Respectful Maternity Care : A Systematic Review.

BACKGROUND: Severe maternal morbidity and mortality are worse in the United States than in all similar countries, with the greatest effect on Black women. Emerging research suggests that disrespectful care during childbirth contributes to this problem. PURPOSE: To conduct a systematic review on definitions and valid measurements of respectful maternity care (RMC), its effectiveness for improving maternal and infant health outcomes for those who are pregnant and postpartum, and strategies for implementation. DATA SOURCES: Systematic searches of Ovid Medline, CINAHL, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, and SocINDEX for English-language studies (inception to July 2023). STUDY SELECTION: Randomized controlled trials and nonrandomized studies of interventions of RMC versus usual care for effectiveness studies; additional qualitative and noncomparative validation studies for definitions and measurement studies. DATA EXTRACTION: Dual data abstraction and quality assessment using established methods, with resolution of disagreements through consensus. DATA SYNTHESIS: Thirty-seven studies were included across all questions, of which 1 provided insufficient evidence on the effectiveness of RMC to improve maternal outcomes and none studied RMC to improve infant outcomes. To define RMC, authors identified 12 RMC frameworks, from which 2 main concepts were identified: disrespect and abuse and rights-based frameworks. Disrespect and abuse components focused on recognizing birth mistreatment; rights-based frameworks incorporated aspects of reproductive justice, human rights, and antiracism. Five overlapping framework themes include freedom from abuse, consent, privacy, dignity, communication, safety, and justice. Twelve tools to measure RMC were validated in 24 studies on content validity, construct validity, and internal consistency, but lack of a gold standard limited evaluation of criterion validity. Three tools specific for RMC had at least 1 study demonstrating consistency internally and with an intended construct relevant to U.S. settings, but no single tool stands out as the best measure of RMC. LIMITATIONS: No studies evaluated other health outcomes or RMC implementation strategies. The lack of definition and gold standard limit evaluation of RMC tools. CONCLUSION: Frameworks for RMC are well described but vary in their definitions. Tools to measure RMC demonstrate consistency but lack a gold standard, requiring further evaluation before implementation in U.S. settings. Evidence is lacking on the effectiveness of implementing RMC to improve any maternal or infant health outcome. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO: CRD42023394769).

Lessons learned from co-production in public health research: the MAMAH case study involving underserved migrant mothers in the UK.

BACKGROUND: Research suggests some migrant women are at increased risk of mortality and morbidity in the perinatal period; however, there is a gap in co-produced research to improve care. The UK National Institute for Health and Care Research (NIHR) defines co-production as "an approach in which researchers, practitioners, and members of the public work together, sharing power and responsibility". We summarise learnings from our study, which aimed to co-produce solutions to improve maternity care for migrant women in the UK, by working with women to identify the most important research priorities. METHODS: We recruited 18 underserved migrant women living in the UK who had given birth in the UK within the past 15 years to create a patient advisory panel. They were recruited via national and local non-governmental organisations and snowball sampling using purposive methods to ensure representation from a range of backgrounds, including those who were refugees, asylum seekers, and undocumented. Underserved was defined as asylum seeking, refugee, undocumented, or low-income mothers (those who were experiencing homelessness or in receipt of welfare support). The women are involved in conceptualisation, analysis, and dissemination of the project. The project is a UK National Institute of Health and Care Research (NIHR) Doctoral Fellowship project lasting 3 years with a variety of research workstreams. FINDINGS: The research funding application process began in January, 2021, and the project was funded and began in November, 2022. The research team struggled to access comprehensive training on co-production, particularly in how to counter power dynamics. We appointed a Lead Patient Advisor who manages the relationship between the academics and the patient advisors. Additionally, we reimburse women's time, childcare, and travel. We have found that online meetings are preferable, as women do not need to travel or arrange childcare. We meet our patient advisory panel four times per year. Some women have been directly involved in research such as systematic review screening and qualitative interviewing and have been given research training. Our initial research priorities did not align with those of the women, and this helped us to reshape our work. Women said that having a Lead Patient Advisor made it easier to participate, particularly as some issues are traumatic. To mitigate this, we have offered support resources and debriefing. Using online interpreters has been challenging, and we have recently split into different language groups to maximise engagement. INTERPRETATION: Overall, as researchers, we have learned that taking a truly co-produced approach is time-consuming but has ensured our research prioritises the views of migrant women giving birth in the UK. FUNDING: National Institute for Health and Care Research (NIHR).

The forgotten girls: the state of evidence for health interventions for pregnant adolescents and their newborns in low-income and middle-income countries.

Every year, an estimated 21 million girls aged 15-19 years become pregnant in low-income and middle-income countries (LMICs). Policy responses have focused on reducing the adolescent birth rate whereas efforts to support pregnant adolescents have developed more slowly. We did a systematic review of interventions addressing any health-related outcome for pregnant adolescents and their newborn babies in LMICs and mapped its results to a framework describing high-quality health systems for pregnant adolescents. Although we identified some promising interventions, such as micronutrient supplementation, conditional cash transfers, and well facilitated group care, most studies were at high risk of bias and there were substantial gaps in evidence. These included major gaps in delivery, abortion, and postnatal care, and mental health, violence, and substance misuse-related outcomes. We recommend that the fields of adolescent, maternal, and sexual and reproductive health collaborate to develop more adolescent-inclusive maternal health care and research, and specific interventions for pregnant adolescents. We outline steps to develop high-quality, evidence-based care for the millions of pregnant adolescents and their newborns who currently do not receive this.

A composite index; socioeconomic deprivation and coverage of reproductive and maternal health interventions.

Objective: To examine inequalities in the coverage of reproductive and maternal health interventions in low- and middle-income countries and territories using a composite index of socioeconomic deprivation status. Methods: We obtained data on education and living standards from national household surveys conducted between 2015 and 2019 to calculate socioeconomic deprivation status. We assessed the coverage of reproductive and maternal health interventions, using three indicators: (i) demand for family planning satisfied with modern methods; (ii) women who received antenatal care in at least four visits; and (iii) the presence of a skilled attendant at delivery. Absolute and relative inequalities were evaluated both directly and using the slope index of inequality and the concentration index. Findings: In the 73 countries and territories with available data, the median proportions of deprivation were 41% in the low-income category, 11% in the lower-middle-income category and less than 1% in the upper-middle-income category. The coverage analysis, conducted for 48 countries with sufficient data, showed consistently lower median coverage among deprived households across all health indicators. The coverage of skilled attendant at delivery showed the largest inequalities, where coverage among the socioeconomically deprived was substantially lower in almost all countries. Antenatal care visits and demand for family planning satisfied with modern methods also showed significant disparities, favouring the less deprived population. Conclusion: The findings highlight persistent disparities in the coverage of reproductive and maternal health interventions, requiring efforts to reduce those disparities and improve coverage, particularly for skilled attendant at delivery.

Obstetric violence is a misnomer.

The term "obstetric violence" has been used in the legislative language of several countries to protect mothers from abuse during pregnancy. Subsequently, it has been expanded to include a spectrum of obstetric procedures, such as induction of labor, episiotomy, and cesarean delivery, and has surfaced in the peer-reviewed literature. The term "obstetric violence" can be seen as quite strong and emotionally charged, which may lead to misunderstandings or misconceptions. It might be interpreted as implying a deliberate act of violence by healthcare providers when mistreatment can sometimes result from systemic issues, lack of training, or misunderstandings rather than intentional violence. "Obstetric mistreatment" is a more comprehensive term that can encompass a broader range of behaviors and actions. "Violence" generally refers to the intentional use of physical force to cause harm, injury, or damage to another person (eg, physical assault, domestic violence, street fights, or acts of terrorism), whereas "mistreatment" is a more general term and refers to the abuse, harm, or control exerted over another person (such as nonconsensual medical procedures, verbal abuse, disrespect, discrimination and stigmatization, or neglect, to name a few examples). There may be cases where unprofessional personnel may commit mistreatment and violence against pregnant patients, but as obstetrics is dedicated to the health and well-being of pregnant and fetal patients, mistreatment of obstetric patients should never be an intended component of professional obstetric care. It is necessary to move beyond the term "obstetric violence" in discourse and acknowledge and address the structural dimensions of abusive reproductive practices. Similarly, we do not use the term "psychiatric violence" for appropriately used professional procedures in psychiatry, such as electroshock therapy, or use the term "neurosurgical violence" when drilling a burr hole. There is an ongoing need to raise awareness about the potential mistreatment of obstetric patients within the context of abuse against women in general. Using the term "mistreatment in healthcare" instead of the more limited term "obstetric violence" is more appropriate and applies to all specialties when there is unprofessional abuse and mistreatment, such as biased care, neglect, emotional abuse (verbal), or physical abuse, including performing procedures that are unnecessary, unindicated, or without informed patient consent. Healthcare providers must promote unbiased, respectful, and patient-centered professional care; provide an ethical framework for all healthcare personnel; and work toward systemic change to prevent any mistreatment or abuse in our specialty.

Proximity to Hospital-Based Obstetric Care in a Maternity Desert in the Deep South.

Objectives. To examine the accessibility of hospital facilities with maternity care services in 1 rural county in Alabama in preparation for the initiation of prenatal care services at a federally qualified health center. Methods. We analyzed driving distance (in miles) from maternal city of residence in Conecuh County, Alabama to hospital of delivery, using 2019-2021 vital statistics data and geographic information system (GIS) software. Results. A total of 370 births to mothers who have home addresses in Conecuh County were reported, and 368 of those were in hospital facilities. The majority of deliveries were less than 30 miles (median = 23 miles) from the maternal city of residence. Some women traveled more than 70 miles for obstetrical care. Conclusions. Pregnant patients in Conecuh County experience significant geographic barriers related to perinatal care access. Using GIS for this analysis is a promising approach to better understand the unique challenges of pregnant individuals in this rural population. Public health policy efforts need to be geographically tailored to address these disparities. (Am J Public Health. 2024;114(S4):S330-S333. https://doi.org/10.2105/AJPH.2024.307692).

Outcomes of the MAMA Training: A Simulation and Experiential Learning Intervention for Labor and Delivery Providers to Improve Respectful Maternity Care for Women Living with HIV in Tanzania.

Respectful maternity care (RMC) for women living with HIV (WLHIV) improves birth outcomes and may influence women's long-term commitment to HIV care. In this study, we evaluated the MAMA training, a team-based simulation training for labor and delivery (L&D) providers to improve RMC and reduce stigma in caring for WLHIV. The study was conducted in six clinical sites in the Kilimanjaro Region of Tanzania. 60 L&D providers participated in the MAMA training, which included a two-and-a-half-day workshop followed by a half-day on-site refresher. We assessed the impact of the MAMA training using a pre-post quasi-experimental design. To assess provider impacts, participants completed assessments at baseline and post-intervention periods, measuring RMC practices, HIV stigma, and self-efficacy to provide care. To evaluate patient impacts, we enrolled birthing women at the study facilities in the pre- (n = 229) and post- (n = 214) intervention periods and assessed self-reported RMC and perceptions of provider HIV stigma. We also collected facility-level data on the proportion of patients who gave birth by cesarean section, disaggregated by HIV status. The intervention had a positive impact on all provider outcomes; providers reported using more RMC practices, lower levels of HIV stigma, and greater self-efficacy to provide care for WLHIV. We did not observe differences in self-reported patient outcomes. In facility-level data, we observed a trend in reduction in cesarean section rates for WLHIV (33.0% vs. 24.1%, p = 0.14). The findings suggest that the MAMA training may improve providers' attitudes and practices in caring for WLHIV giving birth and should be considered for scale-up.

Maternal mortality during war time in Tigray, Ethiopia: A community-based study.

OBJECTIVE: This study seeks to examine the impact of war on maternal mortality following an exacerbation in the dynamics of inequality in maternal health caused by the continuing conflict. DESIGN: Community-based cross-sectional study. SETTING: Tigray region of Northern Ethiopia, between November 2020 and May 2022. POPULATION: This study surveyed a total of 189 087 households from six of the seven zones of Tigray in 121 tabiyas from 31 districts selected. A multistage cluster sampling technique was used to select the districts and tabiyas. METHODS: The study was conducted in two phases. In the first phase, reproductive-age deaths that occurred during the study period were screened. In the second phase, verbal autopsies were conducted at the screened households. MAIN OUTCOME MEASURES: Maternal mortality ratio level and cause-specific mortality. RESULTS: The results of the study showed that the maternal mortality ratio was 840 (95% CI 739-914) per 100 000 live births. Haemorrhage, 107 (42.8%), pregnancy-induced hypertension, 21 (8.4%), and accidents, 14 (5.6%), were the main causes of mortality. Additionally, 203 (81.2%) of the mothers died outside of a health facility. CONCLUSIONS: This study has shown a higher maternal mortality ratio following the dynamics of the Tigray war, as compared with the pre-war level of 186/100 000. Furthermore, potentially many of the pregnancy-related deaths could have been prevented with access to preventive and emergency services. Given the destruction and looting of many facilities, the restoration and improvement of the Tigray health system must take precedence.

Interprofessional obstetric simulation training improves postpartum haemorrhage management and decreases maternal morbidity: a before-and-after study.

OBJECTIVE: To determine the impact of the Obstetric Simulation Training and Teamwork (OB-STaT) curriculum on postpartum haemorrhage (PPH) rates and outcomes. DESIGN: Before-and-after study. SETTING: Maternity care hospitals within the USA. POPULATION: Patients who delivered between February 2018 and November 2019. METHODS: Interprofessional obstetric teamwork training (OB-STaT) conducted at each hospital. Electronic medical records for deliveries were reviewed for 6 months before and after conducting OB-STaT at participating hospitals. MAIN OUTCOME MEASURES: The PPH rate (blood loss of ≥1000 ml), uterotonic medications used, tranexamic acid use, blood product transfusion, hysterectomy, length of stay and composite maternal morbidity (postpartum haemorrhage, hysterectomy, transfusion of ≥4 units of blood products and intensive care unit admission for PPH). RESULTS: A total of 9980 deliveries were analysed: 5059 before and 4921 after OB-STaT. The PPH rates did not change significantly (5.48% before vs 5.14% after, p = 0.46). Composite maternal morbidity decreased significantly by 1.1% (6.35%-5.28%, p = 0.03), massive transfusions decreased by 57% (0.42%-0.18%, p = 0.04) and the mean postpartum length of stay decreased from 2.05 days (1.05 days SD) to 2.01 days (0.91 days SD) (p = 0.04). Following OB-STaT, haemorrhage medication use increased by 36% (14.8%-51.2%, p = 0.03), the use of tranexamic acid for PPH treatment almost doubled (2.7%-4.8%, p < 0.001) and the rate of hysterectomy significantly increased (0%-0.1%, p = 0.03). CONCLUSIONS: Although the PPH rates did not decrease, OB-STaT significantly improved maternal morbidity, decreased massive transfusions, and improved PPH management by increasing the utilization of uterotonic medications, tranexamic acid and hysterectomy.

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.

Respectful maternity care interventions to address women mistreatment in childbirth: What has been done?

INTRODUCTION: Over the last decade, there has been an increasing number of studies regarding experiences of mistreatment, disrespect and abuse (D&A) during facility-based childbirth. These negative experiences during labour have been proven to create a barrier for seeking both facility-based childbirth and postnatal health care, as well as increasing severe postpartum depression among the women who experienced them. This constitutes a serious violation of human rights. However, few studies have carried out specifically designed interventions to reduce these practices. The aim of this scoping review is to synthetise available evidence on this subject, and to identify initiatives that have succeeded in reducing the mistreatment, D&A that women suffer during childbirth in health facilities. METHODS: A PubMed search of the published literature was conducted, and all original studies evaluating the efficacy of any type of intervention specifically designed to reduce these negative experiences and promote RMC were selected. RESULTS: Ten articles were included in this review. Eight studies were conducted in Africa, one in Mexico, and the other in the U.S. Five carried out a before-and-after study, three used mixed-methods, one was a comparative study between birth centres, and another was a quasi-experimental study. The most common feature was the inclusion of some sort of RMC training for providers at the intervention centre, which led to the conclusion that this training resulted in an improvement in the care received by the women in childbirth. Other strategies explored by a small number of articles were open maternity days, clinical checklists, wall posters and constant user feedback. DISCUSSION: These results indicate that there are promising interventions to reduce D&A and promote RMC for women during childbirth in health facilities. RMC training for providers stands as the most proven strategy, and the results suggest that it improves the experiences of care received by women in labour. CONCLUSION: The specific types of training and the different initiatives that complement them should be evaluated through further scientific research, and health institutions should implement RMC interventions that apply these strategies to ensure human rights-based maternity care for women giving birth in health facilities around the world.

Appraising LaQshya's potential in measuring quality of care for mothers and newborns: a comprehensive review of India's Labor Room Quality Improvement Initiative.

BACKGROUND: Poor intrapartum care in India contributes to high maternal and newborn mortality. India's Labor Room Quality Improvement Initiative (LaQshya) launched in 2017, aims to improve intrapartum care by minimizing complications, enforcing protocols, and promoting respectful maternity care (RMC). However, limited studies pose a challenge to fully examine its potential to assess quality of maternal and newborn care. This study aims to bridge this knowledge gap and reviews LaQshya's ability to assess maternal and newborn care quality. Findings will guide modifications for enhancing LaQshya's effectiveness. METHODS: We reviewed LaQshya's ability to assess the quality of care through a two-step approach: a comprehensive descriptive analysis using document reviews to highlight program attributes, enablers, and challenges affecting LaQshya's quality assessment capability, and a comparison of its measurement parameters with the 352 quality measures outlined in the WHO Standards for Maternal and Newborn Care. Comparing LaQshya with WHO standards offers insights into how its measurement criteria align with global standards for assessing maternity and newborn care quality. RESULTS: LaQshya utilizes several proven catalysts to enhance and measure quality- institutional structures, empirical measures, external validation, certification, and performance incentives for high-quality care. The program also embodies contemporary methods like quality circles, rapid improvement cycles, ongoing facility training, and plan-do-check, and act (PDCA) strategies for sustained quality enhancement. Key drivers of LaQshya's assessment are- leadership, staff mentoring, digital infrastructure and stakeholder engagement from certified facilities. However, governance issues, understaffing, unclear directives, competency gaps, staff reluctance towards new quality improvement approaches inhibit the program, and its capacity to enhance quality of care. LaQshya addresses 76% of WHO's 352 quality measures for maternal and newborn care but lacks comprehensive assessment of crucial elements: harmful labor practices, mistreatment of mothers or newborns, childbirth support, and effective clinical leadership and supervision. CONCLUSION: LaQshya is a powerful model for evaluating quality of care, surpassing other global assessment tools. To achieve its maximum potential, we suggest strengthening district governance structures and offering tailored training programs for RMC and other new quality processes. Furthermore, expanding its quality measurement metrics to effectively assess provider accountability, patient outcomes, rights, staff supervision, and health facility leadership will increase its ability to assess quality improvements.

Women's experience of childbirth care in health facilities: a qualitative assessment of respectful maternity care in Afghanistan.

BACKGROUND: Respectful maternity care (RMC) remains a key challenge in Afghanistan, despite progress on improving maternal and newborn health during 2001-2021. A qualitative study was conducted in 2018 to provide evidence on the situation of RMC in health facilities in Afghanistan. The results are useful to inform strategies to provide RMC in Afghanistan in spite of the humanitarian crisis due to Taliban's takeover in 2021. METHODS: Focus group discussions were conducted with women (4 groups, 43 women) who had used health facilities for giving birth and with providers (4 groups, 21 providers) who worked in these health facilities. Twenty key informant interviews were conducted with health managers and health policy makers. Motivators for, deterrents from using, awareness about and experiences of maternity care in health facilities were explored. RESULTS: Women gave birth in facilities for availability of maternity care and skilled providers, while various verbal and physical forms of mistreatment were identified as deterrents from facility use by women, providers and key informants. Low awareness, lack of resources and excessive workload were identified among the reasons for violation of RMC. CONCLUSION: Violation of RMC is unacceptable. Awareness of women and providers about the rights of women to respectful maternity care, training of providers on the subject, monitoring of care to prevent mistreatment, and conditioning any future technical and financial assistance to commitments to RMC is recommended.

Factors intervening in the childbirth experience: a mixed-methods study.

OBJECTIVE: To analyze the childbirth experience focusing on the intervening factors and on the delivery method. METHOD: A sequential and explanatory mixed-methods study guided by the World Health Organization document for positive childbirth experiences. The participants were puerperal women in a maternity teaching hospital from inland São Paulo (Brazil). The first quantitative stage involved descriptive analysis with Poisson regression of 265 answers to the "Termômetro da Iniciativa Hospital Amigo da Mulher e da Criança" ("Women- and Baby-Friendly Hospital Initiative Thermometer") questionnaire. The second stage, qualitative, thematically analyzed the interviews conducted with 44 puerperal women who took part in the first stage. Data integration was by connection. THE RESULTS AND DISCUSSION: The analysis by connection showed that among the factors that restricted the positive experience, C-section was predominant (61.9%), understood as an option due to fear of pain, the treatment modality and previous traumas. Restrictions referring to the presence of a companion (99.6%), not having privacy (83%), disrespectful situations (69.5%), too many touches (56.9%) and the absence of skin-to-skin contact (55%), among others, potentiated fear, loneliness, concern, shame, the perception of disrespect and insecurity with the assistance provided. The promoting factors were as follows: choosing the companion (95.4%) for collaborating in the safety perception, not having infections (83.9%), having continuous team monitoring (82.2%) and pain relief methods (78.9%), which were valued by the women. CONCLUSION: The intervening factors that promoted positive experiences were related to clinical and protocol-related issues and to service availability. The restrictive factors were associated with excess interventions, deprivation of rights and of choice, absence of privacy and restriction referring to the presence of a companion. Women with a normal postpartum period felt more insecure and disrespected when compared to those subjected to C-sections, whose choices were considered, although they had lower prevalence of skin-to-skin contact. There is an urgent need to apprehend women's experiences and turn them into actions that guarantee their lives in a safe and respectful way.

Quality improvement in maternal and reproductive health services.

As maternal mortality and morbidity rates stagnate or increase worldwide, there is an urgent need to address health system issues that impede access to high-quality care. Learning from efforts to address the value, safety, and effectiveness of reproductive and maternal health care is essential to advancing quality improvement efforts.

Exploring how non-clinical factors in childbirth care shape users' experiences in public health facilities in rural Chiapas, Mexico: a qualitative study using the WHO health systems responsiveness framework.

INTRODUCTION: Many Mexicans face barriers to receive delivery care from qualified professionals, especially indigenous and poor sectors of the population, which represent most of the population in the state of Chiapas. When access to institutional delivery care is an option, experiences with childbirth care are often poor. This underscores the need for evidence to improve the quality of services from the user's perspective. The present study was conceived with the objective of understanding how non-clinical aspects of care shape women's birthing experiences in public health institutions in Chiapas. METHODS: We conducted an exploratory qualitative study. Data collection consisted in 20 semi-structured interviews to women who had delivered in a public health facility in Chiapas during the last six months prior to the interview. For the design of the interview guide we used the WHO health system responsiveness framework, which focus on the performance of the health system in terms of the extent to which it delivers services according to the "universally legitimate expectations of individuals" and focuses on the non-financial and non-clinical qualities of care. The resulting data were analyzed using thematic analysis methodology. RESULTS: We identified a total of 16 themes from the data, framed in eight categories which followed the eight domains of the WHO health systems responsiveness framework: Choice of the provider and the facility, prompt attention, quality of basic amenities, access to social support, respectful treatment, privacy, involvement in decisions, and communication. We shed light on the barriers women face in receiving prompt care, aspects of health facilities that impact women's comfort, the relevance of being provided with adequate food and drink during institutional delivery, how accompaniment contributes positively to the birthing experience, the aspects of childbirth that women find important to decide on, and how providers' interpersonal behaviors affect the birthing experience. CONCLUSIONS: We have identified non-clinical aspects of childbirth care that are important to the user experience and that are not being satisfactorily addressed by public health institutions in Chiapas. This evidence constitutes a necessary first step towards the design of strategies to improve the responsiveness of the Chiapas health system in childbirth care.

Global burden of potentially life-threatening maternal conditions: a systematic review and meta-analysis.

BACKGROUND: Potentially life-threatening maternal conditions (PLTCs) is an important proxy indicator of maternal mortality and the quality of maternal health services. It is helpful to monitor the rates of severe maternal morbidity to evaluate the quality of maternal care, particularly in low- and lower-middle-income countries. This study aims to systematically identify and synthesize available evidence on PLTCs. METHODS: We searched studies in English from 2009‒2023 in PubMed, the National Library of Medicine (NLM) Gateway, the POPLINE database, and the Science Direct website. The study team independently reviewed the illegibility criteria of the articles. Two reviewers independently appraised the included articles using the Joanna Briggs Instrument for observational studies. Disputes between the reviewers were resolved by consensus with a third reviewer. Meta-analysis was conducted in Stata version 16. The pooled proportion of PLTCs was calculated using the random effects model. The heterogeneity test was performed using the Cochrane Q test, and its level was determined using the I2 statistical result. Using Egger's test, the publication bias was assessed. RESULT: Thirty-two cross-sectional, five case-control, and seven cohort studies published from 2009 to 2023 were included in the meta-analysis. The highest proportion of PLTC was 17.55% (95% CI: 15.51, 19.79) in Ethiopia, and the lowest was 0.83% (95% CI: 0.73, 0.95) in Iraq. The pooled proportion of PLTC was 6.98% (95% CI: 5.98-7.98). In the subgroup analysis, the pooled prevalence varied based on country income level: in low-income 13.44% (95% CI: 11.88-15.00) I2 = 89.90%, low-middle income 7.42% (95% CI: 5.99-8.86) I2 = 99.71%, upper-middle income 6.35% (95% CI: 4.21-8.50) I2 = 99.92%, and high-income 2.67% (95% CI: 2.34-2.99) I2 = 99.57%. Similarly, it varied based on the diagnosis criteria; WHO diagnosis criteria used 7.77% (95% CI: 6.10-9.44) I2 = 99.96% at P = 0.00, while the Centers for Disease Controls (CDC) diagnosis criteria used 2.19% (95% CI: 1.89-2.50) I2 = 99.41% at P = 0.00. CONCLUSION: The pooled prevalence of PLTC is high globally, predominantly in low-income countries. The large disparity of potentially life-threatening conditions among different areas needs targeted intervention, particularly for women residing in low-income countries. The WHO diagnosis criteria minimize the underreporting of severe maternal morbidity. TRIAL REGISTRATION: CRD42023409229.

Standards of care and determinants of women's satisfaction with delivery services in Nepal: a multi-perspective analysis using data from a health facility-based survey.

BACKGROUND: Compliance with standards of care is required for sustained improvement in the quality of delivery services. It thus represents a key challenge to improving maternal survival and meeting the Sustainable Development Goal (SDG) target of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. This study examines the extent to which normal low-risk health facility deliveries in Nepal meet the standards of quality of care and assesses the effect of the standards of quality of care and various contextual factors on women's satisfaction with the services they receive. METHODS: Drawing on the 2021 Nepal Health Facility Survey, the sample comprised 320 women who used health facilities for normal, low-risk delivery services. A weighted one-sample t-test was applied to examine the proportion of deliveries meeting the eight standards of care. Women's overall satisfaction level was computed from seven satisfaction variables measured on a Likert scale, using principal component analysis. The composite measure was then dichotomized. Binary logistic regression was used to analyze the determinants of women's satisfaction with delivery care services. RESULTS: Deliveries complying with the eight standards of care and its 53 indicators varied widely; output indicators were more frequently met than input indicators. Of the eight standards of care, the "functional referral system" performed highest (92.0%), while "competent, motivated human resources" performed the least (52.4%). Women who were attended by a provider when they called for support (AOR: 5.29; CI: 1.18, 23.64), who delivered in health facilities that displayed health statistics (AOR 3.16; CI: 1.87, 5.33), who experienced caring behaviors from providers (AOR: 2.59; CI: 1.06, 6.30) and who enjoyed audio-visual privacy (AOR 2.13; CI: 1.04, 4.38) had higher satisfaction levels compared to their counterparts. The implementation of the Maternity Incentive Scheme and presence of a maternal waiting room in health facilities, however, were associated with lower satisfaction levels. CONCLUSIONS: Nepal performed moderately well in meeting the standards of care for normal, low-risk deliveries. To meet the SDG target Nepal must accelerate progress. It needs to focus on people-centered quality improvement to routinely assess the standards of care, mobilize available resources, improve coordination among the three tiers of government, and implement high-impact programs.

Exploring the implementation of an SMS-based digital health tool on maternal and infant health in informal settlements.

BACKGROUND: The rapid urbanization of Kenya has led to an increase in the growth of informal settlements. There are challenges with access to maternal, newborn, and child health (MNCH) services and higher maternal mortality rates in settlements. The Kuboresha Afya Mitaani (KAM) study aimed to improve access to MNCH services. We evaluate one component of the KAM study, PROMPTS (Promoting Mothers through Pregnancy and Postpartum), an innovative digital health intervention aimed at improving MNCH outcomes. PROMPTS is a two-way AI-enabled SMS-based platform that sends messages to pregnant and postnatal mothers based on pregnancy stage, and connects mothers with a clinical help desk to respond and refer urgent cases in minutes. METHODS: PROMPTS was rolled out in informal settlements in Mathare and Kawangware in Nairobi County. The study adopted a pre-post intervention design, comparing baseline and endline population outcomes (1,416 participants, Baseline = 678, Endline = 738). To further explore PROMPTS's effect, outcomes were compared between endline participants enrolled and not enrolled in PROMPTS (738 participants). Outcomes related to antenatal (ANC) and postnatal (PNC) service uptake and knowledge were assessed using univariate and multivariate linear and logistic regression. RESULTS: Between baseline and enldine, mothers were 1.85 times more likely to report their babies and 1.88 times more likely to report themselves being checked by a provider post-delivery. There were improvements in moms and babies receiving care on time. 45% of the 738 endline participants were enrolled in the PROMPTS program, with 87% of these participants sending at least one message to the system. Enrolled mothers were 2.28 times more likely to report completing four or more ANC visits relative to unenrolled mothers. Similarly, enrolled mothers were 4.20 times more likely to report their babies and 1.52 times more likely to report themselves being checked by a provider post-delivery compared to unenrolled mothers. CONCLUSIONS: This research demonstrates that a digital health tool can be used to improve care-seeking and knowledge levels among pregnant and postnatal women in informal settlements. Additional research is needed to refine and target solutions amongst those that were less likely to enroll in PROMPTS and to further drive improved MNCH outcomes amongst this population.

Maternal delay for institutional delivery and associated factors among postnatal mothers at Southeastern Ethiopia: a cross sectional study.

BACKGROUND: Maternal delay in timely seeking health care, inadequate health care and the inability to access health facilities are the main causes of maternal mortality in low and middle income countries. The three-delay approach was used to pinpoint responsible factors for maternal death. There was little data on the delay in decision making to seek institutional delivery service in the study area. Therefore, the aim of this study was to assess the extent of the first maternal delay for institutional delivery and its associated factors among postpartum mothers in the Bale and east Bale zones. METHODS: An institutional-based cross-sectional study was conducted among 407 postpartum mothers from April 6 to May 6, 2022. A systematic sampling technique was used to select study participants. The data were collected electronically using an Open Data Kit and exported to SPSS window version 25 for cleaning and analysis. Both bivariate and multivariable analysis was done by using binary logistic regression model to identify factors associated with maternal delay for institutional delivery services. Statistical significance was declared at P-value < 0.05. RESULTS: In this study, the magnitude of the first maternal delay in making the decision to seek institutional delivery service was 29.2% (95% CI: 24.9, 33.9). Previous pregnancy problems (AOR = 1.8; 95% CI: 1.06, 3.08), knowing the danger signs of labor and childbirth (AOR = 1.78; 95% CI: 1.11, 2.85) and decision-making (AOR = 0.42; 95% CI: 0.20, 0.85) were significantly associated with the first maternal delay. CONCLUSION: This study identified a significant number of postnatal mothers experienced delay in making decisions to seek institutional delivery service in the study area. Promoting women's empowerment and building on key danger signs should be emphasized.