Accountability for maternal and newborn health: Why measuring and monitoring broader social, political, and health system determinants matters.

This article offers four key lessons learned from a set of seven studies undertaken as part of the collection entitled, "Improving Maternal Health Measurement to Support Efforts toward Ending Preventable Maternal Mortality". These papers were aimed at validating ten of the Ending Preventable Maternal Mortality initiative indicators that capture information on distal causes of maternal mortality. These ten indicators were selected through an inclusive consultative process, and the research designs adhere to global recommendations on conducting indicator validation studies. The findings of these papers are timely and relevant given growing recognition of the role of macro-level social, political, and economic factors in maternal and newborn survival. The four key lessons include: 1) Strengthen efforts to capture maternal and newborn health policies to enable global progress assessments while reducing multiple requests to countries for similar data; 2) Monitor indicator "bundles" to understand degree of policy implementation, inconsistencies between laws and practices, and responsiveness of policies to individual and community needs; 3) Promote regular monitoring of a holistic set of human resource metrics to understand how to effectively strengthen the maternal and newborn health workforce; and 4) Develop and disseminate clear guidance for countries on how to assess health system as well as broader social and political determinants of maternal and newborn health. These lessons are consistent with the Kirkland principles of focus, relevance, innovation, equity, global leadership, and country ownership. They stress the value of indicator sets to understand complex phenomenon related to maternal and newborn health, including small groupings of complementary indicators for measuring policy implementation and health workforce issues. They also stress the fundamental ethos that maternal and newborn health indicators should only be tracked if they can drive actions at global, regional, national, or sub-national levels that improve lives.

Persistent inequities in maternal mortality in Latin America and the Caribbean, 1990-2019.

BACKGROUND: Despite the resources and personnel mobilized in Latin America and the Caribbean to reduce the maternal mortality ratio (MMR, maternal deaths per 100 000 live births) in women aged 10-54 years by 75% between 2000 and 2015, the region failed to meet the Millenium Development Goals (MDGs) due to persistent barriers to access quality reproductive, maternal, and neonatal health services. METHODS: Using 1990-2019 data from the Global Burden of Disease project, we carried out a two-stepwise analysis to (a) identify the differences in the MMR temporal patterns and (b) assess its relationship with selected indicators: government health expenditure (GHE), the GHE as percentage of gross domestic product (GDP), the availability of human resources for health (HRH), the coverage of effective interventions to reduce maternal mortality, and the level of economic development of each country. FINDINGS: In the descriptive analysis, we observed a heterogeneous overall reduction of MMR in the region between 1990 and 2019 and heterogeneous overall increases in the GHE, GHE/GDP, and HRH availability. The correlation analysis showed a close, negative, and dependent association of the economic development level between the MMR and GHE per capita, the percentage of GHE to GDP, the availability of HRH, and the coverage of SBA. We observed the lowest MMRs when GHE as a percentage of GDP was close to 3% or about US$400 GHE per capita, HRH availability of 6 doctors, nurses, and midwives per 1,000 inhabitants, and skilled birth attendance levels above 90%. CONCLUSIONS: Within the framework of the Sustainable Development Goals (SDGs) agenda, health policies aimed at the effective reduction of maternal mortality should consider allocating more resources as a necessary but not sufficient condition to achieve the goals and should prioritize the implementation of new forms of care with a gender and rights approach, as well as strengthening actions focused on vulnerable groups.

'That is because we are alone': A relational qualitative study of socio-spatial inequities in maternal and newborn health programme coverage in rural Uttar Pradesh, India.

This qualitative study was conducted in Uttar Pradesh state, India to explore how interrelated socio-economic position and spatial characteristics of four diverse villages may have influenced equity in coverage of community-based maternal and newborn health (MNH) services. We conducted social mapping and three focus group discussions in each village, among women of lower and higher socio-economic position who recently gave birth, and with community health workers (n = 134). Data were analysed in NVivo 11.0 using thematic framework analysis. The extent of socio-economic hierarchies and spatial disparateness within the village, combined with distance to larger centers, together shaped villages' level of socio-spatial remoteness. Disadvantaged socio-economic groups expressed being more often spatially isolated, with less access to infrastructure, resources or services, which was heightened if the village was physically distant from larger centers. In more socio-spatially remote villages, inequities in coverage of MNH services that disadvantaged lower socio-economic position groups were compounded as these groups more often experienced ASHA vacancies, as well as greater distance to and poorer perceived quality of health services nearest the village. The results inform a conceptual framework of 'socio-spatial remoteness' that can guide public health research and programmes to more comprehensively address health inequities within India and beyond.

Scoping Review of Fall Risk Assessment Tools for Women Who Receive Maternity Care.

OBJECTIVE: To identify and describe fall risk assessment tools used for women who receive maternity care. DATA SOURCES: PubMed, CINAHL Complete, MEDLINE Complete, Cochrane Library, Scopus, SciELO, and Repositórios Científicos de Acesso Aberto de Portugal (RCAAP). STUDY SELECTION: We considered reports published until November 28, 2022, that included women during pregnancy, childbirth, or the postpartum period; involved the use of fall risk assessment tools, regardless of context; and were published in English, French, Portuguese, or Spanish. DATA EXTRACTION: We extracted the following data from the included reports: author(s)/year/country, aim/sample, research design/type of report, tool (i.e., the fall risk assessment tool used), findings, reliability, and validity. DATA SYNTHESIS: We found 13 reports in which the authors addressed nine fall risk assessment tools. Seven of these tools were applied during pregnancy (Kyle's tool, Pregnant Women Information Form and Assessment Scale for Risk of Falling in Pregnant Women, Obstetric Fall Risk Assessment System), labor (Obstetric Fall Risk Assessment System), the postpartum period (Cooksey-Post Obstetric Delivery Fall Risk Assessment, Kyle's tool, Risk of Falling in Post-partum Women (SLOPE), Obstetric Fall Risk Assessment System, Post-epidural Fall Risk Assessment Score, and Maternal Fall Risk Assessment Scale). The Dionne's Egress Test and the Motor Strength Scale do not address the characteristics of the women who receive maternity care. Psychometric characteristics were available for the Pregnant Women Information Form and Assessment Scale for Risk of Falling in Pregnant Women, Post-epidural Fall Risk Assessment Score, Maternal Fall Risk Assessment Scale, and Risk of Falling in Post-partum Women. CONCLUSION: Some fall risk assessment tools are used to assess women who receive maternity care without proper validation in this specific population. The use of fall risk assessment tools that are validated for women who receive maternity care may help nurses make clinical judgments when assessing fall risk and implement measures for fall prevention.

ASRHR in Ethiopia: reviewing progress over the last 20 years and looking ahead to the next 10 years.

Over the last two decades, improvements in Ethiopia's socio-economic context, the prioritization of health and development in the national agenda, and ambitious national health and development policies and programmes have contributed to improvements in the living standards and well-being of the population as a whole including adolescents. Improvements have occurred in a number of health outcomes, for example reduction in levels of harmful practices i.e., in child marriage and female genital mutilation/cutting (FGM/C), reduction in adolescent childbearing, increase in positive health behaviours, for example adolescent contraceptive use, and maternal health care service use. However, this progress has been uneven. As we look to the next 10 years, Ethiopia must build on the progress made, and move ahead understanding and overcoming challenges and making full use of opportunities by (i) recommitting to strong political support for ASRHR policies and programmes and to sustaining this support in the next stage of policy and strategy development (ii) strengthening investment in and financing of interventions to meet the SRH needs of adolescents (iii) ensuring laws and policies are appropriately communicated, applied and monitored (iv) ensuring strategies are evidence-based and extend the availability of age-disaggregated data on SRHR, and that implementation of these strategies is managed well (v) enabling meaningful youth engagement by institutionalizing adolescent participation as an essential element of all programmes intended to benefit adolescents, and (vi) consolidating gains in the area of SRH while strategically broadening other areas without diluting the ASRHR focus.

Inclusive, supportive and dignified maternity care (SDMC)-Development and feasibility assessment of an intervention package for public health systems: A study protocol.

INTRODUCTION: Mistreatment, discrimination, and poor psycho-social support during childbirth at health facilities are common in lower- and middle-income countries. Despite a policy directive from the World Health Organisation (WHO), no operational model exists that effectively demonstrates incorporation of these guidelines in routine facility-based maternity services. This early-phase implementation research aims to develop, implement, and test the feasibility of a service-delivery strategy to promote the culture of supportive and dignified maternity care (SDMC) at public health facilities. METHODS: Guided by human-centred design approach, the implementation of this study will be divided into two phases: development of intervention, and implementing and testing feasibility. The service-delivery intervention will be co-created along with relevant stakeholders and informed by contextual evidence that is generated through formative research. It will include capacity-building of maternity teams, and the improvement of governance and accountability mechanisms within public health facilities. The technical content will be primarily based on WHO's intrapartum care guidelines and mental health Gap Action Programme (mhGAP) materials. A mixed-method, pre-post design will be used for feasibility assessment. The intervention will be implemented at six secondary-level healthcare facilities in two districts of southern Sindh, Pakistan. Data from multiple sources will be collected before, during and after the implementation of the intervention. We will assess the coverage of the intervention, challenges faced, and changes in maternity teams' understanding and attitude towards SDMC. Additionally, women's maternity experiences and psycho-social well-being-will inform the success of the intervention. EXPECTED OUTCOMES: Evidence from this implementation research will enhance understanding of health systems challenges and opportunities around SDMC. A key output from this research will be the SDMC service-delivery package, comprising a comprehensive training package (on inclusive, supportive and dignified maternity care) and a field tested strategy to ensure implementation of recommended practices in routine, facility-based maternity care. Adaptation, Implementation and evaluation of SDMC package in diverse setting will be way forward. The study has been registered with clinicaltrials.gov (Registration number: NCT05146518).

Heart work: Indigenous doulas responding to challenges of western systems and revitalizing Indigenous birthing care in Canada.

BACKGROUND: In Canada, there has been a significant increase in the training of Indigenous doulas, who provide continuous, culturally appropriate support to Indigenous birthing people during pregnancy, birth, and the postpartum period. The purpose of our project was to interview Indigenous doulas across Canada in order to document how they worked through the logistics of providing doula care and to discern their main challenges and innovations. POPULATION/SETTING: Our paper analyzes interviews conducted with members of five Indigenous doula collectives across Canada, from the provinces of British Columbia, Manitoba, Ontario, Quebec and Nova Scotia. METHODS: Semi-structured interviews were conducted with members of the five Indigenous doula collectives across Canada in 2020 as part of the project, "She Walks With Me: Supporting Urban Indigenous Expectant Mothers Through Culturally Based Doulas." Interview transcripts were approved by participants and subsequently coded by the entire research team to identify key themes. RESULTS: Our paper examines two themes that emerged in interviews: the main challenges Indigenous doulas describe confronting when working within western systems, and how they navigate and overcome these obstacles. Specifically, interview participants described tensions with the biomedical approach to maternal healthcare and conflicts with the practice of Indigenous infant apprehension. In response to these challenges, Indigenous doulas are working to develop Indigenous-specific doula training curricula, engaging in collective problem-solving, and advocating for the reformation of a grant program in order to fund more Indigenous doulas. CONCLUSIONS: Both the biomedical model of maternal healthcare and the crisis of Indigenous infant apprehension renders Canadian hospitals unsafe and uncomfortable spaces for many Indigenous birthing people and their families. Indigenous doulas are continually navigating these challenges and creatively and concertedly working towards the revitalization of Indigenous birthing care. Indigenous doula care is critical to counter systemic, colonial barriers and issues that disproportionately impact Indigenous families, as well as recentering birth as the foundation of Indigenous sovereignty and community health.

Strategies to improve the quality of midwifery care and developing midwife-centered care in Iran: analyzing the attitudes of midwifery experts.

BACKGROUND: In recent years, extensive studies have been designed and performed in the context of providing midwifery care in developed countries, which has been unfortunately neglected in some low resources and upper middle-income countries such as Iran. This study was conducted to identify the best strategies for improving the quality of midwifery care and developing midwife-centered care in Iran. METHODS: This was a qualitative study using focus group discussion and content analysis method. Data were collected from 121 participants including midwifery board members, gynecologists, heads of midwifery departments, midwifery students, in charge midwives in hospitals, and midwives in the private sector. Focused-group discussions were used for data collection, and data were analyzed using content analysis method. RESULTS: The main themes extracted from the participants' statements regarding improving the quality of midwifery care were as follows: Promotion and development of education, Manpower management, Rules, and regulations and standards for midwifery services, and Policy making. CONCLUSION: This study showed that to improve midwifery care, health policy makers should take into account both the quality and quantity of midwifery education, and promote midwifery human resources through employment. Furthermore, insurance support, encouragement, supporting and motivating midwives, enhancing and improving the facilities, providing hospitals and maternity wards with cutting-edge equipment, promoting and reinforcing the position of midwives in the family doctor program, and using a referral system were the strategies proposed by participants for improving midwifery care. Finally, establishing an efficient and powerful monitoring system to control the practice of gynecologists and midwives, promoting the collaborative practice of midwives and gynecologists, and encouraging team-work with respect to midwifery care were other strategies to improve the midwifery services in Iran. Authorities and policymakers may set the stage for developing high quality and affordable midwifery care by relying on the strategies presented in this study.

Challenges and barriers to optimal maternity care for recently migrated women - a mixed-method study in Norway.

BACKGROUND: Migrant women are at increased risk for complications related to pregnancy and childbirth, possibly due to inadequate access and utilisation of healthcare. Recently migrated women are considered a vulnerable group who may experience challenges in adapting to a new country. We aimed to identify challenges and barriers recently migrated women face in accessing and utilising maternity healthcare services. METHODS: In the mixed-method MiPreg-study, we included recently migrated (≤ five years) pregnant women born in low- or middle-income countries and healthcare personnel. First, we conducted 20 in-depth interviews with migrant women at Maternal and Child Health Centres (MCHC) and seven in-depth interviews with midwives working at either the hospital or the MCHCs in Oslo. Afterwards, we triangulated our findings with 401 face-to-face questionnaires post-partum at hospitals among migrant women. The data were thematically analysed by grouping codes after careful consideration and consensus between the researchers. RESULTS: Four main themes of challenges and barriers faced by the migrant women were identified: (1) Navigating the healthcare system, (2) Language, (3) Psychosocial and structural factors, and (4) Expectations of care. Within the four themes we identified a range of individual and structural challenges, such as limited knowledge about available healthcare services, unmet needs for interpreter use, limited social support and conflicting recommendations for pregnancy-related care. The majority of migrant women (83.6%) initiated antenatal care in the first trimester. Several of the challenges were associated with vulnerabilities not directly related to maternal health. CONCLUSION: A combination of individual, structural and institutional barriers hinder recently migrated women in achieving optimal maternal healthcare. Suggested strategies to address the challenges include improved provision of information about healthcare structure to migrant women, increased use of interpreter services, appropriate psychosocial support and strengthening diversity- and intercultural competence training among healthcare personnel.

Assessment of maternal health services: a comparative study of urban and rural primary health facilities in Kano State, Northwest Nigeria.

INTRODUCTION: all pregnant women are at potential risk of obstetric complications; majority of which can be treated if appropriate care is accessed promptly. A shift in focus to quality of care has the potential to unlock significant returns for every mother and newborn to end preventable maternal and infant deaths. The study aimed to assess the quality of maternal health services in primary health facilities in urban and rural communities of Kano State. METHODS: using a comparative cross-sectional study design that utilized mixed method of data collection, interviewer administered questionnaire were used to collect information from 438 women (219) each attending health facilities for maternal health services in rural and urban areas of Kano using multistage sampling technique from June to November, 2019. Six Key Informant Interviews with the heads of units/ facilities were purposively conducted. Quality of care was assessed using perspectives and system models based on the components of antenatal care received, postnatal care and perception of care received. A statistical significance was set at p-value < 0.05. Thematic framework analysis was used to analyze verbatim transcript from qualitative interviews. RESULTS: the age of the respondents ranged from 18-48 years with majority having secondary education in both communities. In both urban and rural communities, majority of the respondents had only 1-3 antenatal care visits making up 63.5% and 70.3% respectively. Almost similar proportions of the urban (58.4%) and rural (50.2%) respondents were delivered by a skilled birth attendant. About two-third of the respondents, 67.6% and 65.3% in the urban and rural communities respectively were completely satisfied with the quality of care received. Qualitative interviews pointed ignorance as the major factor that prevent mothers from accessing quality care and reported that satisfactory services were provided in all facilities. CONCLUSION: considerable disparity exists between urban and rural communities in quality of maternal health services with better provision of most services in the urban communities. There is need for improvement in the desirable and minimum acceptable quality of maternal health services in Kano State.

Facility-level determinants of quality routine intrapartum care in Afghanistan.

BACKGROUND: Although there have been notable improvements in availability and utilization of maternal health care in Afghanistan over the last few decades, risk of maternal mortality remains very high. Previous studies have highlighted gaps in quality of emergency obstetric and newborn care practices, however, little is known about the quality of routine intrapartum care at health facilities in Afghanistan. METHODS: We analyzed a subset of data from the 2016 Afghanistan Maternal and Newborn Health Quality of Care Assessment that comprised of observations of labor, delivery and immediate post-partum care, as well as health facility assessments and provider interviews across all accessible public health facilities with an average of five or more births per day in the preceding year (N = 77). Using the Quality of the Process of Intrapartum and Immediate Postpartum Care index, we calculated a quality of care score for each observation. We conducted descriptive and bivariate analyses and built a multivariate linear regression model to identify facility-level factors associated with quality of care scores. RESULTS: Across 665 childbirth observations, low quality of care was observed such that no health facility type received an average quality score over 56%. The multivariate regression model indicated that availability of routine labor and delivery supplies, training in respectful maternity care, perceived gender equality for training opportunities, recent supervision, and observation during supervision have positive, statistically significant associations with quality of care. CONCLUSIONS: Quality of routine intrapartum care at health facilities in Afghanistan is concerningly low. Our analysis suggests that multi-faceted interventions are needed to address direct and indirect contributors to quality of care including clinical care practices, attention to client experiences during labor and childbirth, and attention to staff welfare and opportunities, including gender equality within the health workforce.

Determinants, reasons for choice and willingness to recommend birthing facility among mothers in public and private health facilities in Ebonyi, Nigeria.

INTRODUCTION: facility-based births remain low in Nigeria despite the enormous benefits on maternal and neonatal health. We compared the determinants, reasons for choice and willingness to recommend public and private birthing facilities among mothers in Ebonyi, Nigeria. METHODS: this was a cross-sectional survey among 620 women whose childbirth occurred in public (teaching) and private-for-profit mission hospitals in Ebonyi, Nigeria. Semi-structured, interviewer-administered questionnaires were used for data collection. RESULTS: the mean age of the respondents was 29.86±4.4. Most had post-secondary education (71.0%), more than 4 antenatal visits (83.4%) and vaginal births (77.7%). Respondents with high economic status [adjusted odds ratio (aOR) 2.88; Confidence Interval (CI) 1.98-4.18], post-secondary education (aOR 1.73; CI 1.13-2.64) and urban residence (aOR 3.51; CI 2.19-5.61) were more likely to utilize public birthing facilities. In the private hospital, religion (78.4%) was the commonest reason for utilization while poor quality of services (61.9%) was the major cause of dissatisfaction. In the public hospital, the main reason for patronage was insurance enrolment (73.2%) while negative provider attitude (66.7%) led to dissatisfaction. In both facilities, majority (92%) were willing to recommend their birth facility to others. CONCLUSION: regardless of facility type, respondents were willing to recommend or reuse the health facility for subsequent obstetric care. Religion and insurance enrolment were the major reasons for choosing the private and public hospital respectively. Residence, educational and income status influenced birthing facility type used. We recommend improved quality of services in private hospitals and provision of insurance with improved provider attitude in public health facilities.

Reported Barriers to Healthcare Access and Service Disruptions Caused by COVID-19 in Burkina Faso, Ethiopia, and Nigeria: A Telephone Survey.

The coronavirus disease 2019 (COVID-19) pandemic may have short-term and long-term impacts on health services across sub-Saharan African countries. A telephone survey in Burkina Faso, Ethiopia, and Nigeria was conducted to assess the effects of the pandemic on healthcare services from the perspectives of healthcare providers (HCPs) and community members. A total of 900 HCPs (300 from each country) and 1,797 adult community members (approximately 600 from each country) participated in the study. Adjusted risk ratios (ARRs) and 95% confidence intervals (CIs) were computed using modified Poisson regression. According to the HCPs, more than half (56%) of essential health services were affected. Child health services and HIV/surgical/other services had a slightly higher percentage of interruption (33%) compared with maternal health services (31%). A total of 21.8%, 19.3%, and 7.7% of the community members reported that their family members and themselves had difficulty accessing childcare services, maternal health, and other health services, respectively. Nurses had a lower risk of reporting high service interruptions than physicians (ARR, 0.85; 95% CI, 0.56-0.95). HCPs at private facilities (ARR, 0.71; 95% CI, 0.59-0.84) had a lower risk of reporting high service interruptions than those at governmental facilities. Health services in Nigeria were more likely to be interrupted than those in Burkina Faso (ARR, 1.38; 95% CI, 1.19-1.59). Health authorities should work with multiple stakeholders to ensure routine health services and identify novel and adaptive approaches to recover referral services, medical care, maternal and child health, family planning, immunization and health promotion, and prevention during the COVID-19 era.

Implementation of a performance-based financing scheme in Malawi and resulting externalities on the quality of care of non-incentivized services.

BACKGROUND: Countries in Africa progressively implement performance-based financing schemes to improve the quality of care provided by maternal, newborn and child health services. Beyond its direct effects on service provision, evidence suggests that performance-based financing can also generate positive externalities on service utilization, such as increased use of those services that reached higher quality standards after effective scheme implementation. Little, however, is known about externalities generated within non-incentivized health services, such as positive or negative effects on the quality of services within the continuum of maternal care. METHODS: We explored whether a performance-based financing scheme in Malawi designed to improve the quality of childbirth service provision resulted positive or negative externalities on the quality of non-targeted antenatal care provision. This non-randomized controlled pre-post-test study followed the phased enrolment of facilities into a performance-based financing scheme across four districts over a two-year period. Effects of the scheme were assessed by various composite scores measuring facilities' readiness to provide quality antenatal care, as well as the quality of screening, prevention, and education processes offered during observed antenatal care consultations. RESULTS: Our study did not identify any statistically significant effects on the quality of ANC provision attributable to the implemented performance-based financing scheme. Our findings therefore suggest not only the absence of positive externalities, but also the absence of any negative externalities generated within antenatal care service provision as a result of the scheme implementation in Malawi. CONCLUSIONS: Prior research has shown that the Malawian performance-based financing scheme was sufficiently effective to improve the quality of incentivized childbirth service provision. Our findings further indicate that scheme implementation did not affect the quality of non-incentivized but clinically related antenatal care services. While no positive externalities could be identified, we also did not observe any negative externalities attributable to the scheme's implementation. While performance-based incentives might be successful in improving targeted health care processes, they have limited potential in producing externalities - neither positive nor negative - on the provision quality of related non-incentivized services.

Barriers inhibiting effective detection and management of postpartum hemorrhage during facility-based births in Madagascar: findings from a qualitative study using a behavioral science lens.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in low-income countries, and is the most common direct cause of maternal deaths in Madagascar. Studies in Madagascar and other low-income countries observe low provider adherence to recommended practices for PPH prevention and treatment. Our study addresses gaps in the literature by applying a behavioral science lens to identify barriers inhibiting facility-based providers' consistent following of PPH best practices in Madagascar. METHODS: In June 2019, we undertook a cross-sectional qualitative research study in peri-urban and rural areas of the Vatovavy-Fitovinany region of Madagascar. We conducted 47 in-depth interviews in 19 facilities and five communities, with facility-based healthcare providers, postpartum women, medical supervisors, community health volunteers, and traditional birth attendants, and conducted thematic analysis of the transcripts. RESULTS: We identified seven key behavioral insights representing a range of factors that may contribute to delays in appropriate PPH management in these settings. Findings suggest providers' perceived low risk of PPH may influence their compliance with best practices, subconsciously or explicitly, and lead them to undervalue the importance of PPH prevention and monitoring measures. Providers lack clear feedback on specific components of their performance, which ultimately inhibits continuous improvement of compliance with best practices. Providers demonstrate great resourcefulness while operating in a challenging context with limited equipment, supplies, and support; however, overcoming these challenges remains their foremost concern. This response to chronic scarcity is cognitively taxing and may ultimately affect clinical decision-making. CONCLUSIONS: Our study reveals how perception of low risk of PPH, limited feedback on compliance with best practices and consequences of current practices, and a context of scarcity may negatively affect provider decision-making and clinical practices. Behaviorally informed interventions, designed for specific contexts that care providers operate in, can help improve quality of care and health outcomes for women in labor and childbirth.

Midwives' experiences of cultural competency training and providing perinatal care for migrant women a mixed methods study: Operational Refugee and Migrant Maternal Approach (ORAMMA) project.

BACKGROUND: The number of international migrants continues to increase worldwide. Depending on their country of origin and migration experience, migrants may be at greater risk of maternal and neonatal morbidity and mortality. Having compassionate and culturally competent healthcare providers is essential to optimise perinatal care. The "Operational Refugee and Migrant Maternal Approach" (ORAMMA) project developed cultural competence training for health professionals to aid with providing perinatal care for migrant women. This presents an evaluation of ORAMMA training and explores midwives' experiences of the training and providing care within the ORAMMA project. METHODS: Cultural competence was assessed before and after midwives (n = 35) received ORAMMA compassionate and culturally sensitive maternity care training in three different European countries. Semi-structured interviews (n = 12) explored midwives' experiences of the training and of caring for migrant women within the ORAMMA project. RESULTS: A significant improvement of the median score pre to post-test was observed for midwives' knowledge (17 to 20, p < 0.001), skills (5 to 6, p = 0.002) and self-perceived cultural competence (27 to 29, p = 0.010). Exploration of midwives' experiences of the training revealed themes of "appropriate and applicable", "made a difference" and "training gaps" and data from ORAMMA project experiences identified three further themes; "supportive care", "working alongside peer supporters" and "challenges faced". CONCLUSIONS: The training improved midwives' knowledge and self-perceived cultural competence in three European countries with differing contexts and workforce provision. A positive experience of ORAMMA care model was expressed by midwives, however clearer expectations of peer supporters' roles and more time within appointments to assess the psychosocial needs of migrant women were desired. Future large-scale research is required to assess the long-term impact of the ORAMMA model and training on practice and clinical perinatal outcomes.

Determinants of completing recommended antenatal care utilization in sub-Saharan from 2006 to 2018: evidence from 36 countries using Demographic and Health Surveys.

BACKGROUND: Every day in 2017, approximately 810 women died from preventable causes related to pregnancy and childbirth, with 99% of these maternal deaths occurring in low and lower-middle-income countries. Sub-Saharan Africa (SSA) alone accounts for roughly 66%. If pregnant women gained recommended ANC (Antenatal Care), these maternal deaths could be prevented. Still, many women lack recommended ANC in sub-Saharan Africa. This study aimed at determining the pooled prevalence and determinants of recommended ANC utilization in SSA. METHODS: We used the most recent standard demographic and health survey data from the period of 2006 to 2018 for 36 SSA countries. A total of 260,572 women who had at least one live birth 5 years preceding the survey were included in this study. A meta-analysis of DHS data of the Sub-Saharan countries was conducted to generate pooled prevalence, and a forest plot was used to present it. A multilevel multivariable logistic regression model was fitted to identify determinants of recommended ANC utilization. The AOR (Adjusted Odds Ratio) with their 95% CI and p-value ≤0.05 was used to declare the recommended ANC utilization determinates. RESULTS: The pooled prevalence of recommended antenatal care utilization in sub-Saharan Africa countries were 58.53% [95% CI: 58.35, 58.71], with the highest recommended ANC utilization in the Southern Region of Africa (78.86%) and the low recommended ANC utilization in Eastern Regions of Africa (53.39%). In the multilevel multivariable logistic regression model region, residence, literacy level, maternal education, husband education, maternal occupation, women health care decision autonomy, wealth index, media exposure, accessing health care, wanted pregnancy, contraceptive use, and birth order were determinants of recommended ANC utilization in Sub-Saharan Africa. CONCLUSION: The coverage of recommended ANC service utilization was with high disparities among the region. Being a rural residence, illiterate, low education level, had no occupation, low women autonomy, low socioeconomic status, not exposed to media, a big problem to access health care, unplanned pregnancy, not use of contraceptive were determinants of women that had no recommended ANC utilization in SSA. This study evidenced the existence of a wide gap between SSA regions and countries. Special attention is required to improve health accessibility, utilization, and quality of maternal health services.

Breastfeeding During a Pandemic: The Influence of COVID-19 on Lactation Services in the Northeastern United States.

BACKGROUND: Pandemic-related restrictions have limited traditional models of lactation support. RESEARCH AIMS: The primary aim of this study was to determine changes to breastfeeding support services during the coronavirus-2019 pandemic according to trained lactation providers. The secondary aim was to assess strengths and limitations of telehealth services. METHODS: A prospective survey was conducted entirely online using the Qualtrics platform during June 2020. Gatekeepers at Connecticut agencies and breastfeeding networks were forwarded an anonymous survey link to distribute to eligible lactation staff. RESULTS: A variety of participants (N = 39) completed the survey and the majority (69.2%; n = 27) were providing only telehealth services. More than half (58.1%; n = 18) of the participants who conducting telehealth in any form, found that virtual lactation support was moderately effective compared to in-person support. Weakness of virtual support included technical and logistical difficulties, challenges assisting with latching or reading body language over the phone or online, and accurately assessing infant growth. Strengths related to virtual support included the flexibility and convenience of home-based support, expanded communication strategies, and safety from virus exposure. Further, visits with a lactation professional decreased significantly during the pandemic. Limited in-hospital and pediatrician support were also noted, particularly among groups without access to telehealth resources. CONCLUSIONS: As a result of the pandemic and associated shifts in lactation services, breastfeeding disparities may be further exacerbated among those without equitable access to lactation support. Challenges and innovations in virtual support may influence adaptive options in the field moving forward.