Intimate partner violence and postpartum healthcare access in Kenya: a cross-sectional study.

BACKGROUND: Intimate partner violence (IPV) impacts physical health, mental health, and healthcare use. IPV during pregnancy, in particular, is associated with lower rates of antenatal care, but no studies have assessed the association between IPV and postpartum healthcare. This study aims to examine the link between IPV (emotional, physical, and sexual) and two outcomes: postpartum healthcare use and access to family planning. METHODS: This study uses data from a cross-sectional survey of 859 women in Nairobi and Kiambu counties in Kenya who gave birth during the COVID-19 pandemic in 2020. RESULTS: In this sample, 36% of women reported ever experiencing IPV. Of those, 33% indicated the frequency of IPV stayed the same or increased during COVID-19. Nearly 17% of women avoided postpartum healthcare and 10% experienced issues accessing family planning. Those who experienced any form of IPV during pregnancy had approximately twice the odds of avoiding postpartum healthcare compared to those who did not experience any form of IPV. Compared to those who did not experience IPV during pregnancy, experiencing sexual IPV was associated with 2.25 times higher odds of reporting issues accessing family planning. Additionally, reporting fair or poor self-rated health was associated with both avoiding postpartum healthcare and reporting issues accessing family planning. Experiencing food insecurity was also associated with avoiding postpartum healthcare. CONCLUSIONS: To our knowledge, this is the first study to establish the link between IPV during pregnancy and postpartum healthcare access. During COVID-19 in Kenya, postpartum women who had experienced IPV were at increased risk of disengagement with healthcare services. Women should be screened for IPV during pregnancy and postpartum in order to better support their healthcare needs. In times of crisis, such as pandemics, policymakers and healthcare providers must address barriers to healthcare for postpartum women.

Integrating support persons into maternity care and associations with quality of care: a postpartum survey of mothers and support persons in Kenya.

BACKGROUND: Despite research that has shown that the presence of support persons during maternity care is associated with more respectful care, support persons are frequently excluded due to facility practices or negative attitudes of providers. Little quantitative research has examined how integrating support persons in maternity care has implications for the quality of care received by women, a potential pathway for improving maternal and neonatal health outcomes. This study aimed to investigate how integrating support persons in maternity care is associated with multiple dimensions of the quality of maternity care. METHODS: We used facility-based cross-sectional survey data from women (n = 1,138) who gave birth at six high-volume facilities in Nairobi and Kiambu counties in Kenya and their support persons (n = 606) present during the immediate postpartum period. Integration was measured by the Person-Centered Integration of Support Persons (PC-ISP) items. We investigated quality of care outcomes including person-centered care outcomes (i.e., Person-Centered Maternity Care (PCMC) and Satisfaction with care) and clinical outcomes (i.e., Implementation of WHO-recommended clinical practices). We used fractional regression with robust standard errors to estimate associations between PC-ISP and care outcomes. RESULTS: Compared to low integration, high integration (≥four woman-reported PC-ISP experiences vs. <4) was associated with multiple dimensions of quality care: 3.71%-point (95% CI: 2.95%, 4.46%) higher PCMC scores, 2.76%-point higher (95% CI: 1.86%, 3.65%) satisfaction with care scores, and 4.43%-point (95% CI: 3.52%, 5.34%) higher key clinical practices, controlling for covariates. PC-ISP indicators related to communication with providers showed stronger associations with quality of care compared to other PC-ISP sub-constructs. Some support person-reported PC-ISP experiences were positively associated with women's satisfaction and key practices. CONCLUSIONS: Integrating support persons, as key advocates for women, is important for respectful maternity care. Practices to better integrate support persons, especially improving communication between support persons with providers, can potentially improve the person-centered and clinical quality of maternity care in Kenya and other low-resource settings.

Beyond "Chilling Effects": Latinx and Asian Immigrants' Experiences With Enforcement and Barriers to Health Care.

OBJECTIVES: Immigration enforcement policies are associated with immigrants' barriers to health care. Current evidence suggests that enforcement creates a "chilling effect" in which immigrants avoid care due to fear of encountering enforcement. Yet, there has been little examination of the impact of immigrants' direct encounters with enforcement on health care access. We examined some of the first population-level data on Asian and Latinx immigrants' encounters with law and immigration enforcement and assessed associations with health care access. METHODS: We analyzed the 2018 and 2019 Research on Immigrant Health and State Policy survey in which Asian and Latinx immigrants in California (n=1681) reported on 7 enforcement experiences (eg, racial profiling and deportation). We examined the associations between measures of individual and cumulative enforcement experiences and the usual sources of care and delay in care. RESULTS: Latinx, compared with Asian respondents, reported the highest levels of enforcement experiences. Almost all individual enforcement experiences were associated with delaying care for both groups. Each additional cumulative experience was associated with a delay in care for both groups (OR=1.30, 95% CI 1.10-1.50). There were no associations with the usual source of care. CONCLUSION: Findings confirm that Latinx immigrants experience high levels of encounters with the enforcement system and highlight new data on Asian immigrants' enforcement encounters. Direct experiences with enforcement have a negative relationship with health care access. Findings have implications for health systems to address the needs of immigrants affected by enforcement and for changes to health and immigration policy to ensure immigrants' access to care.

Access to support during childbirth?: women's preferences and experiences of support person integration in a cross-sectional facility-based survey.

BACKGROUND: Integrating support persons into maternity care, such as making them feel welcome or providing them with information, is positioned to increase support for women and improve birth outcomes. Little quantitative research has examined what support women need and how the healthcare system currently facilitates support for women. We introduce the Person-Centered Integration of Support Persons (PC-ISP) concept, based on a review of the literature and propose four PC-ISP domains-Welcoming environment, Decision-making support, Provision of information and education and Ability to ask questions and express concerns. We report on women's preferences and experiences of PC-ISP. METHODS: We developed PC-ISP measures based on the literature and applied these in a facility-based survey with 1,138 women after childbirth in six health facilities in Nairobi and Kiambu counties in Kenya from September 2019 to January 2020. RESULTS: We found an unmet need for integrating support persons during childbirth. Between 73.6 and 93.6% of women preferred integration of support persons during maternity care, but only 45.3-77.9% reported to have experienced integration. Women who reported having a male partner support person reported more PC-ISP experiences (B0.13; 95% CI 0.02, 0.23) than those without. Employed women were more likely to report having the opportunity to consult support persons on decisions (aOR1.26; 95% CI 1.07, 1.50) and report that providers asked if support persons should be informed about their condition and care (aOR1.29; 95% CI 1.07, 1.55). Women with more providers attending birth were more likely to report opportunities to consult support persons on decisions (aOR1.53; 95% CI 1.09, 2.15) and that support persons were welcome to ask questions (aOR1.84, 95% CI 1.07, 2.54). CONCLUSIONS: Greater efforts to integrate support persons for specific roles, including decision-making support, bridging communication and advocacy, are needed to meet women's needs for support in maternity care.

"It is not by choice that I gave birth at home": the social determinants of home births during COVID-19 in peri-urban and urban Kenya, a qualitative study.

BACKGROUND: The COVID-19 pandemic significantly impacted the provision of global maternal health services, with an increase in home births. However, there are little data on women's decision-making and experiences leading up to home births during the pandemic. The objective of this study is to examine the economic, social, and health system factors associated with home births in Kenya. METHODS: Community health volunteers (CHVs) and village leaders helped identify potential participants for an in-depth, one-on-one, qualitative telephone interview in Nairobi and Kiambu County in Kenya. In total, the study interviewed 28 mothers who had home births. RESULTS: This study identified a number of economic, social, neighborhood, and health system factors that were associated with birthing at home during the COVID-19 pandemic. Only one woman had planned on birthing at home, while all other participants described various reasons they had to birth at home. Themes related to home births during the pandemic included: (1) unmet preferences related to location of birth; (2) burdens and fear of contracting COVID-19 leading to delayed or missed care; (3) lack of perceived community safety and fear of encounters with law enforcement; and (4) healthcare system changes and uncertainty that led to home births. CONCLUSION: Addressing and recognizing women's social determinants of health is critical to ensuring that preferences on location of birth are met.

Person-centred sexual and reproductive health: A call for standardized measurement.

Person-centred sexual and reproductive health (PCSRH) care refers to care that is respectful of and responsive to people's preferences, needs, and values, and which empowers them to take charge of their own sexual and reproductive health (SRH). It is an important indicator of SRH rights and quality of care. Despite the recognition of the importance of PCSRH, there is a gap in standardized measurement in some SRH services, as well as a lack of guidance on how similar person-centred care measures could be applied across the SRH continuum. Drawing on validated scales for measuring person-centred family planning, abortion, prenatal and intrapartum care, we propose a set of items that could be validated in future studies to measure PCSRH in a standardized way. A standardized approach to measurement will help highlight gaps across services and facilitate efforts to improve person-centred care across the SRH continuum. PATIENT OR PUBLIC CONTRIBUTION: This viewpoint is based on a review of validated scales that were developed through expert reviews and cognitive interviews with services users and providers across the different SRH services. They provided feedback on the relevance, clarity, and comprehensiveness of the items in each scale.

Association between immigration enforcement encounters and COVID-19 testing and delays in care: a cross-sectional study of undocumented young adult immigrants in california.

BACKGROUND: Undocumented immigrants are expected to face increased risks related to COVID-19 due to marginalizing restrictive immigration policies. However, few studies have assessed the prevalence of direct encounters with the immigration enforcement system among the undocumented and its impacts on their COVID-related health behaviors and outcomes. In this study, we quantify undocumented immigrants' lifetime exposure to various immigration enforcement tactics and their association with delays in COVID-19 testing and healthcare behaviors. METHODS: This cross-sectional study included a non-random sample of 326 Asian and Latinx undocumented immigrants in California from September 2020 to February 2021. The primary exposure was immigration enforcement encounter scores ranging from 0-9, assessed through self-reports of direct experiences with the immigration system, immigration officials, and law enforcement. The main outcomes were positive test for COVID-19, had or suspected having COVID-19, and delayed or avoided testing and/or treatment for COVID-19 due to immigration status. We used multivariable logistic regression models to examine the association between the primary exposure and outcomes of interest. RESULTS: Among 326 participants, 7% had received a positive COVID-19 test result, while 43% reported having or suspected having COVID-19. Almost 13% delayed or avoided COVID-19 testing and/or treatment because of their immigration status. Overall, an increase in immigration enforcement encounters was associated with higher odds of suspecting having had COVID-19 (aOR = 1.13; 95% CI: 1.01,1.26). Reporting an additional enforcement encounter was associated with higher odds of delaying or avoiding testing and/or treatment because of immigration status (aOR = 1.53, 95% CI: 1.26,1.86). Compared to their Latino counterparts, Asian respondents were more likely to report higher odds of delaying or avoiding testing and/or treatment (aOR = 3.13, 95% CI: 1.17,8.42). There were no significant associations between the enforcement score and testing positive for COVID-19. Additionally, while Latinxs were more likely to report immigration enforcement encounters than Asians, there were no differences in the effects of race on COVID-19 testing and healthcare behaviors in models with race as an interaction term (p < 0.05). CONCLUSIONS: Immigration enforcement encounters compound barriers to COVID-19 testing and treatment for undocumented immigrants.

The association between Deferred Action for Childhood Arrivals, health access, and mental health: the role of discrimination, medical mistrust, and stigma.

OBJECTIVE: There are approximately 11 million undocumented immigrants in the US, including 1.3 million young adults who are eligible for the Deferred Action for Childhood Arrivals (DACA) program. It is unclear how DACA influences engagement in healthcare or depressive symptoms, and the role of discrimination, medical mistrust, and stigma in healthcare settings. This study assesses the association of DACA on undocumented young adults' engagement with health care and depressive symptoms. DESIGN: We conducted an internet-based survey examining the health-related experiences of undocumented Latino and Asians and Pacific Islander (API) young adults in California (n = 218) between June and August 2017. Multivariable logistic regressions were conducted to assess the influence of DACA, discrimination, medical mistrust, and stigma on healthcare engagement and depressive symptoms. RESULTS: Approximately 78% of respondents had a gap in healthcare, and about 31% reported high levels of depressive symptoms. Controlling for demographic characteristics, compared to those without DACA, DACA-recipients had lower odds of reporting gaps in healthcare engagement (aOR = 0.270, p < 0.05) and depressive symptoms (aOR = 0.115, p < 0.01). Those facing discrimination, medical mistrust, and stigma in healthcare settings were less likely to have a healthcare visit and more likely to have higher depressive symptoms. CONCLUSIONS: DACA is a potential strategy to improve healthcare access and address the mental health of undocumented populations. In particular, issues of discrimination, stigma by healthcare providers, and medical mistrust need to be addressed.

Development of the person-centered prenatal care scale for people of color.

BACKGROUND: Given the stark disparities in maternal mortality and adverse birth outcomes among Black, indigenous, and other people of color, there is a need to better understand and measure how individuals from these communities experience their care during pregnancy. OBJECTIVE: This study aimed to develop and validate a tool that can be used to measure person-centered prenatal care that reflects the experiences of people of color. STUDY DESIGN: We followed standard procedures for scale development-integrated with community-based participatory approaches-to adapt a person-centered maternity care scale that was initially developed and validated for intrapartum care in low-resource countries to reflect the needs and prenatal care experiences of people of color in the United States. The adaptation process included expert reviews with a Community Advisory Board, consisting of community members, community-based health workers, and social service providers from San Francisco, Oakland, and Fresno, to assess content validity. We conducted cognitive interviews with potential respondents to assess the clarity, appropriateness, and relevance of the questions, which were then refined and administered in an online survey to people in California who had given birth in the past year. Data from 293 respondents (84% of whom identified as Black) who received prenatal care were used in psychometric analysis to assess construct and criterion validity and reliability. RESULTS: Exploratory factor analysis yielded 3 factors with eigenvalues of >1, but with 1 dominant factor. A 34-item version of the person-centered prenatal care scale was developed based on factor analyses and recommendations from the Community Advisory Board. We also developed a 26-item version using stricter criteria for relevance, factor loadings, and uniqueness. Items were grouped into 3 conceptual domains representing subscales for "dignity and respect," "communication and autonomy," and "responsive and supportive care." The Cronbach alphas for the 34-item and the 26-item versions and for the subscales were >0.8. Scores based on the sum of responses for the 2 person-centered prenatal care scale versions and all subscales were standardized to range from 0 to 100, where higher scores indicate more person-centered prenatal care. These scores were correlated with global measures of prenatal care satisfaction suggesting good criterion validity. CONCLUSION: We present 2 versions of the person-centered prenatal care scale: a 34-item and a 26-item version. Both versions have high validity and reliability in a sample made up predominantly of Black women. This scale will facilitate measurement to improve person-centered prenatal care for people of color and could contribute to reducing disparities in birth outcomes. The similarity with the original scale also suggests that the person-centered prenatal care may be applicable across different contexts. However, validation with more diverse samples in additional settings is needed.

The association between social ties and depression among Asian and Pacific Islander undocumented young adults.

BACKGROUND: The mental health of Asian and Pacific Islander (API) undocumented young adults has been understudied, despite an increasingly restrictive immigration climate that would ostensibly raise mental health risks. This study examined the role of social ties and depression among API undocumented young adults. We distinguished between two types of social ties, bonding and bridging, and additionally considered the absence of ties (e.g. isolation). METHODS: We used primary data collected among 143 API undocumented young adults. We first identified correlates for each type of social tie and then examined the association for each measure with depression. RESULTS: Higher levels of bonding and bridging ties were associated with lower odds of a positive depression screen. In contrast, isolation was associated with higher odds of a positive depression screen. There were no significant associations between total social ties and depression. CONCLUSIONS: Our findings suggest that both bonding and bridging ties are important factors in the mental health of API undocumented young adults. Factors that facilitate these types of ties, such as DACA, can be effective interventions for improving mental health among this population.

Person-centred care for abortion services in private facilities to improve women's experiences in Kenya.

Globally, access to good quality abortion services and post-abortion care is a critical determinant for women's survival after unsafe abortion. Unsafe abortions account for high levels of maternal death in Kenya. We explored women's experiences and perceptions of their abortion and post-abortion care experiences in Kenya through person-centred care. This qualitative study included focus group discussions and in-depth interviews with women aged 18-35 who received safe abortion services at private clinics. Through thematic analyses of women's testimonies, we identified gaps in the abortion care and person-centred domains which seemed to be important throughout the abortion process. When women received clear communication and personalised comprehensive information on abortion and post-abortion care from their healthcare providers, they reported more positive experiences overall and higher reproductive autonomy. Communication and supportive care were particularly valued during the post-abortion period, as was social support more generally. Further research is needed to design, implement and test the feasibility and acceptability of person-centred abortion care interventions in community and clinical settings with the goal of improving women's abortion experiences and overall reproductive health outcomes.

Development and validation of a person-centered abortion scale: the experiences of care in private facilities in Kenya.

BACKGROUND: There is a need for a standardized way to measure person-centered care for abortion. This study developed and validated a measure of person-centered abortion care. METHODS: Items for person-centered abortion care were developed from literature reviews, expert review, and cognitive interviews, and administered with 371 women who received a safe abortion service from private health clinics in Nairobi, Kenya. Exploratory factor analyses were performed and stratified by surgical abortion procedures and medication abortion. Bivariate linear regressions assessed for criterion validity. RESULTS: We developed a 24-item unifying scale for person-centered abortion care including two sub-scales. The two sub-scales identified were: 1) Respectful and Supportive Care (14 items for medication abortion, 15 items for surgical abortion); and 2) Communication and Autonomy (9 items for both medication and surgical abortion). The person-centered abortion care scale had high content, construct, criterion validity, and reliability. CONCLUSIONS: This validated scale will facilitate measurement and further research to better understand women's experiences during abortion care and to improve the quality of women's overall reproductive health experiences to improve health outcomes.

The health profile of newly-arrived refugee women and girls and the role of region of origin: using a population-based dataset in California between 2013 and 2017.

BACKGROUND: There has been an increasing number of refugee women globally; yet, there is little recent data describing the health profile of refugee women by region of origin in the United States. It is important to monitor the health status of women by region of origin to provide needed targeted interventions. METHODS: We analyzed the Refugee Health Electronic Information System (RHEIS), a population-based dataset that included 14,060 female refugees who entered California between October 3, 2013 and February 15, 2017. We assessed differences in health status by region of origin. RESULTS: Almost one out of three women experienced a traumatic event. Women from Africa and Latin America and the Caribbean experienced higher levels of trauma compared to other regions, including sexual assault, physical, and weapon assault. More than half of women and girls (56.6%) reported experiences of persecution, with Southeast Asians reporting the highest levels. Among women of reproductive age, 7.0% of women were currently pregnant at the time of arrival to the US, 19.0% ever had a spontaneous abortion, and 8.6% reported ever having an abortion. One in three women from Africa reported female genital cutting. Moreover, 80.0% of women reported needing language assistance at the time of their health assessment. CONCLUSIONS: Refugee women and girls experience high levels of trauma and persecution, suggesting the need for trauma-informed care. Those working with refugee women, such as resettlement agencies and health providers, should be equipped with information about antenatal care, nutrition, and pregnancy to newly arrived women. Lastly, differences in health status by region of origin indicate a need for tailored interventions and linguistically appropriate health information.

Providers and women's perspectives on person-centered maternity care: a mixed methods study in Kenya.

BACKGROUND: Globally, there has been increasing attention to women's experiences of care and calls for a person-centered care approach. At the heart of this approach is the patient-provider relationship. It is necessary to examine the extent to which providers and women agree on the care that is provided and received. Studies have found that incongruence between women's and providers' perceptions may negatively impact women's compliance, satisfaction, and future use of health facilities. However, there are no studies that examine patient and provider perspectives on person-centered care. METHODS: To fill this gap in the literature, we use cross-sectional data of 531 women and 33 providers in seven government health facilities in Kenya to assess concordance and discordance in person-centered care measures. Additionally, we analyze 41 in-depth interviews with providers from three of these facilities to examine why differences in reporting may occur. Descriptive statistical methods were used to measure the magnitude of differences between reports of women and reports of providers. Thematic analyses were conducted for provider surveys. RESULTS: Our findings suggest high discordance between women and providers' perspectives in regard to person-centered care experiences. On average, women reported lower levels of person-centered care compared to providers, including low respectful and dignified care, communication and autonomy, and supportive care. Providers were more likely to report higher rates of poor health facility environment such as having sufficient staff. We summarize the overarching reasons for the divergence in women and provider reports as: 1) different understanding or interpretation of person-centered care behaviors, and 2) different expectations, norms or values of provider behaviors. Providers rationalized abuse towards women, did not allow a companion of choice, and blamed women for poor patient-provider communication. Women lacked assurance in privacy and confidentiality, and faced challenges related to the health facility environment. Providers attributed poor person-centered care to both individual and facility/systemic factors. CONCLUSIONS: Implications of this study suggests that providers should be trained on person-centered care approaches and women should be counseled on understanding patient rights and how to communicate with health professionals.

Impact of a social franchise intervention program on the adoption of long and short acting family planning methods in hard to reach communities in Myanmar.

Myanmar has experienced slowly rising levels of contraceptive use in recent years. Between 2014 and 2016, Population Services International (PSI)/Myanmar implemented a multi-pronged intervention to increase contraceptive use by leveraging its social marketing clinics and providers, and providing additional community outreach. The aim of this study is to explore trends over time in contraceptive uptake and assess whether exposure to the PSI program was associated with women adopting a method. Baseline and end line data were collected using a repeated cross-sectional survey of married women of reproductive age in 2014 and 2016. We find that use of the implant and intrauterine device (IUD) has increased among contraceptive users over time, although there was no significant association for short-term methods. There was also an increase in all types of method use between time periods compared to non-users of contraception. Women who reported seeing a PSI contraception pamphlet had increased odds of having adopted an IUD or implant in the study period. This suggests that interventions that address both supply and demand side barriers to contraception can have an impact on contraceptive uptake, especially more effective long acting methods.

Racial/Ethnic Disparities in Arrests for Drug Possession After California Proposition 47, 2011-2016.

OBJECTIVES: To evaluate the effects of California Proposition 47, which reclassified felony drug offenses to misdemeanors in 2014, on racial/ethnic disparities in drug arrests. METHODS: Using data on all drug arrests made in California from 2011 to 2016, we compared racial/ethnic disparities in drug arrests between Whites, Blacks, and Latinos, immediately and 1 year after policy changes, controlling for secular and seasonal trends. RESULTS: In the month following passage, absolute Black-White disparities in monthly felony drug arrests decreased from 81 to 44 per 100 000 and continued to decrease over time. There was an immediate increase of 27% in the relative disparity, however, because a higher proportion of felony offense types among Whites was reclassified. Total drug arrest rates also declined, suggesting drug law enforcement was deprioritized. During the first year after enactment, felony drug arrests fell by an estimated 51 985 among Whites, 15 028 among Blacks, and 50 113 among Latinos. CONCLUSIONS: Reducing criminal penalties for drug possession can reduce racial/ethnic disparities in criminal justice exposure and has implications for improving health inequalities linked to social determinants of health.

Development of a Person-Centered Family Planning Scale in India and Kenya.

Despite recognition that person-centered care is a critical component to providing high quality family planning services, there lacks consensus on how to operationalize and measure it. This paper describes the development and validation of a person-centered family planning (PCFP) scale in India and Kenya. Cross-sectional data were collected from 522 women in Kenya and 225 women in India who visited a health facility providing family planning services. Psychometric analyses, including exploratory factor analysis, were employed to assess the validity and reliability of the PCFP scale. Separate scales were developed for India and Kenya due to context-specific items. We assessed criterion validity by examining the association between PCFP and global measures of quality and satisfaction with family planning care. The analysis resulted in a multidimensional PCFP scale, including 20 items in Kenya and 22 items in India. Through iterative factor analysis, two subscales were identified for both countries: "autonomy, respectful care, and communication" and "health facility environment." This scale may be used to evaluate quality improvement interventions and experiences of women globally to support women in achieving their reproductive health goals.

The influence of a community-level breast-feeding promotion intervention programme on breast-feeding practices in Myanmar.

OBJECTIVE: Breast-feeding in the first 6 months of life is critical for ensuring both child health and well-being. Despite efforts to improve breast-feeding practices, recent studies have reported that Myanmar continues to have low rates of exclusive breast-feeding.Design/Setting/SubjectsA community-based breast-feeding promotion programme using trained community members was implemented for 1 year in hard-to-reach townships of Myanmar. The present study assessed the breast-feeding practices using a cross-sectional survey of 610 mothers of children under 2 years old: specifically, breast-feeding within 24 h, exclusive breast-feeding up to 6 months and breast-feeding duration. RESULTS: Using Cox models for breast-feeding duration before 24 months, the hazard of breast-feeding cessation was lower in programme v. non-programme townships (hazard ratio (HR)=0·55; 95 % CI 0·32, 0·95). Mothers who worked as shop owners or ran a family business had lower hazard of breast-feeding cessation (HR=0·13, P<0·05) v. those who worked as supervisors, managers, self-employed and businesswomen. The hazard of breast-feeding cessation was higher in women in higher wealth quintiles v. those in the lowest quintile (lower quintile, HR=3·49, P<0·1; higher quintile, HR=3·50, P<0·1; highest quintile, HR=3·47, P<0·1). CONCLUSIONS: The intervention did not affect exclusive breast-feeding practices or breast-feeding within the first 24 h. Potential reasons include existing high levels of early initiation of breast-feeding due to ongoing government-led maternal and child health activities, and social and traditional practices related to complementary feeding. Community-based breast-feeding programmes should continue to promote exclusive breast-feeding and develop strategies to support working mothers.

Interventions to improve the person-centered quality of family planning services: a narrative review.

Person-centered care, a key component of quality of care, is receiving increased attention for maternal and reproductive health. While many interventions have aimed to improve person-centered care for family planning, there is no known narrative review of person-centered-focused interventions in family planning and the outcomes of these interventions. This narrative review fills this gap by conducting a rigorous analysis of interventions that address person-centered care and measure family planning related outcomes, including quality, knowledge and use/continuation. The search of the published and grey literature, from 1990 to 2015 identified 5530 papers, of which 25 were ultimately included in the analysis (after exclusion criteria was applied). We grouped these interventions under seven domains of person-centered care: dignity, autonomy, privacy/confidentiality, communication, social support, supportive care, and trust. We find that person-centered interventions had high success in improving perceptions of quality and knowledge of family planning among clients; however, results were less consistent in improving family planning uptake and continuation. These findings will help program and policy makers develop interventions that incorporate person-centered components to have the highest likelihood for success in improving clients' experiences and family planning use.

Validation of the person-centered maternity care scale in India.

BACKGROUND: Person-centered care during childbirth is recognized as a critical component of quality of maternity care. But there are few validated tools to measure person-centered maternity care (PCMC). This paper aims to fill this measurement gap. We present the results of the psychometric analysis of the PCMC tool that was previously validated in Kenya using data from India. We aim to assess the validity and reliability of the PCMC scale in India, and to compare the results to those found in the Kenya validation. METHODS: We use data from a cross-sectional survey conducted from August to October 2017 with recently delivered women at 40 government facilities in Uttar Pradesh, India (N = 2018). The PCMC measure used is a previously validated scale with subscales for dignity and respect, communication and autonomy, and supportive care. We performed psychometric analyses, including iterative exploratory and confirmatory factor analysis, to assess construct and criterion validity and reliability. RESULTS: The results provide support for a 27-item PCMC scale in India with a possible score range from 0 to 81, compared to the 30-item PCMC scale in Kenya with a 0 to 90 possible score range. The overall PCMC scale has good reliability (Cronbach alpha = 0.85). Similar to Kenya, we are able to group the items in to three conceptual domains representing subscales for "Dignity and Respect," "Communication and Autonomy," and "Supportive Care." The sub-scales also have relatively good reliability (Cronbach alphas range from 0.67 to 0.73). In addition, increasing scores on the scale is associated with future intentions to deliver in the same facility, suggesting good criterion validity. CONCLUSIONS: This research extends the PCMC literature by presenting results of validating the PCMC scale in a new context. The psychometric analysis using data from Uttar Pradesh, India corroborates the Kenya analysis showing the scale had good content, construct, and criterion validity, as well as high reliability. The overlap in items suggests that this scale can be used across different contexts to compare women's experiences of care, and to inform and evaluate quality improvement efforts to promote comprehensive PCMC.