Challenging the utility of 24-hour recall of exclusive breast feeding in Japan.

INTRODUCTION: WHO recommends exclusive breast feeding from birth to 6 months. However, to monitor populations, it recommends using the proportion of infants under 6 months who were exclusively breastfed during the previous 24 hours. To assess the usefulness of 24-hour recall, we (1) compared the prevalence of exclusive breast feeding measured by since-birth recall to the prevalence measured by 24-hour recall and (2) quantified each indicator's association with WHO-recommended, well-established methods for in-hospital breastfeeding support. METHODS: We conducted two online surveys of mothers in Japan (total n=4247) who had a healthy singleton delivery in the previous 25 months. They reported on their breast feeding (a) from birth to 5 months; or (b) during the previous 24 hours, for those with infants under 5 months; or (c) both, for those who participated in the initial survey and also in the follow-up survey. All mothers also reported on their in-hospital support. The strength of each indicator's association with provision of in-hospital support was quantified as the area under the curve (AUC). RESULTS: The prevalences of exclusive breast feeding by since-birth recall were 4.4% (first survey) and 2.5% (second survey). By 24-hour recall, the prevalence appeared to be 29.8%. More in-hospital support was moderately well associated with more exclusive breast feeding measured by since-birth recall: AUC 0.72 (95%CI 0.66 to 0.78). That association is consistent with the known benefits of in-hospital support. In contrast, when exclusive breast feeding was measured by 24-hour recall, its association with in-hospital support appeared to be extremely weak: AUC 0.59 (95% CI 0.54 to 0.65). CONCLUSION: Using 24-hour recall substantially overestimates the prevalence of exclusive breast feeding since birth, and it conceals the benefits of in-hospital breastfeeding support. To monitor population achievement of exclusive breast feeding for the first 6 months, or to evaluate breastfeeding interventions, 24-hour recall of exclusive breast feeding should not be used alone.

Impact of oral intervention on the oral and overall health of children living with HIV in Cambodia: a randomized controlled trial.

BACKGROUND: Maintaining oral health is essential for improving overall health of children living with HIV. Therefore, we evaluated the effectiveness of an oral health intervention for improving their oral and overall health. In addition, we examined their longitudinal association between changes in oral and overall health. METHODS: We conducted a 2-year randomized controlled trial involving children living with HIV in Cambodia. Children aged 3-15 years and their caregivers were randomly allocated either to the intervention (group A) or control (group B) arm. A second control arm (group C) included children without HIV. The group A children received oral health education sessions and practiced home-based daily care. RESULTS: In the baseline survey, 482 children participated (group A: n = 160, group B: n = 168, group C: n = 154), and 350 completed the endline survey. An interaction effect in teeth brushing duration was observed in children in group A relative to group B (AOR = 2.69, 95% CI: 1.37-5.31) and group C (AOR = 3.78, 95% CI: 1.70-8.40). Longitudinal associations were observed between changes in oral hygiene and overall health, as presented by alterations in dental caries in permanent teeth with viral load detection (adjusted odds ratio = 3.58, 95% CI: 1.10 - 11.73), in salivary flow quantity with the overall quality of life (ß = 0.07, 95% CI: < 0.01 - 0.13), as well as in dental caries, salivary pH, debris index with body mass index for age among group A children. CONCLUSIONS: Oral health intervention may improve oral care behaviors and potentially enhance overall health among children living with HIV in antiretroviral therapy in a resource-constrained setting. TRIAL REGISTRATION: ISRCTN 15177479.

Does benefits-of-breastfeeding language or risks-of-formula-feeding language promote more-positive attitudes toward breastfeeding among midwives and nurses?

BACKGROUND: Midwives and nurses are crucial in breastfeeding support. Few studies have explored appropriate language for nursing education on breastfeeding. We assessed the impact of the language used on breastfeeding attitudes among midwives and nurses. METHODS: A quasi-experimental study was conducted online in Japan among 174 midwives and nurses who had work experience in obstetrics or pediatrics. Participants were allocated to three groups to receive different text messages as the intervention (the benefit of breastfeeding for Group 1; the risk of formula feeding for Group 2; the importance of childcare for Group 3 as the comparison). The Japanese version of the Iowa Infant Feeding Attitude Scale (IIFAS-J) was used to assess breastfeeding attitudes before and after reading the texts. Also, participant reactions to the text were assessed by their responses to three statements. ANOVA, the chi-square test, and the t-test were used for outcome assessments. RESULTS: The post-test IIFAS-J score was significantly higher than the pre-test score only for Group 1 (p <  0.01). The percentage of participants who agreed with the content of the text was 70.7% in Group 1 and 48.3% in Group 2. The percentage of participants who reported discomfort with the text was 34.5% in Group 1 and 55.2% in Group 2. No significant difference among groups existed regarding interest in the text. In all three groups, participants who agreed with the text had a higher post-test IIFAS-J score than those who disagreed with the text (6.85 points higher, p <  0.01 in Group 1; 7.19 points higher, p <  0.01 in Group 2; 8.00 points higher, p <  0.02 in Group 3). Discomfort with the text and interest in the text were associated with a significantly higher post-test IIFAS-J score in Group 1 and Group 2 but not in Group 3. CONCLUSIONS: "Benefits of breastfeeding" language, which conveys the information in a positive manner, appears to be more appropriate than "risks of infant formula" language for creating a positive attitude toward breastfeeding in nursing education. TRIAL REGISTRATION: This study was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN000023322). Registered 05/08/2016.

Maternal heated tobacco product use during pregnancy and allergy in offspring.

BACKGROUND: Little is known about the association between maternal use of heated tobacco products (HTPs) during pregnancy and the onset of allergy among offspring. This study aimed to determine whether maternal HTP smoking is associated with allergy in their offspring and to evaluate the potential dose-response association. METHODS: In this web-based, cross-sectional survey conducted in July and August 2021 in Japan, we investigated 5688 pairs of postpartum women and infants (<3 years). Clinical diagnoses of infant asthma, rhinitis, conjunctivitis, or atopic dermatitis were reported. Using multilevel Poisson regression, we estimated the prevalence ratios (PRs) and 95% confidence intervals (CIs) of allergy in infants with HTP smoking categories cross-classified by pregnancy periods, and adjusted for potential covariates including maternal cigarette smoking and partner's smoking status. Non-smokers served as the reference group. RESULTS: In total, 2.4% women smoked HTPs during pregnancy. Allergy occurred in 7.8% of the infants. The prevalence of allergy increased among the offspring of current HTP smokers during pregnancy at 15.2% (PR = 1.98, 95% CI 1.28-3.05); this association was the most pronounced during the first trimester but attenuated before pregnancy and postpartum. Dose-response associations were observed, for example a one-unit increase in daily maternal HTP use during pregnancy was associated with a 5% increase in allergy onset. Sub-group analyses excluding cigarette smokers during pregnancy and sensitivity analyses using the International Study of Asthma and Allergies in Childhood questionnaire showed a similar pattern. CONCLUSIONS: Maternal HTP smoking during pregnancy is associated with allergy in the offspring.

Influence of the COVID-19 pandemic on breastfeeding support for healthy mothers and the association between compliance with WHO recommendations for breastfeeding support and exclusive breastfeeding in Japan.

Background: Professional breastfeeding support contributes to maternal and child health. However, the influence of the current coronavirus disease 2019 (COVID-19) pandemic on breastfeeding support has not been carefully examined. Therefore, we assessed maternal breastfeeding intention and professional breastfeeding support before and during the pandemic. We further examined the association of compliance with World Health Organization (WHO) recommendations for professional breastfeeding support with exclusive breastfeeding during the pandemic. Methods: This cross-sectional, internet-based, questionnaire study analyzed data from 484 healthy women with live singleton births between 15 October 2019 and 25 October 2020 in Japan. A delivery before 5 March 2020 was classified as a before-pandemic delivery (n = 135), and a delivery after 6 March 2020 was a during-pandemic delivery (n = 349). Among the ten breastfeeding support steps recommended by the WHO, we assessed the five steps that are measurable by maternal self-report and would likely exhibit variability. Receipt of a free formula sample or invitation to a free sample campaign by the time of survey was also asked. Infant feeding status at the time of the survey was measured among women with infants younger than 5 months, which was a subgroup of mothers who delivered during the pandemic. Mothers were asked what was given to infants during the 24 h before the survey and when nothing other than breast milk was given, the status was classified as exclusive breastfeeding. Results: While 82.2% of women with a delivery before the pandemic intended to breastfeed, the rate was 75.6% during the pandemic (p = 0.120). The average number of breastfeeding support steps received was 3.24 before the pandemic but it was 3.01 during the pandemic (p = 0.069). In particular, rooming-in was less frequent (39.3% before vs. 27.8% during the pandemic, p = 0.014). Among mothers with infants younger than 5 months who had a delivery during the pandemic (n = 189), only 37.0% (n = 70) reported exclusively breastfeeding during the 24 h before completing the survey. Multiple logistic regression analysis indicated that receiving support for all five steps was positively associated with exclusive breastfeeding during the 24 h before the survey (adjusted odds ratio 4.51; 95% CI [1.50-13.61]). Receipt of a free formula sample or invitation to a free sample campaign was negatively associated with exclusive breastfeeding (adjusted odds ratio 0.43; 95% CI [0.19-0.98]). Other factors related to non-exclusive breastfeeding were older maternal age, lower education level, primiparity, and no breastfeeding intention. Conclusions: The pandemic weakened breastfeeding support for healthy women in Japan; however, support practice that adhered to WHO recommendations appeared to be effective during the pandemic.

Threatened abortion, threatened premature labor, and preterm birth during the first state of emergency for COVID-19 in 2020 in Japan.

AIM: This study examined the maternal experience of threatened abortion, threatened premature labor, or preterm birth before, during, and after the first state of emergency for COVID-19 in 2020 in Japan. METHODS: This was a cross-sectional, internet-based questionnaire survey. We recruited 600 postpartum women and divided them into three groups by date of delivery: before (October 2019-March 2020), during (April-May 2020), and after (June-October 2020) the first state of emergency. The outcome was the presence of at least one of the following complications: threatened abortion, threatened premature labor, and/or preterm birth. The prevalence ratios (PRs) of the outcome were calculated and compared among the three groups using a multivariable Poisson regression model with adjustment for potential confounders. RESULTS: Of the 553 women eligible for analysis, those who delivered during (PR 0.69, 95% confidence interval [CI] 0.47-0.99) and after (PR 0.62, 95% CI 0.42-0.90) the state of emergency were less likely to have experienced either threatened abortion, threatened premature labor, or preterm birth than those who delivered before the state of emergency. Among the adjustment variables, smoking at the time of survey (PR 1.68, 95% CI 1.01-2.80) and living in the prefectures with a population of >5 million (PR 0.71, 95% CI 0.51-0.97) were associated with the study outcome. CONCLUSION: Threatened abortion, threatened premature labor, or preterm birth appeared to decrease during and after the first state of emergency in 2020. The longitudinal effects of coronavirus disease on maternal and newborn health should be monitored continuously.

Development of the breastfeeding support scale to measure breastfeeding support from lay and professional persons, and its predictive validity in Japan.

BACKGROUND: International and national organizations recommend exclusive breastfeeding for the first 6 months of life, but many women stop earlier. Lay and professional persons can support mothers' efforts to overcome breastfeeding difficulties. Considering breastfeeding support to comprise emotional support, practical help, and information offered to women who desire to breastfeed (by professionals, family members, and others), we developed and tested a scale to measure it in Japan. METHODS: A total of 31 items were generated by literature review and from the authors' clinical experiences. Those items were tested with 243 mothers who visited public health centers in Tokyo for their infant's health check-up 3 months after birth. Breastfeeding support and infant feeding status were then assessed 5 months after birth. All the data were collected by using self-administered questionnaires. RESULTS: On the basis of the results of factor analysis, the number of items was reduced to 11. There were three factors: support from breastfeeding peers and from people in specifically named healthcare professions, practical help, and support from people the mother can rely on to help meet emotional needs and address breastfeeding concerns. Internal-consistency reliability (alpha) of scores on the 11-item scale was 0.83 when measured 3 months postpartum and 0.85 when measured 5 months postpartum. Higher scores on the 11-item scale 3 months postpartum were associated with more breastfeeding exclusivity both at that time (Kruskal-Wallis test, chi-squared = 14.871, df = 3, n = 211, p = 0.002, eta-squared = 0.071) and also 5 months postpartum (Kruskal-Wallis test, chi-squared = 8.556, df = 3, n = 159, p = 0.036, eta-squared = 0.054). Further, the area under the Receiver Operating Characteristic curve was 0.73 (95% CI [0.57-0.88]), which indicates that scores on the 11-item scale 3 months postpartum may be useful to predict which mothers will be less exclusive in breastfeeding 5 months postpartum. In conclusion, scores on this 11-item scale were reasonably reliable and valid for measuring breastfeeding support provided by lay and professional persons to mothers in Japan. Further research is required to evaluate this scale's applicability in other settings.

Evaluation of a package of continuum of care interventions for improved maternal, newborn, and child health outcomes and service coverage in Ghana: A cluster-randomized trial.

BACKGROUND: In low- and middle-income countries (LMICs), the continuum of care (CoC) for maternal, newborn, and child health (MNCH) is not always complete. This study aimed to evaluate the effectiveness of an integrated package of CoC interventions on the CoC completion, morbidity, and mortality outcomes of woman-child pairs in Ghana. METHODS AND FINDINGS: This cluster-randomized controlled trial (ISRCTN: 90618993) was conducted at 3 Health and Demographic Surveillance System (HDSS) sites in Ghana. The primary outcome was CoC completion by a woman-child pair, defined as receiving antenatal care (ANC) 4 times or more, delivery assistance from a skilled birth attendant (SBA), and postnatal care (PNC) 3 times or more. Other outcomes were the morbidity and mortality of women and children. Women received a package of interventions and routine services at health facilities (October 2014 to December 2015). The package comprised providing a CoC card for women, CoC orientation for health workers, and offering women with 24-hour stay at a health facility or a home visit within 48 hours after delivery. In the control arm, women received routine services only. Eligibility criteria were as follows: women who gave birth or had a stillbirth from September 1, 2012 to September 30, 2014 (before the trial period), from October 1, 2014 to December 31, 2015 (during the trial period), or from January 1, 2016 to December 31, 2016 (after the trial period). Health service and morbidity outcomes were assessed before and during the trial periods through face-to-face interviews. Mortality was assessed using demographic surveillance data for the 3 periods above. Mixed-effects logistic regression models were used to evaluate the effectiveness as difference in differences (DiD). For health service and morbidity outcomes, 2,970 woman-child pairs were assessed: 1,480 from the baseline survey and 1,490 from the follow-up survey. Additionally, 33,819 cases were assessed for perinatal mortality, 33,322 for neonatal mortality, and 39,205 for maternal mortality. The intervention arm had higher proportions of completed CoC (410/870 [47.1%]) than the control arm (246/620 [39.7%]; adjusted odds ratio [AOR] for DiD = 1.77; 95% confidence interval [CI]: 1.08 to 2.92; p = 0.024). Maternal complications that required hospitalization during pregnancy were lower in the intervention (95/870 [10.9%]) than in the control arm (83/620 [13.4%]) (AOR for DiD = 0.49; 95% CI: 0.29 to 0.83; p = 0.008). Maternal mortality was 8/6,163 live births (intervention arm) and 4/4,068 live births during the trial period (AOR for DiD = 1.60; 95% CI: 0.40 to 6.34; p = 0.507) and 1/4,626 (intervention arm) and 9/3,937 (control arm) after the trial period (AOR for DiD = 0.11; 95% CI: 0.11 to 1.00; p = 0.050). Perinatal and neonatal mortality was not significantly reduced. As this study was conducted in a real-world setting, possible limitations included differences in the type and scale of health facilities and the size of subdistricts, contamination for intervention effectiveness due to the geographic proximity of the arms, and insufficient number of cases for the mortality assessment. CONCLUSIONS: This study found that an integrated package of CoC interventions increased CoC completion and decreased maternal complications requiring hospitalization during pregnancy and maternal mortality after the trial period. It did not find evidence of reduced perinatal and neonatal mortality. TRIAL REGISTRATION: The study protocol was registered in the International Standard Randomised Controlled Trial Number Registry (90618993).

EMBRACE intervention to improve the continuum of care in maternal and newborn health in Ghana: The RE-AIM framework-based evaluation.

BACKGROUND: Improving maternal and newborn health remains one of the most critical public health challenges, particularly in low- and lower-middle-income countries. To overcome this challenge, interventions to improve the continuum of care based on real-world settings need to be provided. The Ghana Ensure Mothers and Babies Regular Access to Care (EMBRACE) Implementation Research Team conducted a unique intervention program involving over 21 000 women to improve the continuum of care, thereby demonstrating an intervention program's effectiveness in a real-world setting. This study evaluates the implementation process of the EMBRACE intervention program based on the RE-AIM framework. METHODS: A cluster-randomized controlled trial was conducted in 32 sub-district-based clusters in Ghana. Interventions comprised of four components, and to evaluate the implementation process, we conducted baseline and endline questionnaire surveys for women who gave birth and lived in the study site. The key informant interviews of health workers and intervention monitoring were conducted at the health facilities in the intervention area. The data were analyzed using 34 components of the RE-AIM framework and classified under five general criteria (Reach, Effectiveness, Adoption, Implementation, and Maintenance). RESULTS: In total, 1480 and 1490 women participated in the baseline and endline questionnaire survey, respectively. In the intervention area, 83.8% of women participated (reach). The completion rate of the continuum of care increased from 7.5% to 47.1%. Newborns who had danger signs immediately after birth decreased after the intervention (relative risk = 0.82, 95% confidence interval = 0.68-0.99) (effectiveness). In the intervention area, 94% of all health facilities participated. Mothers willing to use their continuum of care cards in future pregnancies reached 87% (adoption). Supervision and manual use resolved the logistical and human resource challenges identified initially (implementation). The government included the continuum of care measures in their routine program and developed a new Maternal and Child Health Record Book, which was successfully disseminated nationwide (maintenance). CONCLUSIONS: Following the RE-AIM framework evaluation, the EMBRACE intervention program was considered effective and as having great potential for scaling across in real-world settings, especially where the continuum of care needs to be improved. TRIAL REGISTRATION: ISRCTN 90618993.

Climate Change, Food Supply, and Dietary Guidelines.

Food production is affected by climate change, and, in turn, food production is responsible for 20-30% of greenhouse gases. The food system must increase output as the population increases and must meet nutrition and health needs while simultaneously assisting in achieving the Sustainable Development Goals. Good nutrition is important for combatting infection, reducing child mortality, and controlling obesity and chronic disease throughout the life course. Dietary guidelines provide advice for a healthy diet, and the main principles are now well established and compatible with sustainable development. Climate change will have a significant effect on food supply; however, with political commitment and substantial investment, projected improvements will be sufficient to provide food for the healthy diets needed to achieve the Sustainable Development Goals. Some changes will need to be made to food production, nutrient content will need monitoring, and more equitable distribution is required to meet the dietary guidelines. Increased breastfeeding rates will improve infant and adult health while helping to reduce greenhouse gases.

Long-term contribution of international electives for medical students to professional identity formation: a qualitative study.

OBJECTIVES: Globalisation has given medical university students the opportunity to pursue international electives in other countries, enhancing the long-term socialisation of medical professionals. This study identified the long-term effects of international electives on the professional identity formation of medical students. DESIGN: This is a qualitative study. SETTING: The authors interviewed Japanese medical professionals who had completed their international electives more than 10 years ago, and analysed and interpreted the data using a social constructivism paradigm. PARTICIPANTS: A total of 23 medical professionals (mean age 36.4 years; range 33-42 years) participated in face-to-face, semistructured in-depth interviews. RESULTS: During the data analysis, 36 themes related to professional identity formation were identified, and the resulting themes had five primary factors (perspective transformation, career design, self-development, diversity of values and leadership). It was concluded that international electives for medical students could promote reflective self-relativisation and contribute to medical professional identity formation. Additionally, such electives can encourage pursuing a specialisation and academic or non-academic work abroad. International electives for medical students could contribute to medical professional identity formation on the basis of cross-cultural understanding. CONCLUSIONS: This study addressed a number of issues regarding the long-term impact of international elective experiences in various countries on the professional identity formation of Japanese medical professionals. This study offers some guidance to mentors conducting international electives and provides useful information for professional identity formation development in medical professionals.

Guidelines for Complementary Feeding of Infants in the Asia Pacific Region: APACPH Public Health Nutrition Group.

Good nutrition in the first "1000 days," including breastfeeding and appropriate complementary foods, prepares for a healthy childhood and adult life, also contributes to the prevention of the double burden of malnutrition. Exclusive breastfeeding provides all required nutrients until an infant is around 6 months of age when complementary foods are needed. A literature review was undertaken of complementary foods in the Asia Pacific region. The foods being used at present are often of low nutrient density may provide insufficient amounts of some critical nutrients, and generally the variety is limited. Guidelines for complementary feeding are provided to assist in education and in public health planning.

The Influence of Breastfeeding Peer Support on Breastfeeding Satisfaction Among Japanese Mothers: A Randomized Controlled Trial.

BACKGROUND: Peer support may help mothers to feel satisfied with their breastfeeding and to continue breastfeeding. However, previous researchers have not examined the influence of peer support on the three breastfeeding-satisfaction domains. RESEARCH AIM: We aimed to examine the influence of telephone-based peer support on the following three domains of breastfeeding satisfaction among Japanese mothers: maternal satisfaction, perceived benefit to the infant, and lifestyle compatibility with breastfeeding. METHODS: Breastfeeding mothers were recruited at four maternity hospitals in Japan to participate in a randomized controlled trial. Data were collected 1 month and 4 months postpartum. Among all of the participants (N = 114), those in the intervention group (n = 60) received telephone-based peer support until 4 months postpartum, and participants in the control group (n = 54) received conventional support. Breastfeeding satisfaction was measured using the short version of the revised Japanese Maternal Breastfeeding Evaluation Scale. Generalized estimating equations and effect size analyses were used to examine the influence of the intervention. RESULTS: On the subscale measuring lifestyle compatibility, participants with peer support had a higher score than those without peer support: regression coefficient 1.54 (95% confidence interval [0.03, 3.04]). The effect size was 0.40 standard deviations among participants with low and mid-level scores at baseline. CONCLUSION: Although peer support did not change maternal satisfaction or perceived benefit to the infant, it did increase lifestyle compatibility with breastfeeding among these Japanese mothers. This is evidence in favor of increasing the use of peer support.

Effect of continuum-of-care intervention package on improving contacts and quality of maternal and newborn healthcare in Ghana: a cluster randomised controlled trial.

OBJECTIVE: To evaluate the effect of a continuum-of-care intervention package on adequate contacts of women and newborn with healthcare providers and their reception of high-quality care. DESIGN: Cluster randomised controlled trial. SETTING: 32 subdistricts in 3 rural sites in Ghana. PARTICIPANTS: The baseline survey involved 1480 women who delivered before the trial, and the follow-up survey involved 1490 women who received maternal and newborn care during the trial. INTERVENTIONS: The intervention package included training healthcare providers, using an educational and recording tool named 'continuum-of-care card', providing the first postnatal care (PNC) by retaining women and newborns at healthcare facility or home visit by healthcare providers. OUTCOME MEASURES: Adequate contacts were defined as at least four contacts during pregnancy, delivery with assistance of skilled healthcare providers at a healthcare facility and three timely contacts within 6 weeks postpartum. High-quality care was defined as receiving 6 care items for antenatal care (ANC), 3 for peripartum care (PPC) and 14 for PNC. RESULTS: The difference-in-difference method was used to assess the effects of the intervention on the study outcome. The percentage of adequate contacts with high-quality care in the intervention group in the follow-up survey and the adjusted difference-in-difference estimators were 12.6% and 2.2 (p=0.61) at ANC, 31.5% and 1.9 (p=0.73) at PPC and 33.7% and 12.3 (p=0.13) at PNC in the intention-to-treat design, whereas 13.0% and 2.8 (p=0.54) at ANC, 34.2% and 2.7 (p=0.66) at PPC and 38.1% and 18.1 (p=0.02) at PNC in the per-protocol design that assigned the study sample by possession of the continuum-of-care card. CONCLUSIONS: The interventions improved contacts with healthcare providers and quality of care during PNC. However, having adequate contact did not guarantee high-quality care. Maternal and newborn care in Ghana needs to improve its continuity and quality. TRIAL REGISTRATION NUMBER: ISRCTN90618993. .

Women's overall satisfaction with health facility delivery services in Ghana: a mixed-methods study.

BACKGROUND: Skilled birth delivery has increased up to nearly 74% in Ghana, but its quality has been questioned over the years. As understanding women's satisfaction could be important to improving service quality, this study aimed to determine what factors were associated with women's overall satisfaction with delivery services quantitatively and qualitatively in rural Ghanaian health facilities. RESULTS: This cross-sectional, mixed methods study used an explanatory sequential design across three Ghana Health Service research areas in 2013. Participants were women who had delivered in the preceding 2 years. Two-stage random sampling was used to recruit women for the quantitative survey. Relationships between women's socio-demographic characteristics and their overall satisfaction with health facility delivery services were examined using univariate and multiple logistic regression analyses. For qualitative analyses, women who completed the quantitative survey were purposively selected to participate in focus group discussions. Data from the focus group discussions were analyzed based on predefined and emerging themes. Overall, 1130 women were included in the quantitative analyses and 136 women participated in 15 focus group discussions. Women's mean age was 29 years. Nearly all women (94%) were satisfied with the overall services received during delivery. Women with middle level/junior high school education [adjusted odds ratio (AOR) = 0.50, 95% confidence interval (CI) = (0.26-0.98)] were less likely to be satisfied with overall delivery services compared to women with no education. Qualitatively, women were not satisfied with the unconventional demands, negative attitude, and unavailability of healthcare workers, as well as the long wait time. CONCLUSIONS: Although most women were satisfied with the overall service they received during delivery, they were not satisfied with specific aspects of the health services; therefore, higher quality service delivery is necessary to improve women's satisfaction. Additional sensitivity training and a reduction in work hours may also improve the experience of clients.

Advice on healthy pregnancy, delivery, motherhood and information on non-communicable diseases in the maternal care programme in Myanmar: a cross-sectional study.

OBJECTIVE: Pregnancy and delivery periods offer an opportunity for counselling women to improve behavioural risk and prevent complications, including non-communicable diseases (NCDs). However, little evidence is available on counselling offered during antenatal and postnatal care (PNC) in Myanmar. This study aimed to assess the contents of advice and information received by women during antenatal and postnatal counselling and to identify factors associated with receiving those advice and information. DESIGN: Cross-sectional study. SETTING: A predominantly rural township in the Ayeyawady region and a predominantly urban township in the Yangon region. PARTICIPANTS: 1500 women who had given birth in the last 6 weeks to 12 months prior to the survey. OUTCOME MEASURES: Receiving advice on 18 items during antenatal counselling, 10 items during postnatal counselling and information on five major NCDs during antenatal care (ANC). RESULTS: Nearly 52% of women received advice on 18 items during antenatal counselling, and 60% received advice on 10 items during postnatal counselling. About 28% received information on five NCDs during ANC. Women who were living in the Yangon site, who had primary school education or lower and who experienced complications were less likely to receive advice on all items during both antenatal and postnatal counselling. Women who received PNC outside of a healthcare facility and were primiparas were also less likely to receive advice on all items during postnatal counselling. Women living in the Yangon site and those who utilised a private care facility were less likely to receive information on NCDs. CONCLUSIONS: Only 60% of women received advice on healthy pregnancy, delivery and motherhood, whereas 30% received information on NCDs. Although non-modifiable maternal factors were associated with these results, counselling practice can be improved and information on NCDs can be offered as the first step of integrated NCDs care in maternal care programme in Myanmar.

Quality gap in maternal and newborn healthcare: a cross-sectional study in Myanmar.

INTRODUCTION: Access to maternal and newborn healthcare has improved in Myanmar. However, regular contact with skilled care providers does not necessarily result in quality care. We assessed adequate contact made by women and newborns with skilled care providers, reception of high-quality care and quality-adjusted contacts during antenatal care (ANC), peripartum care (PPC) and postnatal care (PNC) in Myanmar. METHODS: This cross-sectional study was conducted in a predominantly urban township of Yangon and a predominantly rural township of Ayeyawady in March 2016. We collected data from 1500 women. We measured quality-adjusted contact, which refers to adequate contact with high-quality care, as follows: ≥4 ANC contacts and receiving 11-14 of 14 intervention items; facility-based delivery assisted by skilled care providers, receiving 7 of 7 PPC intervention items; and receiving the first PNC contact ≤24 hours postpartum and ≥2 additional contacts, and receiving 16-17 of 17 intervention items. Using multilevel logistic regression analysis with a random intercept at cluster level, we identified factors associated with adequate contact and high-quality ANC, PPC and PNC. RESULTS: The percentage of crude adequate contact was 60.9% for ANC, 61.3% for PPC and 11.5% for PNC. However, the percentage of quality-adjusted contact was 14.6% for ANC, 15.2% for PPC and 3.6% for PNC. Adequate contact was associated with receiving high-quality care at ANC, PPC and PNC. Being a teenager, low educational level, multiparity and low level in the household wealth index were negatively associated with adequate contact with healthcare providers for ANC and PPC. Receiving a maternal and child health handbook was positively associated with adequate contact for ANC and PPC, and with receiving high-quality ANC, PPC and PNC. CONCLUSION: Women and newborns do not receive quality care during contact with skilled care providers in Myanmar. Continuity and quality of maternal and newborn care programmes must be improved.