp]. CONCLUSIONS: The intervention increased PPIUD counseling rates and PPIUD uptake among women in the six study hospitals. If counseling had covered all women in the sample, PPIUD uptake would have been higher. Our results suggest that providing high quality counseling and insertion services generates higher demand for PPIUD services and could reduce unmet need. TRIAL REGISTRATION: Trial registered on March 11, 2016 with ClinicalTrials.gov, NCT02718222 .

Comparative satisfaction of receiving medical abortion service from nurses and auxiliary nurse-midwives or doctors in Nepal: results of a randomized trial.

BACKGROUND: Early first-trimester medical abortion (MA) service (≤ 63 days) has been provided by doctors and nurses under doctors' supervision since 2009 in Nepal. This paper assesses whether MA services provided by specifically trained and certified nurses and auxiliary nurse-midwives independently from doctors' supervision, is considered as satisfactory by women as those provided by doctors. METHODS: The data come from a multi-center, randomized, controlled equivalence trial conducted between April 2009 and March 2010 in five district hospitals in Nepal. Women seeking MA were randomly assigned to doctors or nurses and auxiliary nurse-midwives(ANMs).Eligible women were administered 200 mg mifepristone orally followed by 800 µg misoprostol vaginally two days later by their assigned providers and followed up 10-14 days later. At the follow-up visit women's reported satisfaction with MA service they received was measured. RESULTS: Of 1295 women screened for eligibility, 535 were randomly assigned to a doctor and 542 to a nurse or ANM. Nineteen women were lost-to-follow up in the former group and 27 were lost-to-follow up or did not complete the acceptability interview in the latter group. This study is, therefore, based on516womenin the doctor's group and 515 women in the nurse or ANM group. All women in the nurse or ANM group reported being satisfied or highly satisfied by MA compared to 99% in the doctor's group. Satisfaction was similar regardless of the type of provider; 38% among nurse or ANM and 35% among the doctor group were "highly satisfied", and 62% and 64%, respectively, were "satisfied". Women's experiences such as 'less than expected amount or duration of bleeding following MA', 'shorter than expected duration of the abortion process', and 'able to manage symptoms', were found to be associated with women's higher satisfaction with MA. Counseling and information on the method, potential complications of MA and post-abortion contraception was nearly universal. No statistically significant differences were found in the level of satisfaction by age, parity, marital status, education or occupation of women. CONCLUSIONS: Women's satisfaction with MA service provided by trained nurses or auxiliary nurse-midwives was similar to that provided by doctors. The findings, therefore, provide support for extending safe and accessible medical abortion services by government-trained nurses and auxiliary nurse midwives to women seeking early first trimester pregnancy termination. TRIAL REGISTRATION: The trial was retrospectively registered with ClinicalTrials.gov (identifier: NCT01186302 ). Registered August 20, 2010.

Optimizing treatment for the prevention of pre-eclampsia/eclampsia in Nepal: is calcium supplementation during pregnancy cost-effective?

BACKGROUND: In Nepal, pre-eclampsia/eclampsia (PE/E) causes an estimated 21% of maternal deaths annually and contributes to adverse neonatal birth outcomes. Calcium supplementation has been shown to reduce the risk of PE/E for pregnant women and preterm birth. This study presents findings from a cost-effectiveness analysis of a pilot project, which provided calcium supplementation through the public sector to pregnant women during antenatal care for PE/E prevention as compared to existing PE/E management in Nepal. METHODS: Economic costs were assessed from program and societal perspectives for the May 2012 to August 2013 analytic time horizon, drawing from implementing partner financial records and the literature. Effects were calculated as disability-adjusted life years (DALYs) averted for mothers and newborns. A decision tree was used to model the cost-effectiveness of three strategies delivered through the public sector: (i) calcium supplementation in addition to the existing standard of care (MgSO4); (ii) standard of care, and (iii) no treatment. Uncertainty was assessed using one-way and probabilistic sensitivity analyses in TreeAge Pro. RESULTS: The costs to start-up calcium introduction in addition to MgSO4 were $44,804, while the costs to support ongoing program implementation were $72,852. Collectively, these values correspond to a program cost per person per year of $0.44. The calcium program corresponded to a societal cost per DALY averted of $25.33 ($25.22-29.50) when compared against MgSO4 treatment. Primary cost drivers included rate for facility delivery, costs associated with hospitalization, and the probability of developing PE/E. The addition of calcium to the standard of care corresponds to slight increases in effect and cost, and has a 84% probability of cost-effectiveness above a WTP threshold of $40 USD when compared to the standard of care alone. CONCLUSIONS: Calcium supplementation for pregnant mothers for prevention of PE/E provided with MgSO4 for treatment holds promise for the cost-effective reduction of maternal and neonatal morbidity and mortality associated with PE/E. The findings of this study compare favorably with other low-cost, high priority interventions recommended for South Asia. Additional research is recommended to improve the rigor of evidence available on the treatment strategies and health outcomes.

Coverage, compliance, acceptability and feasibility of a program to prevent pre-eclampsia and eclampsia through calcium supplementation for pregnant women: an operations research study in one district of Nepal.

BACKGROUND: Calcium supplementation during pregnancy has been shown to reduce the incidence of pre-eclampsia/eclampsia among women with low calcium intake. Universal free calcium supplementation through government antenatal care (ANC) services was piloted in the Dailekh district of Nepal. Coverage, compliance, acceptability and feasibility of the intervention were evaluated. METHODS: Antenatal care providers were trained to distribute and counsel pregnant women about calcium use, and female community health volunteers (FCHVs) were trained to reinforce calcium-related messages. A post-intervention cluster household survey was conducted among women who had given birth in the last six months. Secondary data analysis was performed using monitoring data from health facilities and FCHVs. RESULTS: One Thousand Two hundred-forty postpartum women were interviewed. Most (94.6 %) had attended at least one ANC visit; the median gestational age at first ANC visit was 4 months. All who attended ANC were counseled about calcium and received calcium tablets to take daily until delivery.79.5 % of the women reported consuming the entire quantity of calcium they received. The full course of calcium (300 tablets for 150 days) was provided to 82.3 % of the women. Consumption of the full course of calcium was reported by 67.3 % of all calcium recipients. Significant predictors of completing a full course were gestational age at first ANC visit and number of ANC visits during their most recent pregnancy (p < 0.01). Nearly all (99.2 %) reported taking the calcium as instructed with respect to dose, timing and frequency. Among women who received both calcium and iron (n = 1,157), 98.0 % reported taking them at different times of the day, as instructed. Over 97 % reported willingness to recommend calcium to others, and said they would like to use it during a subsequent pregnancy. There were no stock-outs of calcium. CONCLUSIONS: Calcium distribution through ANC was feasible and effective, achieving 94.6 % calcium coverage of pregnant women in the district. Most women (over 80 %) attended ANC early enough in pregnancy to receive the full course of calcium supplements and benefit from the intervention. High coverage, compliance, acceptability among pregnant women and feasibility were reported, suggesting that this intervention can be scaled up in other areas of Nepal.

Post-pregnancy family planning in Southeast Asia with a focus on novel training techniques.

Postpartum Family Planning is a critical strategy in the first 12 months post-childbirth. It aims to prevent unintended, closely spaced pregnancies and thereby help reducing maternal, neonatal as well as child morbidity and mortality. Despite its significance, many women remain without contraception despite a desire to avoid pregnancy. The World Health Organization suggests a 24-month inter-pregnancy interval after delivery, emphasizing the importance of contraceptive counselling from the antenatal to the immediate postpartum period. In South Asia, utilization of PPFP is minimal, even though the inclination towards birth spacing is high. Addressing these needs requires strengthening the capacity of service providers and promoting evidence-based practices. Novel training approaches in South Asia are Competency-Based On-the-Job Training, Group Based Training, Simulation Training, E-Learning, Mentorship Programs, and Continuing Professional Development. Among these, On-the-Job Training and Group Based Training were notably implemented. Emphasizing PPFP and ensuring proper training in this domain is essential for women's health and well-being post-delivery.

Can midlevel health-care providers administer early medical abortion as safely and effectively as doctors? A randomised controlled equivalence trial in Nepal.

BACKGROUND: Medical abortion is under-used in developing countries. We assessed whether early fi rst-trimester medical abortion provided by midlevel providers (government-trained, certified nurses and auxiliary nurse midwives) was as safe and effective as that provided by doctors in Nepal. METHODS: This multicentre randomised controlled equivalence trial was done in fi ve rural district hospitals in Nepal. Women were eligible for medical abortion if their pregnancy was of less than 9 weeks (63 days) and if they resided less than 90 min journey away from the study clinic. Women were ineligible if they had any contraindication to medical abortion. We used a computer-generated randomisation scheme stratified by study centre with a block size of six. Women were randomly assigned to a doctor or a midlevel provider for oral administration of 200 mg mifepristone followed by 800 µg misoprostol vaginally 2 days later, and followed up 10-4 days later. The primary endpoint was complete abortion without manual vacuum aspiration within 30 days of treatment. The study was not masked. Abortions were recorded as complete, incomplete, or failed (continuing pregnancy). Analyses for primary and secondary endpoints were by intention to treat, supplemented by per-protocol analysis of the primary endpoint. This trial is registered with ClinicalTrials.gov, NCT01186302. FINDINGS: Of 1295 women screened, 535 were randomly assigned to a doctor and 542 to a midlevel provider. 514 and 518, respectively, were included in the analyses of the primary endpoint. Abortions were judged complete in 504 (97.3%) women assigned to midlevel providers and in 494 (96.1%) assigned to physicians. The risk difference for complete abortion was 1.24% (95% CI -0.53 to 3.02), which falls within the predefined equivalence range (-5% to 5%). Five cases (1%) were recorded as failed abortion in the doctor cohort and none in the midlevel provider cohort; the remaining cases were recorded as incomplete abortions. No serious complications were noted. INTERPRETATION: The provision of medical abortion up to 9 weeks' gestation by midlevel providers and doctors was similar in safety and effectiveness. Where permitted by law, appropriately trained midlevel health-care providers can provide safe, low-technology medical abortion services for women independently from doctors. FUNDING: UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), World Health Organization.

A prospective study of complications from comprehensive abortion care services in Nepal.

BACKGROUND: In March 2002, Nepal's Parliament approved legislation to permit abortion on request up to 12 weeks of pregnancy. Between 2004 and 2007, 176 comprehensive abortion care (CAC) service sites were established in Nepal, leading to a rise in safe, legal abortions. Though monitoring systems have been developed, reporting of complications has not always been complete or accurate. The purpose of this study was to report the frequency and type of abortion complications arising from CAC procedures in different types of facilities in Nepal. METHODS: A total of 7,386 CAC clients from a sample of facilities across Nepal were enrolled over a three-month period in 2008. Data collection included an initial health questionnaire at the time of abortion care and a follow-up questionnaire assessing complications, administered two weeks after the abortion procedure. A total of 7,007 women (95%) were successfully followed up. Complication rates were assessed overall and by facility type. Multivariable logistic regression was used to assess the association between experiencing a complication and client demographic and facility characteristics. RESULTS: Among the 7,007 clients who were successfully followed, only 1.87% (n = 131) experienced signs and symptoms of complications at the two-week follow up, the most common being retained products of conception (1.37%), suspected sepsis (0.39%), offensive discharge (0.51%) and moderate bleeding (0.26%). Women receiving care at non-governmental organization (NGO) facilities were less likely to experience complications than women at government facilities, adjusting for individual and facility characteristics (AOR = 0.18; 95% CI: 0.08-0.40). Compared to women receiving CAC at 4-5 weeks gestation, women at 10-12 weeks gestation were more likely to experience complications, adjusting for individual and facility characteristics (AOR = 4.21; 95% CI: 1.38-12.82). CONCLUSIONS: The abortion complication rate in Nepali CAC facilities is low and similar to other settings; however, significant differences in complication rates were observed by facility type and gestational age. Interventions such as supportive supervision to improve providers' uterine evacuation skills and investment in equipment for infection control may lower complication rates in government facilities. In addition, there should be increased focus on early pregnancy detection and access to CAC services early in pregnancy in order to prevent complications.

Developing rubella vaccination policy in Nepal--results from rubella surveillance and seroprevalence and congenital rubella syndrome studies.

BACKGROUND: The Government of Nepal is interested in preventing congenital rubella syndrome (CRS). Surveillance data were analyzed and studies conducted to assess the burden of rubella and CRS and aid in developing a rubella vaccination strategy. METHODS: (1) Analysis of rubella cases reported through measles surveillance, 2004-2009; (2) in 2008, rubella seroprevalence among women 15 to 39 years of age was evaluated; and (3) in 2009, children attending a school for the deaf were examined for ocular defects associated with CRS. RESULTS: From 2004-2009, there were 3,710 confirmed rubella cases and more than 95% of these cases were less than 15 years of age. Of 2,224 women of childbearing age (WCBA) tested for anti-rubella IgG, 2,020 (90.8%) were seropositive. Using a catalytic infection model, approximately 1,426 infants were born with CRS (192/100,000 live births) in 2008. Among 243 students attending a school for the deaf, 18 (7.4%) met the clinical criteria for CRS. CONCLUSIONS: Rubella and CRS were documented as significant public health problems in Nepal. A comprehensive approach is necessary, including introducing rubella vaccine in the routine program, assuring immunity among WCBA, strengthening routine immunization, integrating rubella surveillance with measles case-based surveillance, and establishing CRS surveillance.

Implementation of maternal and perinatal death surveillance and response (MPDSR) in humanitarian settings: insights and experiences of humanitarian health practitioners and global technical expert meeting attendees.

BACKGROUND: Maternal and perinatal death surveillance and response (MPDSR) is a system of identifying, analysing and learning lessons from such deaths in order to respond and prevent future deaths, and has been recommended by WHO and implemented in many low-and-middle income settings in recent years. However, there is limited documentation of experience with MPDSR in humanitarian settings. A meeting on MPDSR in humanitarian settings was convened by WHO, UNICEF, CDC and Save the Children, UNFPA and UNHCR on 17th-18th October 2019, informed by semi-structured interviews with a range of professionals, including expert attendees. CONSULTATION FINDINGS: Interviewees revealed significant obstacles to full implementation of the MPDSR process in humanitarian settings. Many obstacles were familiar to low resource settings in general but were amplified in the context of a humanitarian crisis, such as overburdened services, disincentives to reporting, accountability gaps, a blame approach, and politicisation of mortality. Factors more unique to humanitarian contexts included concerns about health worker security and moral distress. There are varying levels of institutionalisation and implementation capacity for MPDSR within humanitarian organisations. It is suggested that if poorly implemented, particularly with a punitive or blame approach, MPDSR may be counterproductive. Nevertheless, successes in MPDSR were described whereby the process led to concrete actions to prevent deaths, and where death reviews have led to improved understanding of complex and rectifiable contextual factors leading to deaths in humanitarian settings. CONCLUSIONS: Despite the challenges, examples exist where the lessons learnt from MPDSR processes have led to improved access and quality of care in humanitarian contexts, including successful advocacy. An adapted approach is required to ensure feasibility, with varying implementation being possible in different phases of crises. There is a need for guidance on MPDSR in humanitarian contexts, and for greater documentation and learning from experiences.

Evaluating the impact of female community health volunteer involvement in a postpartum family planning intervention in Nepal: A mixed-methods study at one-year post-intervention.

INTRODUCTION: This is a one-year post-intervention study following an initiative to provide orientation to female community health volunteers (FCHVs) on postpartum family planning in Nepal. In light of positive results in the earlier post-intervention study, this study was designed to provide a more long-term perspective on sustainability by assessing the effect at one-year post-intervention. METHODS: This mixed-methods study was conducted in January 2020 in Morang district, Nepal. We collected quantitative data from a knowledge assessment of FCHVs who had participated in the intervention on postpartum family planning, data on their community-based counseling coverage and through interviews with postpartum mothers in two selected hospitals. Qualitative data were collected through six key informant interviews with health providers and four focus group discussions with FCHVs involved in the intervention. We performed descriptive and multivariate analyses for quantitative data and thematic analysis for qualitative data. RESULTS: In total, 206 FCHVs participated in the one-year post-intervention study with significant improvement in knowledge of postpartum family planning as compared to pre-intervention period. The adjusted odds ratios (AOR) for knowledge of the 5 key messages on postpartum family planning as compared to the pre-intervention period included 1) knowledge on postpartum family planning can be used immediately after birth (AOR = 18.1, P<0.001), 2) postpartum intra-uterine device (PPIUD) can provide protection up to 12 years (AOR = 2.9, P = 0.011), 3) mothers who undergo cesarean section can use PPIUD (AOR = 2.3, P<0.001), 4) PPIUD can be inserted immediately after birth (AOR = 6.2, P <0.001), and 5) women should go for follow-up immediately if the IUD strings are seen outside vulva (AOR = 2.0, P = 0.08). The FCHVs answering 4 or more questions correctly was 10 times higher (AOR = 10.1, P<0.001) at one-year post-intervention, whereas it was 25 times higher at immediate-post-test (AOR = 25.1, p<0.001) as compared to pre-intervention phase. The FCHVs had counseled 71% of the pregnant women (n = 538) within their communities at one-year post-intervention. The postpartum mothers in hospitals had a 2 times higher odds of being counseled by FCHVs during their pregnancy at one-year post-intervention (AOR = 1.8, P = 0.039) than in pre-intervention phase. The qualitative findings suggested a positive impression regarding the FCHV's involvement in postpartum family planning counseling in the communities, however, supervision and monitoring over a longer term was identified as a key challenge and that may influence sustainability of community-based and hospital-based postpartum family planning services. CONCLUSION: The FCHVs' knowledge and community-based activities on postpartum family planning remained higher than in the pre-intervention. However, it declined when compared to the immediate post-intervention period. We propose regular supervision and monitoring of the work of the FCHVs to sustain progress.

Should female community health volunteers (FCHVs) facilitate a response to gender-based violence (GBV)? A mixed methods exploratory study in Mangalsen, Nepal.

ABSTRACTAs part of a multisectoral response to gender-based violence (GBV), Nepal is testing the feasibility of having female community health volunteers (FCHVs) play a formal role in identifying GBV survivors and referring them to specialised services at health facilities. This study followed 116 FHCVs in Mangalsen municipality who attended a one-day orientation on GBV. Over the following year, data were collected from knowledge and attitude assessments of FCHVs, focus group discussions with FCHVs, and members of Mothers' Groups for Health. Most Significant Change stories were collected from FCHVs, in-depth interviews with stakeholders, and service statistics. Results show that the FCHVs' knowledge increased, attitudes changed, and confidence in addressing GBV grew. During the study period, FCHVs identified 1,253 GBV survivors and referred 221 of them to health facilities. In addition to assisting GBV survivors, FCHVs worked to prevent GBV by mediating conflicts and curbing harmful practices such as menstrual isolation. Stakeholders viewed FCHVs as a sustainable resource for identifying and referring GBV survivors to services, while women trusted them and looked to them for help. Results show that, with proper training and safety mechanisms, FCHVs can raise community awareness about GBV, facilitate support for survivors, and potentially help prevent harmful practices.

Maternal Mortality in the United States Compared With Ethiopia, Nepal, Brazil, and the United Kingdom: Contrasts in Reproductive Health Policies.

Maternal mortality is falling in most of the world's countries, but, for 20 years, the United States has seen no reduction. Over this period, a dozen countries in various stages of development, all spending much less than the United States on health, achieved their United Nations' Millennium Development Goal of 2015 (Millennium Development Goal 5: improve maternal health), with substantial reductions in maternal mortality rates. To consider whether interventions successful in reducing global maternal mortality rates could help the United States to lower its rate, the American College of Obstetricians and Gynecologists, at the 2018 International Federation of Gynecology and Obstetrics' Rio de Janeiro World Congress, convened a panel of the presidents and representatives from five national societies with wide maternal mortality rate ranges and health expenditures and whose national societies had focused on reducing maternal mortality for Millennium Development Goal 5. They identified expanded access to reproductive health care, particularly contraception and safe abortion, as key interventions that had proven effective in decreasing maternal mortality rates worldwide.

Assessing Implementation of Maternal and Perinatal Death Surveillance and Response in Rwanda.

Maternal deaths remain a major public health concern in low- and middle-income countries. Implementation of maternal and perinatal deaths surveillance and response (MPDSR) is vital to reduce preventable deaths. The study aimed to assess implementation of MPDSR in Rwanda. We applied mixed methods following the six-step audit cycle for MPDSR to determine the level of implementation at 10 hospitals and three health centers. Results showed various stages of implementation of MPDSR across facilities. Maternal death audits were conducted regularly, and facilities had action plans to address modifiable factors. However, perinatal death audits were not formally done. Implementation was challenged by lack of enough motivated staff, heavy workload, lack of community engagement, no linkages with existing quality improvement efforts, no guidelines for review of stillbirths, incomplete medical records, poor classification of cause of death, and no sharing of feedback among others. Implementation of MPDSR varied from facility to facility indicating varying capacity gaps. There is need to integrate perinatal death audits with maternal death audits and ensure the process is part of other quality improvement initiatives at the facility level. More efforts are needed to support health facilities to improve implementation of MPDSR and contribute to achieving sustainable development goal (SDG) 3.

"It might be a statistic to me, but every death matters.": An assessment of facility-level maternal and perinatal death surveillance and response systems in four sub-Saharan African countries.

BACKGROUND: Maternal and perinatal death surveillance and response (MPDSR) systems aim to understand and address key contributors to maternal and perinatal deaths to prevent future deaths. From 2016-2017, the US Agency for International Development's Maternal and Child Survival Program conducted an assessment of MPDSR implementation in Nigeria, Rwanda, Tanzania, and Zimbabwe. METHODS: A cross-sectional, mixed-methods research design was used to assess MPDSR implementation. The study included a desk review, policy mapping, semistructured interviews with 41 subnational stakeholders, observations, and interviews with key informants at 55 purposefully selected facilities. Using a standardised tool with progress markers defined for six stages of implementation, each facility was assigned a score from 0-30. Quantitative and qualitative data were analysed from the 47 facilities with a score above 10 ('evidence of MPDSR practice'). RESULTS: The mean calculated MPDSR implementation progress score across 47 facilities was 18.98 out of 30 (range: 11.75-27.38). The team observed variation across the national MPDSR guidelines and tools, and inconsistent implementation of MPDSR at subnational and facility levels. Nearly all facilities had a designated MPDSR coordinator, but varied in their availability and use of standardised forms and the frequency of mortality audit meetings. Few facilities (9%) had mechanisms in place to promote a no-blame environment. Some facilities (44%) could demonstrate evidence that a change occurred due to MPDSR. Factors enabling implementation included clear support from leadership, commitment from staff, and regular occurrence of meetings. Barriers included lack of health worker capacity, limited staff time, and limited staff motivation. CONCLUSION: This study was the first to apply a standardised scoring methodology to assess subnational- and facility-level MPDSR implementation progress. Structures and processes for implementing MPDSR existed in all four countries. Many implementation gaps were identified that can inform priorities and future research for strengthening MPDSR in low-capacity settings.

Prevalence of Postpartum Family Planning Service Coverage in Selected Referral Facilities of Nepal.

INTRODUCTION: Nepal Society of Obstetricians and Gynecologists jointly with the Nepalese government and with the support from the International Federation of Obstetrics and Gynecology has implemented an initiative to institutionalize postpartum family planning services in selected major referral facilities of Nepal to address the gap of low uptake of postpartum family planning in Nepal. The aim of the study is to find the prevalence of the service coverage of postpartum contraception in the selected facilities. METHODS: A descriptive cross-sectional study was conducted in seven major referral facilities across Nepal. Data were collected from the hospital records of all women who delivered in these facilities between October 2018 and March 2019. Ethical approval for this study was obtained from Nepal Health Research Council. Data analysis was done with SPSS version 23. RESULTS: Among the 29,072 deliveries from all the facilities, postpartum family planning counseling coverage was 27,301 (93.9%). The prevalence of uptake of Postpartum Intrauterine Device is 1581 (5.4%) and female sterilization is 1830 (6.3%). In total 11387 mothers (52.2%) had the intention to choose a postpartum family planning method. However, 36% of mothers neither used nor had the intention to choose a postpartum family planning method. CONCLUSIONS: The coverage of Postpartum Intrauterine Device counseling service coverage in Nepal is higher in 2018 as compared to 2016-2017 and in other countries implementing Postpartum Intrauterine Device initiatives. However, the prevalence of service coverage of immediate Postpartum Family Planning methods, mainly Postpartum Intrauterine Device in 2018 is lower in Nepal as compared to 2016-2017, and other countries implementing Postpartum Intrauterine Device initiative. More efforts are needed to encourage mothers delivering in the facilities to use the postpartum family planning method.

Postpartum hemorrhage care bundles to improve adherence to guidelines: A WHO technical consultation.

OBJECTIVE: To systematically develop evidence-based bundles for care of postpartum hemorrhage (PPH). METHODS: An international technical consultation was conducted in 2017 to develop draft bundles of clinical interventions for PPH taken from the WHO's 2012 and 2017 PPH recommendations and based on the validated "GRADE Evidence-to-Decision" framework. Twenty-three global maternal-health experts participated in the development process, which was informed by a systematic literature search on bundle definitions, designs, and implementation experiences. Over a 6-month period, the expert panel met online and via teleconferences, culminating in a 2-day in-person meeting. RESULTS: The consultation led to the definition of two care bundles for facility implementation. The "first response to PPH bundle" comprises uterotonics, isotonic crystalloids, tranexamic acid, and uterine massage. The "response to refractory PPH bundle" comprises compressive measures (aortic or bimanual uterine compression), the non-pneumatic antishock garment, and intrauterine balloon tamponade (IBT). Advocacy, training, teamwork, communication, and use of best clinical practices were defined as PPH bundle supporting elements. CONCLUSION: For the first response bundle, further research should assess its feasibility, acceptability, and effectiveness; and identify optimal implementation strategies. For the response to refractory bundle, further research should address pending controversies, including the operational definition of refractory PPH and effectiveness of IBT devices.

Institutionalizing postpartum family planning and postpartum intrauterine device services in Nepal: Role of training and mentorship.

OBJECTIVE: To explore the perceptions of key stakeholders on different modalities of training and mentoring activities for healthcare providers of postpartum family planning and postpartum intrauterine devices (PPFP/PPIUD). METHODS: In this qualitative study, data were collected from 40 participants in December 2017 via focus group discussions (FGD) and in-depth interviews (IDI) in three hospitals implementing PPFP/PPIUD services and government line agencies in Nepal. Data were analyzed through content analysis and grouped into themes and categories. RESULTS: The majority of participants reported that PPFP/PPIUD training and mentoring was useful and contributed to their professional development. Most found that on-the-job training (OJT) was more effective than group-based training (GBT). CONCLUSION: Training and mentoring activities were perceived to be useful by health providers and OJT was the approach preferred by the majority. Further studies are necessary to explore the existing challenges and long-term effects of each modality of training and mentoring on health providers' competency and attitudes and on the uptake of PPIUD by postpartum mothers.

Factors influencing the likelihood of acceptance of postpartum intrauterine devices across four countries: India, Nepal, Sri Lanka, and Tanzania.

OBJECTIVE: To examine the factors that positively influenced the likelihood of accepting provision of postpartum intrauterine devices (PPIUDs) across four countries: Sri Lanka, Nepal, Tanzania, and India. METHODS: Healthcare providers were trained across 24 facilities in counselling and insertion of PPIUDs as part of a large multicountry study. Women delivered were asked to take part in a 15-minute face-to-face structured interview conducted by in-country data collection officers prior to discharge. Univariate analysis was performed to investigate factors associated with acceptance. RESULTS: From January 2016 to November 2017, 6477 health providers were trained, 239 033 deliveries occurred, and 219 242 interviews were conducted. Of those interviewed, 68% were counselled on family planning and 56% on PPIUD, with 20% consenting to PPIUD. Multiple counselling sessions was the only factor resulting in higher consent rates (OR 1.30-1.39) across all countries. Odds ratios for women's age, parity, and cadre of provider counselling varied between countries. CONCLUSION: Consent for contraception, specifically PPIUD, is such a culturally specific topic and generalization across countries is not possible. When planning contraceptive policy changes, it is important to have an understanding of the sociocultural factors at play.