Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries.

BACKGROUND: Persistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region. METHODS: We conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality. RESULTS: The percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor. CONCLUSIONS: Addressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed.

Stillbirth rates and their determinants in a national maternity hospital in Phnom Penh, Cambodia in 2017-2020: a cross-sectional assessment with a nested case-control study.

BACKGROUND: In Cambodia, stillbirths and their underlying factors have not been systematically studied. This study aimed to assess the proportion and trends in stillbirths between 2017 and 2020 in a large maternity referral hospital in the country and identify their key determinants to inform future prevention efforts. METHODS: This was a retrospective cross-sectional analysis with a nested case-control study of women giving birth at the National Maternal and Child Health Centre (NMCHC) in Phnom Penh, 2017-2020. We calculated percentages of singleton births at ≥ 22 weeks' gestation resulting in stillbirth and annual stillbirth rates by timing: intrapartum (fresh) or antepartum (macerated). Multivariable logistic regression was used to explore factors associated with stillbirth, where cases were all women who gave birth to a singleton stillborn baby in the 4-year period. One singleton live birth immediately following each case served as an unmatched control. Multiple imputation was used to handle missing data for gestational age. RESULTS: Between 2017 and 2020, 3.2% of singleton births ended in stillbirth (938/29,742). The stillbirth rate increased from 24.8 per 1000 births in 2017 to 38.1 per 1000 births in 2020, largely due to an increase in intrapartum stillbirth rates which rose from 18.8 to 27.4 per 1000 births in the same period. The case-control study included 938 cases (stillbirth) and 938 controls (livebirths). Factors independently associated with stillbirth were maternal age ≥ 35 years compared to < 20 years (aOR: 1.82, 95%CI: 1.39, 2.38), extreme (aOR: 3.29, 95%CI: 2.37, 4.55) or moderate (aOR: 2.45, 95%CI: 1.74, 3.46) prematurity compared with full term, and small-for-gestational age (SGA) (aOR: 2.32, 1.71, 3.14) compared to average size-for-age. Breech/transverse births had nearly four times greater odds of stillbirth (aOR: 3.84, 95%CI: 2.78, 5.29), while caesarean section reduced the odds by half compared with vaginal birth (aOR: 0.50, 95%CI: 0.39, 0.64). A history of abnormal vaginal discharge increased odds of stillbirth (aOR: 1.42, 95%CI: 1.11, 1.81) as did a history of stillbirth (aOR: 3.08, 95%CI: 1.5, 6.5). CONCLUSIONS: Stillbirth prevention in this maternity referral hospital in Cambodia requires strengthening preterm birth detection and management of SGA, intrapartum care, monitoring women with stillbirth history, management of breech births, and further investigation of high-risk referral cases.

In Cambodia, there is very little information published on stillbirths to know precisely how many there are and to understand the underlying reasons they occur so they can be prevented in the future. Our study aimed to quantify the number of stillborn babies and identify some underlying risk factors from one of the largest maternity referral hospitals in Phnom Penh, Cambodia. We examined data from almost 30,000 health facility medical files of women who gave birth between 2017 and 2020 which included 938 stillbirths. We found that about 3.2% of births ended in a stillbirth and that this percentage increased between 2017 and 2020. Women who had preterm babies, or whose babies were small in weight for their gestational age, and babies that were born breech had a higher chance of being stillborn. Women who had abnormal vaginal discharge, which can indicate a possible infection, also had a higher odds of having a stillbirth. We also found that women who had a stillbirth previously had almost three times higher chance of having another stillborn baby. Having a caesarean section reduced the likelihood of having a stillborn baby by about half. These findings suggest that efforts are needed to better identify and manage women with preterm births and monitor fetal growth as well as ensure breech births are managed adequately.

Methodological reflections on health system-oriented assessment of maternity care in 16 hospitals in sub-Saharan Africa: an embedded case study.

Health facility assessments (HFAs) assessing facilities' readiness to provide services are well-established. However, HFA questionnaires are typically quantitative and lack depth to understand systems in which health facilities operate-crucial to designing context-oriented interventions. We report lessons from a multiple embedded case study exploring the experiences of HFA data collectors in implementing a novel HFA tool developed using systems thinking approach. We assessed 16 hospitals in four countries (Benin, Malawi, Tanzania and Uganda) as part of a quality improvement implementation research. Our tool was organized in 17 sections and included dimensions of hospital governance, leadership and financing; maternity care standards and procedures; ongoing quality improvement practices; interactions with communities and mapping of the areas related to maternal care. Data for this study were collected using in-depth interviews with senior experts who conducted the HFA in the countries 1-3 months after completion of the HFAs. Data were analysed using the inductive thematic analysis approach. Our HFA faced challenges in logistics (accessing key hospital-based respondents, high turnover of managerial staff and difficulty accessing information considered sensitive in the context) and methodology (response bias, lack of data quality and data entry into an electronic platform). Data elements of governance, leadership and financing were the most affected. Opportunities and strategies adopted aimed at enhancing data collection (building on prior partnerships and understanding local and institutional bureaucracies) and enhancing data richness (identifying respondents with institutional memory, learning from experience and conducting observations at various times). Moreover, HFA data collectors conducted abstraction of records and interviews in a flexible and adaptive way to enhance data quality. Lessons and new skills learned from our HFA could be used as inputs to respond to the growing need of integrating the systems thinking approach in HFA to improve the contextual understanding of operations and structure.

Evaluation of Three Blended Learning Courses to Strengthen Health Professionals' Capacity in Primary Health Care, Management of Sexual and Reproductive Health Services and Research Methods in Guinea.

Background: Three blended courses on Primary Health Care (eSSP), Management of Sexual and Reproductive Health Services (eSSR), and Research Methods (eMR) were developed and implemented between 2017 and 2021 by the Maferinyah National Training and Research Center in Rural Health, a training and research institution of the Ministry of Health in Guinea. The study objectives were to evaluate the reasons for dropout and abstention, the learners' work behavior following the training, and the impact of the behavior change on the achievements of learners' organizations or services. Methods: We evaluated the three implemented courses in 2021, focusing on levels 3 and 4 of the Kirkpatrick training evaluation model. Quantitative and qualitative data were collected through an open learning platform (Moodle), via an electronic questionnaire, during the face-to-face component of the courses (workshops), and at learners' workplaces. Descriptive statistics and thematic analysis were performed for quantitative and qualitative data, respectively. Results: Out of 1,016 applicants, 543 including 137 (25%) women were enrolled in the three courses. Over the three courses, the completion rates were similar (67-69%) along with 20-29% dropout rates. Successful completion rates were 72% for eSSP, 83% for eMR and 85% for eSSR. Overall success rate (among all enrollees) ranged from 50% (eSSP) to 58% (eSSR). The majority (87%) of the learners reported applying the knowledge and skills they acquired during the courses through activities such as supervision (22%), service delivery (20%), and training workshops (14%). A positive impact of the training on utilization/coverage of services and increased revenues for their health facilities were also reported by some trainees. Conclusion: These findings showed fair success rates and a positive impact of the training on learners' work behavior and the achievements of their organizations.

"So hard not to feel blamed!": Assessment of implementation of Benin's Maternal and Perinatal Death Surveillance and Response strategy from 2016-2018.

OBJECTIVE: To assess the implementation of the Maternal and Perinatal Death Surveillance and Response (MPDSR) strategy institutionalized in Benin in 2013 to address the alarmingly high maternal and neonatal death rates. METHODS: A retrospective, mixed-methods study was performed. We used all maternal and neonatal death notifications and reviews from 2016 to 2018, reviewed the reports of 63 MPDSR working groups, and held two online group discussions. Descriptive quantitative analysis was performed, and content analysis was applied to qualitative data. RESULTS: Deaths were under-notified, with estimated notification rates at 46%-48% for maternal and 16%-21% for neonatal deaths over the 3 years. Review completion rates were low, corresponding to 50%-56% of maternal and 8%-17% of neonatal deaths. Causes of undernotification included very low notification of community-based and private health facility deaths, and fear of blame. Low review completion rates were due to heavy workload, staffing shortages, fear of blame, and weak leadership. Moreover, reviews were of poor quality and the response was weak. CONCLUSION: Maternal and Perinatal Death Surveillance and Response is operational in Benin. However, this assessment highlights the need to strengthen the notification strategy, continuously build MPDSR committee members' capacities, engage decision-makers for an effective response, and create a better blame-free, accountable, and learning culture.

Maternal and newborn healthcare providers' work-related experiences during the COVID-19 pandemic, and their physical, psychological, and economic impacts: Findings from a global online survey.

The COVID-19 pandemic continues to have substantial impacts on health systems globally. This study describes experiences during the COVID-19 pandemic, and physical, psychological and economic impacts among maternal and newborn healthcare providers. We conducted a global online cross-sectional survey of maternal and newborn healthcare providers. Data collected between July and December 2020 included demographic characteristics, work-related experiences, and physical, psychological, and economic impacts of COVID-19. Descriptive statistics of quantitative data and content analysis of qualitative data were conducted. Findings were disaggregated by country income-level. We analysed responses from 1,191 maternal and newborn healthcare providers from 77 countries: middle-income 66%, high-income 27%, and low-income 7%. Most common cadres were nurses (31%), midwives/nurse-midwives (25%), and obstetricians/gynaecologists (21%). Quantitative and qualitative findings showed that 28% of respondents reported decreased workplace staffing levels following changes in staff-rotation (53%) and staff self-isolating after exposure to SARS-CoV-2 (35%); this led to spending less time with patients, possibly compromising care quality. Reported insufficient access to personal protective equipment (PPE) ranged from 12% for gloves to 32% for N-95 masks. Nonetheless, wearing PPE was tiresome, time-consuming, and presented potential communication barriers with patients. 58% of respondents reported higher stress levels, mainly related to lack of access to information or to rapidly changing guidelines. Respondents noted a negative financial impact-a decrease in income (70% among respondents from low-income countries) concurrently with increased personal expenditures (medical supplies, transportation, and PPE). Negative physical, psychological and economic impacts of COVID-19 on maternal and newborn healthcare providers were ongoing throughout 2020, especially in low-income countries. This can have severe consequences for provision and quality of essential care. There is need to increase focus on the implementation of interventions aiming to support healthcare providers, particularly those in low- and middle-income countries to protect essential health services from disruption.

Interventions to increase facility births and provision of postpartum care in sub-Saharan Africa: a scoping review.

BACKGROUND: Most maternal deaths occur during the intrapartum and peripartum periods in sub-Saharan Africa, emphasizing the importance of timely access to quality health service for childbirth and postpartum care. Increasing facility births and provision of postpartum care has been the focus of numerous interventions globally, including in sub-Saharan Africa. The objective of this scoping review is to synthetize the characteristics and effectiveness of interventions to increase facility births or provision of postpartum care in sub-Saharan Africa. METHODS: We searched for systematic reviews, scoping reviews, qualitative studies and quantitative studies using experimental, quasi experimental, or observational designs, which reported on interventions for increasing facility birth or provision of postpartum care in sub-Saharan Africa. These studies were published in English or French. The search comprised six scientific literature databases (Pubmed, CAIRN, la Banque de Données en Santé Publique, the Cochrane Library). We also used Google Scholar and snowball or citation tracking. RESULTS: Strategies identified in the literature as increasing facility births in the sub-Saharan African context include community awareness raising, health expenses reduction (transportation or user fee), non-monetary incentive programs (baby kits), or a combination of these with improvement of care quality (patient's privacy, waiting time, training of provider), and or follow-up of pregnant women to use health facility for birth. Strategies that were found to increase provision of postpartum care include improvement of care quality, community-level identification and referrals of postpartum problems and transport voucher program. CONCLUSIONS: To accelerate achievements in facility birth and provision of postpartum care in sub-Saharan Africa, we recommend strategies that can be implemented sustainably or produce sustainable change. How to sustainably motivate community actors in health interventions may be particularly important in this respect. Furthermore, we recommend that more intervention studies are implemented in West and Central Africa, and focused more on postpartum. In in sub-Saharan Africa, many women die when giving or few days after birth. This happens because they do not have access to good health services in a timely manner during labor and after giving birth. Worldwide, many interventions have been implemented to Increase the number of women giving birth in a health facility or receiving care from health professional after giving birth. The objective of this study is to synthetize the characteristics and effectiveness of interventions that have been implemented in sub-Saharan Africa, aiming to increase the number of women giving birth in a health facility or receiving care from health professional after birth. To proceed with this synthesis, we did a review of studies that have reported on such interventions in sub-Saharan Africa. These studies were published in English or French. The interventions identified to increase the number of women giving birth in a health facility include community awareness raising, reduction of health expenses (transportation or user fee), non-monetary incentive programs (baby kits), or a combination of these with improvement of care quality (patient's privacy, waiting time, training of provider), and or follow-up of pregnant women to use health facility for birth. Interventions implemented to increase the number women receiving care from a health professional after birth include improvement of care quality, transport voucher program and community-level identification and referrals to the health center of mothers' health problems. In sub-Saharan Africa, to accelerate increase in the number of women giving birth in a health facility and receiving care from a health professional after, we recommend interventions that can be implemented sustainably or produce sustainable change. How to sustainably motivate community actors in health interventions may be particularly important in this respect. Furthermore, we recommend the conduct in West and Central Africa, of more studies targeting interventions to increase the number of women giving birth in a health facility and or receiving care from a health professional after birth.

RéSUMé: CONTEXTE: La plupart des décès maternels surviennent pendant les périodes intrapartum et péripartum en Afrique subsaharienne, ce qui souligne l'importance de l'accès à temps aux services de santé de qualité pour l'accouchement et les soins post-partum. L'augmentation des accouchements institutionnels et l'offre de soins post-partum ont fait l'objet de nombreuses interventions dans le monde entier, y compris en Afrique subsaharienne. L'objectif de cette étude est de synthétiser les caractéristiques et l'efficacité des interventions visant à accroître les accouchements institutionnels ou l'offre de soins post-partum en Afrique subsaharienne. MéTHODES: Nous avons recherché des revues systématiques, des revues de portée, des études qualitatives et des études quantitatives utilisant des types expérimentaux, quasi expérimentaux ou d'observation, qui rapportaient sur des interventions visant à accroître les accouchements institutionnels et l'offre de soins post-partum en Afrique subsaharienne. Ces études ont été publiées en anglais ou en français. La recherche a porté sur six bases de données de littérature scientifique (Pubmed, CAIRN, la Banque de Données en Santé Publique, la Cochrane Library). Nous avons également utilisé Google Scholar et le suivi des boules de neige ou des citations. RéSULTATS: Les stratégies identifiées dans la littérature comme accroissant les accouchements intentionnels dans le contexte de l'Afrique subsaharienne comprennent la sensibilisation des communautés, la réduction des dépenses de santé (transport ou frais d'utilisation), des programmes d'incitation non monétaires (kits pour bébés), ou une combinaison de ces éléments avec l'amélioration de la qualité des soins (respect de la vie privée du patient, temps d'attente, formation du prestataire), et ou le suivi des femmes enceintes pour qu'elles utilisent l'établissement de santé pour l'accouchement. Les stratégies qui ont été trouvées pour accroitre l'offre des soins post-partum comprennent l'amélioration de la qualité des soins, l'identification au niveau communautaire et la référence des problèmes post-partum et le programme de bons de transport. CONCLUSIONS: Pour accélérer les réalisations en matière d'accouchement institutionnel et d'offre de soins post-partum en Afrique subsaharienne, nous recommandons des stratégies qui peuvent être mises en œuvre de manière durable ou produire des changements durables. La manière de motiver durablement les acteurs communautaires dans les interventions sanitaires peut être particulièrement importante à cet égard. En outre, nous recommandons que davantage d'études d'intervention soient mises en œuvre en Afrique de l'Ouest et du Centre, et qu'elles soient davantage axées sur les soins post-partum.

Access to prevention of mother-to-child transmission of HIV along HIV services cascade through integrated active case management in 15 operational districts in Cambodia.

INTRODUCTION: Following the introduction of option B+ in 2013, and with the perspective of eliminating mother-to-child transmission of HIV by 2025, Cambodia has implemented an integrated active case management (IACM) approach since 2014 to improve the notification and follow-up of all HIV-infected cases including pregnant women, and to ensure access to and use of the full prevention of mother-to-child transmission (PMTCT) service package by HIV-infected pregnant women and their HIV-exposed infants. This study aimed to analyse PMTCT cascade data in 15 operational districts (ODs) implementing the IACM approach in Cambodia. METHODS: We analysed PMTCT cohort data from 15 ODs implementing IACM approach between 1 January 2014 and 31 December 2016. We measured key indicators along the PMTCT cascade and compared them to available (cross-sectional) PMTCT indicators during the 2011 to 2013 period. RESULTS: During the period 2014 to 2016, among 938 identified HIV-infected pregnant women, 308 (32.8%) were tested HIV positive during their pregnancy, 9 (1.0%) during labour, while the remaining 621 (66.2%) were women on antiretroviral therapy (ART) who became pregnant. During the study period, 867 (92.4%) of the 938 women received ART during pregnancy and labour. Subsequently, 456 (85.6%) of the 533 HEI born and alive during the study period received 6-week antiretroviral (ARV) prophylaxis, 390 (76.6%) and 396 (77.8%) of the 509 infants aged six weeks or older received cotrimoxazole prophylaxis and HIV-DNA PCR test respectively. Among the 396 HEI who received HIV-DNA PCR test, 7 (1.8%) were found HIV positive. The comparison with cross-sectional PMTCT indicator obtained during the previous 2011 to 2013 period in the same 15 ODs, showed a significant increase in ARV uptake among HIV-infected pregnant women (from 72.3% to 92.4%), in cotrimoxazole uptake (from 41.6% to 73.2%), and in HIV-DNA PCR testing coverage among HEI (from 41.2% to 74.3%). CONCLUSIONS: The implementation of option B+ and IACM may have contributed to the improvement of the PMTCT cascade in Cambodia. However, some gaps in accessing PMTCT services along the HIV cascade persist and need to be addressed.

Determinants of institutional delivery among young married women in Nepal: Evidence from the Nepal Demographic and Health Survey, 2011.

OBJECTIVES: To identify the determinants of institutional delivery among young married women in Nepal. DESIGN: Nepal Demographic and Health Survey (NDHS) data sets 2011 were analysed. Bivariate and multivariate logistic regression analyses were performed using a subset of 1662 ever-married young women (aged 15-24 years). OUTCOME MEASURE: Place of delivery. RESULTS: The rate of institutional delivery among young married women was 46%, which is higher than the national average (35%) among all women of reproductive age. Young women who had more than four antenatal care (ANC) visits were three times more likely to deliver in a health institution compared with women who had no antenatal care visit (OR: 3.05; 95% CI: 2.40 to 3.87). The probability of delivering in an institution was 69% higher among young urban women than among young women who lived in rural areas. Young women who had secondary or above secondary level education were 1.63 times more likely to choose institutional delivery than young women who had no formal education (OR: 1.626; 95% CI: 1.171 to 2.258). Lower use of a health institution for delivery was also observed among poor young women. Results showed that wealthy young women were 2.12 times more likely to deliver their child in an institution compared with poor young women (OR: 2.107; 95% CI: 1.53 to 2.898). Other factors such as the age of the young woman, religion, ethnicity, and ecological zone were also associated with institutional delivery. CONCLUSIONS: Maternal health programs should be designed to encourage young women to receive adequate ANC (at least four visits). Moreover, health programs should target poor, less educated, rural, young women who live in mountain regions, are of Janajati ethnicity and have at least one child as such women are less likely to choose institutional delivery in Nepal.

Exploring Maternal Health Care-Seeking Behavior of Married Adolescent Girls in Bangladesh: A Social-Ecological Approach.

BACKGROUND: The huge proportion of child marriage contributes to high rates of pregnancies among adolescent girls in Bangladesh. Despite substantial progress in reducing maternal mortality in the last two decades, the rate of adolescent pregnancy remains high. The use of skilled maternal health services is still low in Bangladesh. Several quantitative studies described the use of skilled maternal health services among adolescent girls. So far, very little qualitative evidence exists about attitudes and practices related to maternal health. To fill this gap, we aimed at exploring maternal health care-seeking behavior of adolescent girls and their experiences related to pregnancy and delivery in Bangladesh. METHODS AND FINDINGS: A prospective qualitative study was conducted among thirty married adolescent girls from three Upazilas (sub-districts) of Rangpur district. They were interviewed in two subsequent phases (2014 and 2015). To triangulate and validate the data collected from these married adolescent girls, key informant interviews (KIIs) and focus group discussions (FGDs) were conducted with different stakeholders. Data analysis was guided by the Social-Ecological Model (SEM) including four levels of factors (individual, interpersonal and family, community and social, and organizational and health systems level) which influenced the maternal health care-seeking behavior of adolescent girls. While adolescent girls showed little decision making-autonomy, interpersonal and family level factors played an important role in their use of skilled maternal health services. In addition, community and social factors and as well as organizational and health systems factors shaped adolescent girls' maternal health care-seeking behavior. CONCLUSIONS: In order to improve the maternal health of adolescent girls, all four levels of factors of SEM should be taken into account while developing health interventions targeting adolescent girls.

Maternal and Child Health Services in the Context of the Ebola Virus Disease: Health Care Workers' Knowledge, Attitudes and Practices in Rural Guinea.

The objective of this study was to document maternal and child health care workers' knowledge, attitudes and practices on service delivery before, during and after the 2014 EVD outbreak in rural Guinea. We conducted a descriptive cross-sectional study in ten health districts between October and December 2015, using a standardized self-administered questionnaire. Overall 299 CHWs (94% response rate) participated in the study, including nurses/health technicians (49%), midwives (23%), managers (16%) and physicians (12%). Prior to the EVD outbreak, 87% of CHWs directly engaged in managing febrile cases within the facility, while the majority (89% and 63%) referred such cases to another facility and/or EVD treatment centre during and after the EVD outbreak, respectively. Compared to the period before the EVD outbreak when approximately half of CHWs (49%) reported systematically measuring body temperature prior to providing any care to patients, most CHWs reported doing so during (98%) and after the EVD outbreak (88%). The main challenges encountered were the lack of capacity to screen for EVD cases within the facility (39%) and the lack of relevant equipment (10%). The majority (91%) of HCWs reported a decrease in the use of services during the EVD outbreak while an increase was reported by 72% of respondents in the period following the EVD outbreak. Infection prevention and control measures established during the EVD outbreak have substantially improved self-reported provider practices for maternal and child health services in rural Guinea. However, more efforts are needed to maintain and sustain the gain achieved.

Determinants and trends in health facility-based deliveries and caesarean sections among married adolescent girls in Bangladesh.

OBJECTIVE: To identify the determinants and measure the trends in health facility-based deliveries and caesarean sections among married adolescent girls in Bangladesh. METHODS: In order to measure the trends in health facility-based deliveries and caesarean sections, Bangladesh Demographic Health Survey (BDHS) data sets were analysed (BDHS; 1993-1994, 1996-1997, 1999-2000, 2004, 2007, 2011). The BDHS 2011 data sets were analysed to identify the determinants of health facility-based deliveries and caesarean sections. A total of 2813 adolescent girls (aged 10-19 years) were included for analysis. Bivariate and multivariate analyses were performed. RESULTS: Health facility-based deliveries have continuously increased among adolescents in Bangladesh over the past two decades from 3% in 1993-1994 to 24.5% in 2011. Rates of population-based and facility-based caesarean sections have increased linearly among all age groups of women including adolescents. Although the country's overall (population-based) caesarean section rate among adolescents was within acceptable range (11.6%), a rate of nearly 50% health facility level caesarean sections among adolescent girls is alarming. Among adolescent girls, use of antenatal care (ANC) appeared to be the most important predictor of health facility-based delivery (OR: 4.04; 95% CI 2.73 to 5.99), whereas the wealth index appeared as the most important predictor of caesarean sections (OR: 5.7; 95% CI 2.74 to 12.1). CONCLUSIONS: Maternal health-related interventions should be more targeted towards adolescent girls in order to encourage them to access ANC and promote health facility-based delivery. Rising trends of caesarean sections require further investigation on indication and provider-client-related determinants of these interventions among adolescent girls in Bangladesh.

What Influences Adolescent Girls' Decision-Making Regarding Contraceptive Methods Use and Childbearing? A Qualitative Exploratory Study in Rangpur District, Bangladesh.

BACKGROUND: Bangladesh has the highest rate of adolescent pregnancy in South Asia. Child marriage is one of the leading causes of pregnancies among adolescent girls. Although the country's contraceptive prevalence rate is quite satisfactory, only 52% of married adolescent girls use contraceptive methods. This qualitative study is aimed at exploring the factors that influence adolescent girls' decision-making process in relation to contraceptive methods use and childbearing. METHODS AND RESULTS: We collected qualitative data from study participants living in Rangpur district, Bangladesh. We conducted 35 in-depth interviews with married adolescent girls, 4 key informant interviews, and one focus group discussion with community health workers. Adolescent girls showed very low decision-making autonomy towards contraceptive methods use and childbearing. Decisions were mainly made by either their husbands or mothers-in-law. When husbands were unemployed and financially dependent on their parents, then the mothers-in-law played most important role for contraceptive use and childbearing decisions. Lack of reproductive health knowledge, lack of negotiation and communication ability with husbands and family members, and mistrust towards contraceptive methods also appeared as influential factors against using contraception resulting in early childbearing among married adolescent girls. CONCLUSIONS: Husbands and mothers-in-law of newly married adolescent girls need to be actively involved in health interventions so that they make more informed decisions regarding contraceptive use to delay pregnancies until 20 years of age. Misunderstanding and distrust regarding contraceptives can be diminished by engaging the wider societal actors in health intervention including neighbours, and other family members.

How Has the Free Obstetric Care Policy Impacted Unmet Obstetric Need in a Rural Health District in Guinea?

INTRODUCTION: In 2010, the Ministry of Health (MoH) of Guinea introduced a free emergency obstetric care policy in all the public health facilities of the country. This included antenatal checks, normal delivery and Caesarean section. OBJECTIVE: This study aims at assessing the changes in coverage of obstetric care according to the Unmet Obstetric Need concept before (2008) and after (2012) the implementation of the free emergency obstetric care policy in a rural health district in Guinea. METHODS: We carried out a descriptive cross-sectional study involving the retrospective review of routine programme data during the period April to June 2014. RESULTS: No statistical difference was observed in women's sociodemographic characteristics and indications (absolute maternal indications versus non-absolute maternal indications) before and after the implementation of the policy. Compared to referrals from health centers of patients, direct admissions at hospital significantly increased from 49% to 66% between 2008 and 2012 (p = 0.001). In rural areas, this increase concerned all maternal complications regardless of their severity, while in urban areas it mainly affected very severe complications. Compared to 2008, there were significantly more Major Obstetric Interventions for Maternal Absolute Indications in 2012 (p < 0.001). Maternal deaths decreased between 2008 and 2012 from 1.5% to 1.1% while neonatal death increased from 12% in 2008 to 15% in 2012. CONCLUSION: The implementation of the free obstetric care policy led to a significant decrease in unmet obstetric need between 2008 and 2012 in the health district of Kissidougou. However, more research is needed to allow comparisons with other health districts in the country and to analyse the trends.

Towards safe abortion access: an exploratory study of medical abortion in Cambodia.

In 2010, following its approval by the Ministry of Health, the medical abortion combination pack Medabon (containing mifepristone and misoprostol) was made available at pharmacies and in a restricted number of health facilities in Cambodia. The qualitative study presented in this paper was conducted in 2012 as a follow-up to longer-term ethnographical research related to reproductive health and fertility regulation between 2008 and 2012. Observations were carried out at several clinic and pharmacy sites and in-depth interviews were conducted with a purposive sample of 20 women who attended two MSI Cambodia centres and 10 women identified through social networks; six men (women's male partners); eight health care providers at the two MSI centres and four pill sellers at private or informal pharmacies (who also provided health care services in private clinics). Although the level of training among the drug sellers and providers varied, their knowledge about medical abortion regimens, correct usage and common side effects was good. Overall, women were satisfied with the services provided. Medical abortion was not always a women-only process in this study as some male partners were also involved in the care process. The study illustrates positive steps forward being taken in making abortion safe and preventing and reducing unsafe abortion practices in Cambodia.

Guidelines and tools for organizing and conducting maternal death reviews.

Maternal death reviews (MDRs) provide the multidisciplinary maternity care team with a process to conduct in-depth review of the health care and circumstances surrounding maternal deaths. From these reviews, recommendations to improve care in primary, secondary, and tertiary healthcare settings can be made. Practical guidelines and training curricula for MDRs are lacking. To fill this gap, a manual comprising guidelines and tools to help health professionals conduct structured MDRs was developed through the FIGO LOGIC initiative.

Training health professionals in conducting maternal death reviews.

In countries where maternal death review (MDR) sessions are proposed as an intervention to improve quality of obstetric care, training focuses on the theory behind this method. However, experience shows that health staff lack confidence to apply the theory if they have not attended a practical training session. To address this problem, a training curriculum based on the new guidelines from the FIGO Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) Initiative for preparing and conducting MDR sessions was designed and tested in Cameroon. This curriculum is competency-based and consists primarily of practical individual or group exercises.

Family planning in Guinea: a need for better public commitment.

OBJECTIVE: To describe the evolution of family planning (FP) in Guinea and to identify strengths, weaknesses, opportunities and threats of the current FP programme. METHODS: Descriptive study of the evolution of FP in Guinea between 1992 and 2010. First, national laws as well as health policies and strategic plans related to reproductive health and family planning were reviewed. Second, FP indicators were extracted from the Guinean Demographic and Health Surveys (1992, 1999 and 2005). Third, FP services, sources of supply and data on FP funding were analysed. RESULTS: Laws, policies and strategic plans in Guinea are supportive of FP programme and services. Public and private actors are not sufficiently coordinated. The general government expenditure on health has remained stable at 6-7% between 2005 and 2011 despite a doubling of total expenditures on health, and contraceptives are supplied by foreign aid. Modern contraceptive prevalence slightly increased from 1.5% in 1992 to 6.8% in 2005 among women aged 15-49. CONCLUSION: A stronger national engagement in favour of repositioning FP should result in improved government funding of the FP programme and the promotion of long-acting and permanent methods.

Sub-Saharan Africa and the health MDGs: the need to move beyond the "quick impact" model.

The Millennium Development Goals (MDGs) were defined in 2001, making poverty the central focus of the global political agenda. In response to MDG targets for health, new funding instruments called Global Health Initiatives were set up to target specific diseases, with an emphasis on "quick win" interventions, in order to show improvements by 2015. In 2005 the UN Millennium Project defined quick wins as simple, proven interventions with "very high potential short-term impact that can be immediately implemented", in contrast to "other interventions which are more complicated and will take a decade of effort or have delayed benefits". Although the terminology has evolved from "quick wins" to "quick impact initiatives" and then to "high impact interventions", the short-termism of the approach remains. This paper examines the merits and limitations of MDG indicators for assessing progress and their relationship to quick impact interventions. It then assesses specific health interventions through both the lens of time and their integration into health care services, and examines the role of health systems strengthening in support of the MDGs. We argue that fast-track interventions promoted by donors and Global Health Initiatives need to be complemented by mid- and long-term strategies, cutting across specific health problems. Implementing the MDGs is more than a process of "money changing hands". Combating poverty needs a radical overhaul of the partnership between rich and poor countries and between rich and poor people within countries.

Sexual and reproductive health and rights in public health education.

This paper addresses the challenges faced in mainstreaming the teaching of sexual and reproductive health and rights into public health education. For this paper, we define sexual and reproductive health and rights education as including not only its biomedical aspects but also an understanding of its history, values and politics, grounded in gender politics and social justice, addressing sexuality, and placed within a broader context of health systems and global health. Using a case study approach with an opportunistically selected sample of schools of public health within our regional contexts, we examine the status of sexual and reproductive health and rights education and some of the drivers and obstacles to the development and delivery of sexual and reproductive health and rights curricula. Despite diverse national and institutional contexts, there are many commonalities. Teaching of sexual and reproductive health and rights is not fully integrated into core curricula. Existing initiatives rely on personal faculty interest or short-term courses, neither of which are truly sustainable or replicable. We call for a multidisciplinary and more comprehensive integration of sexual and reproductive health and rights in public health education. The education of tomorrow's public health leaders is critical, and a strategy is needed to ensure that they understand and are prepared to engage with the range of sexual and reproductive health and rights issues within their historical and political contexts.