The quality of routine data for measuring facility-based maternal mortality in public and private health facilities in Kampala City, Uganda.

BACKGROUND: Routine health facility data are an important source of health information in resource-limited settings. Regular quality assessments are necessary to improve the reliability of routine data for different purposes, including estimating facility-based maternal mortality. This study aimed to assess the quality of routine data on deliveries, livebirths and maternal deaths in Kampala City, Uganda. METHODS: We reviewed routine health facility data from the district health information system (DHIS2) for 2016 to 2021. This time period included an upgrade of DHIS2, resulting in two datasets (2016-2019 and 2020-2021) that were managed separately. We analysed data for all facilities that reported at least one delivery in any of the six years, and for a subset of facilities designated to provide emergency obstetric care (EmOC). We adapted the World Health Organization data quality review framework to assess completeness and internal consistency of the three data elements, using 2019 and 2021 as reference years. Primary data were collected to verify reporting accuracy in four purposively selected EmOC facilities. Data were disaggregated by facility level and ownership. RESULTS: We included 255 facilities from 2016 to 2019 and 247 from 2020 to 2021; of which 30% were EmOC facilities. The overall completeness of data for deliveries and livebirths ranged between 53% and 55%, while it was < 2% for maternal deaths (98% of monthly values were zero). Among EmOC facilities, completeness was higher for deliveries and livebirths at 80%; and was < 6% for maternal deaths. For the whole sample, the prevalence of outliers for all three data elements was < 2%. Inconsistencies over time were mostly observed for maternal deaths, with the highest difference of 96% occurring in 2021. CONCLUSIONS: Routine data from childbirth facilities in Kampala were generally suboptimal, but the quality was better in EmOC facilities. Given likely underreporting of maternal deaths, further efforts to verify and count all facility-related maternal deaths are essential to accurately estimate facility-based maternal mortality. Data reliability could be enhanced by improving reporting practices in EmOC facilities and streamlining reporting processes in private-for-profit facilities. Further qualitative studies should identify critical points where data are compromised, and data quality assessments should consider service delivery standards.

Stillbirth mortality by Robson ten-group classification system: A cross-sectional registry of 80 663 births from 16 hospital in sub-Saharan Africa.

OBJECTIVE: To assess stillbirth mortality by Robson ten-group classification and the usefulness of this approach for understanding trends. DESIGN: Cross-sectional study. SETTING: Prospectively collected perinatal e-registry data from 16 hospitals in Benin, Malawi, Tanzania and Uganda. POPULATION: All women aged 13-49 years who gave birth to a live or stillborn baby weighting >1000 g between July 2021 and December 2022. METHODS: We compared stillbirth risk by Robson ten-group classification, and across countries, and calculated proportional contributions to mortality. MAIN OUTCOME MEASURES: Stillbirth mortality, defined as antepartum and intrapartum stillbirths. RESULTS: We included 80 663 babies born to 78 085 women; 3107 were stillborn. Stillbirth mortality by country were: 7.3% (Benin), 1.9% (Malawi), 1.6% (Tanzania) and 4.9% (Uganda). The largest contributor to stillbirths was Robson group 10 (preterm birth, 28.2%) followed by Robson group 3 (multipara with cephalic term singleton in spontaneous labour, 25.0%). The risk of dying was highest in births complicated by malpresentations, such as nullipara breech (11.0%), multipara breech (16.7%) and transverse/oblique lie (17.9%). CONCLUSIONS: Our findings indicate that group 10 (preterm birth) and group 3 (multipara with cephalic term singleton in spontaneous labour) each contribute to a quarter of stillbirth mortality. High mortality risk was observed in births complicated by malpresentation, such as transverse lie or breech. The high mortality share of group 3 is unexpected, demanding case-by-case investigation. The high mortality rate observed for Robson groups 6-10 hints for a need to intensify actions to improve labour management, and the categorisation may support the regular review of labour progress.

Prevalence of and risk factors for iron deficiency among pregnant women with moderate or severe anaemia in Nigeria: a cross-sectional study.

BACKGROUND: Anaemia during pregnancy causes adverse outcomes to the woman and the foetus, including anaemic heart failure, prematurity, and intrauterine growth restriction. Iron deficiency anaemia (IDA) is the leading cause of anaemia and oral iron supplementation during pregnancy is widely recommended. However, little focus is directed to dietary intake. This study estimates the contribution of IDA among pregnant women and examines its risk factors (including dietary) in those with moderate or severe IDA in Lagos and Kano states, Nigeria. METHODS: In this cross-sectional study, 11,582 women were screened for anaemia at 20-32 weeks gestation. The 872 who had moderate or severe anaemia (haemoglobin concentration < 10 g/dL) were included in this study. Iron deficiency was defined as serum ferritin level < 30 ng/mL. We described the sociodemographic and obstetric characteristics of the sample and their self-report of consumption of common food items. We conducted bivariate and multivariable logistic regression analysis to identify risk factors associated with IDA. RESULTS: Iron deficiency was observed among 41% (95%CI: 38 - 45) of women with moderate or severe anaemia and the prevalence increased with gestational age. The odds for IDA reduces from aOR: 0.36 (95%CI: 0.13 - 0.98) among pregnant women who consume green leafy vegetables every 2-3 weeks, to 0.26 (95%CI: 0.09 - 0.73) among daily consumers, compared to those who do not eat it. Daily consumption of edible kaolin clay was associated with increased odds of having IDA compared to non-consumption, aOR 9.13 (95%CI: 3.27 - 25.48). Consumption of soybeans three to four times a week was associated with higher odds of IDA compared to non-consumption, aOR: 1.78 (95%CI: 1.12 - 2.82). CONCLUSION: About 4 in 10 women with moderate or severe anaemia during pregnancy had IDA. Our study provides evidence for the protective effect of green leafy vegetables against IDA while self-reported consumption of edible kaolin clay and soybeans appeared to increase the odds of having IDA during pregnancy. Health education on diet during pregnancy needs to be strengthened since this could potentially increase awareness and change behaviours that could reduce IDA among pregnant women with moderate or severe anaemia in Nigeria and other countries.

Perspectives and experiences of healthcare providers on the response to the COVID-19 pandemic in three maternal and neonatal referral hospitals in Guinea in 2020: a qualitative study.

BACKGROUND: The COVID-19 pandemic has adversely affected access to essential healthcare services. This study aimed to explore healthcare providers' perceptions and experiences of the response to the COVID-19 pandemic in three referral maternal and neonatal hospitals in Guinea. METHODS: We conducted a longitudinal qualitative study between June and December 2020 in two maternities and one neonatology referral ward in Conakry and Mamou. Participants were purposively recruited to capture diversity of professional cadres, seniority, and gender. Four rounds of in-depth interviews (46 in-depth interviews with 18 respondents) were conducted in each study site, using a semi-structured interview guide that was iteratively adapted. We used both deductive and inductive approaches and an iterative process for content analysis. RESULTS: We identified four themes and related sub-themes presented according to whether they were common or specific to the study sites, namely: 1) coping strategies & care reorganization, which include reducing staffing levels, maintaining essential healthcare services, suspension of staff daily meetings, insertion of a new information system for providers, and co-management with COVID-19 treatment center for caesarean section cases among women who tested positive for COVID-19; 2) healthcare providers' behavior adaptations during the response, including infection prevention and control measures on the wards and how COVID-19-related information influenced providers' daily work; 3) difficulties encountered by providers, in particular unavailability of personal protective equipment (PPE), lack of financial motivation, and difficulties reducing crowding in the wards; 4) providers perceptions of healthcare service use, for instance their fear during COVID-19 response and perceived increase in severity of complications received and COVID-19 cases among providers and parents of newborns. CONCLUSION: This study provides insights needed to be considered to improve the preparedness and response of healthcare facilities and care providers to future health emergencies in similar contexts.

Is MIStreatment of women during facility-based childbirth an independent risk factor for POstpartum Depression in Ethiopia and Guinea? A mixed methods prospective study protocol-MISPOD study.

BACKGROUND: Worldwide, 10% of postpartum women experience postpartum depression, which can lead to diverse sequalae at individual, family, and societal levels. In sub-Saharan Africa, it is estimated that 17% of women experience depression in the postpartum period, which could be an underestimate as 48% of women in the region do not receive postnatal care (81% in Ethiopia and 51% in Guinea) and a large share of postpartum depression remains undiagnosed and untreated as a result. Globally, despite a critical evidence gap, there are growing reports of postpartum depression among women mistreated (disrespected and abused) during childbirth in health facilities, making a strong case to examine the association between mistreatment and postpartum depression. This study in Addis Ababa (Ethiopia) and Conakry (Guinea) uses a mixed methods design to 1) examine the link between mistreatment and postpartum depression, 2) explore the health system capacity to provide respectful maternity care and maternal mental health services, and 3) explore the experiences of women in accessing care and support for postpartum depression. METHODS: We will conduct a prospective longitudinal survey of women (434 in Addis Ababa and 408 in Conakry) from the third trimester of pregnancy to eight weeks postpartum and carry out in-depth interviews with key health system informants (20-25 in each city) and women who recovered from a clinically confirmed episode of postpartum depression (15-25 in each city). Quantitative data from the women's survey will be analysed using a multilevel mixed-effects model; qualitative data from key-informants will be analysed by using a hybrid thematic analysis approach, whereas data from women's in-depth interviews will be analysed using the phenomenological approach. The inclusion of two different settings in our study (Addis Ababa and Conakry) will enable us to apply a comparative health systems lens to explore the dynamics of respectful maternity care and maternal mental health services within the broader health systems of the two countries (Ethiopia and Guinea). DISCUSSION: The findings from this study will inform actions aimed at mitigating the mistreatment of women in maternity settings and improving promotive, preventive, and treatment interventions for postpartum depression in Ethiopia and Guinea. The findings can also be extrapolated to other low-resource settings.

Acceptability of IV iron treatment for iron deficiency anaemia in pregnancy in Nigeria: a qualitative study with pregnant women, domestic decision-makers, and health care providers.

BACKGROUND: Anaemia in pregnancy causes a significant burden of maternal morbidity and mortality in sub-Saharan Africa, with prevalence ranging from 25 to 45% in Nigeria. The main treatment, daily oral iron, is associated with suboptimal adherence and effectiveness. Among pregnant women with iron deficiency, which is a leading cause of anaemia (IDA), intravenous (IV) iron is an alternative treatment in moderate or severe cases. This qualitative study explored the acceptability of IV iron in the states of Kano and Lagos in Nigeria. METHODS: We purposively sampled various stakeholders, including pregnant women, domestic decision-makers, and healthcare providers (HCPs) during the pre-intervention phase of a hybrid clinical trial (IVON trial) in 10 healthcare facilities across three levels of the health system. Semi-structured topic guides guided 12 focus group discussions (140 participants) and 29 key informant interviews. We used the theoretical framework of acceptability to conduct qualitative content analysis. RESULTS: We identified three main themes and eight sub-themes that reflected the prospective acceptability of IV iron therapy. Generally, all stakeholders had a positive affective attitude towards IV iron based on its comparative advantages to oral iron. The HCPs noted the effectiveness of IV iron in its ability to evoke an immediate response and capacity to reduce anaemia-related complications. It was perceived as a suitable alternative to blood transfusion for specific individuals based on ethicality. However, to pregnant women and the HCPs, IV iron could present a higher opportunity cost than oral iron for the users and providers as it necessitates additional time to receive and administer it. To all stakeholder groups, leveraging the existing infrastructure to facilitate IV iron treatment will stimulate coherence and self-efficacy while strengthening the existing trust between pregnant women and HCPs can avert misconceptions. Finally, even though high out-of-pocket costs might make IV iron out of reach for poor women, the HCPs felt it can potentially prevent higher treatment fees from complications of IDA. CONCLUSIONS: IV iron has a potential to become the preferred treatment for iron-deficiency anaemia in pregnancy in Nigeria if proven effective. HCP training, optimisation of information and clinical care delivery during antenatal visits, uninterrupted supply of IV iron, and subsidies to offset higher costs need to be considered to improve its acceptability. Trial registration ISRCTN registry ISRCT N6348 4804. Registered on 10 December 2020 Clinicaltrials.gov NCT04976179. Registered on 26 July 2021.

Low blood level in pregnancy is of public health importance and with common occurrence worldwide, but with a higher rate in low resource settings where its burden greatly affects both the mother and her baby. This low blood level is usually caused by poor intake of an iron-rich diet. It could lead to fatigue, decreased work capacity, and dizziness if not detected. Without treatment, this condition could affect the baby, possibly leading to its sudden demise in the womb, immediately after birth, or even the woman's death.The use of oral iron has been the primary treatment; however, it is associated with significant side effects, which have led to poor compliance. Fortunately, an alternative therapy in the form of a drip has been shown to overcome these challenges. However, it is not routinely used in countries like Nigeria. Moreover, being effective is different from being utilised. Therefore, this study was conducted to understand the factors that will make this treatment widely accepted.We interviewed pregnant women, family support and health care providers in 10 health facilities in Lagos and Kano States, Nigeria. Our findings revealed good attitudes to iron drip. However, its inclusion into routine antenatal health talk, training of health care providers, availability of space, drugs and health workers who will provide this care, and ensuring this drug is of low cost are some of the efforts needed for this treatment to be accepted.

Assessing post-abortion care using the WHO quality of care framework for maternal and newborn health: a cross-sectional study in two African hospitals in humanitarian settings.

BACKGROUND: Abortion-related complications remain a main cause of maternal mortality. There is little evidence on the availability and quality of post-abortion care (PAC) in humanitarian settings. We assessed the quality of PAC in two hospitals supported by an international organization in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR). METHODS: We mapped indicators corresponding to the eleven domains of the WHO Maternal and Newborn Health quality-of-care framework to assess inputs, processes (provision and experience of care), and outcomes of PAC. We measured these indicators in four components of a cross-sectional multi-methods study: 1) an assessment of the hospitals' PAC signal functions, 2) a survey of the knowledge, attitudes, practices, and behavior of 140 Nigerian and 84 CAR clinicians providing PAC, 3) a prospective review of the medical records of 520 and 548 women presenting for abortion complications and, 4) a survey of 360 and 362 of these women who were hospitalized in the Nigerian and CAR hospitals, respectively. RESULTS: Among the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26 in the CAR hospital. In both hospitals, less than 2.5% were treated with dilatation and sharp curettage. Over 80% of women received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients with no documented indication. Among discharged women in CAR, 99% received contraceptive counseling but only 39% did in Nigeria. Over 80% of women in Nigeria reported positive experiences of respect and preservation of dignity. Conversely, in CAR, 37% reported that their privacy was always respected during examination and 62% reported short or very short waiting time before seeing a health provider. In terms of communication, only 15% felt able to ask questions during treatment in both hospitals. The risk of abortion-near-miss happening ≥ 24h after presentation was 0.2% in Nigeria and 1.1% in CAR. Only 65% of women in the Nigerian hospital and 34% in the CAR hospital reported that the staff provided them best care all the time. CONCLUSION: Our comprehensive assessment identified that these two hospitals in humanitarian settings provided lifesaving PAC. However, hospitals need to strengthen the patient-centered approach engaging patients in their own care and ensuring privacy, short waiting times and quality provider-patient communication. Health professionals would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance.

In humanitarian contexts, abortion complications are a leading cause of maternal mortality. Providing quality post-abortion care (PAC) is therefore an important part of needed services. We assessed the quality of PAC in two hospitals supported by an international organization in Jigawa State (Nigeria) and Bangui (Central African Republic). We measured quality indicators in four components: 1) an assessment of the equipment and human resources available in hospitals, 2) a survey of the knowledge, attitudes, practices, and behavior of clinicians providing PAC, 3) an assessment of the medical care provided by clinicians to women presenting with abortion complications and, 4) a survey of a subgroup of these women who were hospitalized. Both hospitals had almost all the equipment and human resources necessary to provide post-abortion care. Less than 2.5% of women received a non-recommended method to evacuate their uterus in both hospitals. More than 80% of women received a blood transfusion or antibiotics when they needed them. However, 30% of women received antibiotics without written justification and only 15% of women reported being able to ask questions about their treatment. Overall, only 65% of Nigerian women and 34% of Central African women said that the staff provided them with the best care all the time. The fact that less than 2% of women experienced a very severe complication 24 hours or more after their arrival at the two hospitals suggests that the care provided was lifesaving. But they urgently need to adopt a better patient-centered approach as well as to improve the rational management of antibiotics.

Comprehensive Analysis and Evaluation of Anomalous User Activity in Web Server Logs.

In this study, we present a novel machine learning framework for web server anomaly detection that uniquely combines the Isolation Forest algorithm with expert evaluation, focusing on individual user activities within NGINX server logs. Our approach addresses the limitations of traditional methods by effectively isolating and analyzing subtle anomalies in vast datasets. Initially, the Isolation Forest algorithm was applied to extensive NGINX server logs, successfully identifying outlier user behaviors that conventional methods often overlook. We then employed DBSCAN for detailed clustering of these anomalies, categorizing them based on user request times and types. A key innovation of our methodology is the incorporation of post-clustering expert analysis. Cybersecurity professionals evaluated the identified clusters, adding a crucial layer of qualitative assessment. This enabled the accurate distinction between benign and potentially harmful activities, leading to targeted responses such as access restrictions or web server configuration adjustments. Our approach demonstrates a significant advancement in network security, offering a more refined understanding of user behavior. By integrating algorithmic precision with expert insights, we provide a comprehensive and nuanced strategy for enhancing cybersecurity measures. This study not only advances anomaly detection techniques but also emphasizes the critical need for a multifaceted approach in protecting web server infrastructures.

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.

Length of stay and determinants of early discharge after facility-based childbirth in Cameroon: analysis of the 2018 Demographic and Health Survey.

BACKGROUND: A minimum length of stay following facility birth is a prerequisite for women and newborns to receive the recommended monitoring and package of postnatal care. The first postnatal care guidelines in Cameroon were issued in 1998 but adherence to minimum length of stay has not been assessed thus far. The objective of this study was to estimate the average length of stay and identify determinants of early discharge after facility birth. METHODS: We analyzed the Cameroon 2018 Demographic and Health Survey. We included 4,567 women who had a live birth in a heath facility between 2013 and 2018. We calculated their median length of stay in hours by mode of birth and the proportion discharged early (length of stay < 24 h after vaginal birth or < 5 days after caesarean section). We assessed the association between sociodemographic, context-related, facility-related, obstetric and need-related factors and early discharge using bivariate and multivariable logistic regression. RESULTS: The median length of stay (inter quartile range) was 36 (9-84) hours after vaginal birth (n = 4,290) and 252 (132-300) hours after caesarean section (n = 277). We found that 28.8% of all women who gave birth in health facilities were discharged too early (29.7% of women with vaginal birth and 15.1% after a caesarean section). Factors which significantly predicted early discharge in multivariable regression were: maternal age < 20 years (compared to 20-29 years, aOR: 1.44; 95%CI 1.13-1.82), unemployment (aOR: 0.78; 95%CI: 0.63-0.96), non-Christian religions (aOR: 1.65; 95CI: 1.21-2.24), and region of residence-Northern zone aOR:9.95 (95%CI:6.53-15.17) and Forest zone aOR:2.51 (95%CI:1.79-3.53) compared to the country's capital cities (Douala or Yaounde). None of the obstetric characteristics was associated with early discharge. CONCLUSIONS: More than 1 in 4 women who gave birth in facilities in Cameroon were discharged too early; this mostly affected women following vaginal birth. The reasons leading to lack of adherence to postnatal care guidelines should be better understood and addressed to reduce preventable complications and provide better support to women and newborns during this critical period.

High severity of abortion complications in fragile and conflict-affected settings: a cross-sectional study in two referral hospitals in sub-Saharan Africa (AMoCo study).

BACKGROUND: Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR). METHODS: We used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records' reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity. RESULTS: We analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%). CONCLUSION: Our data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings.

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.

"So let me give you money, you give me what I want": decision-making priorities around contraceptive method and source choice among young women in Kenya.

BACKGROUND: Many factors influence young women's choice of contraceptive methods and where to source them, yet less is known about whether one of these choices (method or source) is prioritized and the relationship between these choices. This study qualitatively explored decision-making around contraceptive method and source choice among young women in Kenya. METHODS: In August-September 2019, 30 in-depth interviews were conducted with women ages 18-24 who had used two or more contraceptive methods and resided in three counties: Nairobi, Mombasa or Migori. Participants were recruited from public and private health facilities and pharmacies. Interview guides captured information about decision-making processes for each contraceptive method the respondent had ever used. Responses were audio-recorded, transcribed, translated into English, coded, and analyzed thematically. RESULTS: The majority of respondents knew which method they wanted to use prior to seeking it from a source. This was true for all types of methods that women ever used. Of the small number of respondents who selected their source first, most were in the post-partum period or experiencing side effects and sought counseling at a source before choosing a method. CONCLUSIONS: This study highlights the importance of providing young women with high quality counseling that provides full information about contraceptive options and addresses that young women's needs vary along the reproductive health continuum of care. This will ensure that young women have information to inform future contraceptive decision-making prior to seeking care.

Effect of the COVID-19 pandemic on maternal and neonatal health services in three referral hospitals in Guinea: an interrupted time-series analysis.

INTRODUCTION: In sub-Saharan Africa, there is limited evidence on the COVID-19 health-related effect from front-line health provision settings. Therefore, this study aimed to analyse the effect of the COVID-19 pandemic on routine maternal and neonatal health services in three referral hospitals. MATERIALS AND METHODS: We conducted an observational study using aggregate monthly maternal and neonatal health services routine data for two years (March 2019-February 2021) in three referral hospitals including two maternities: Hôpital National Ignace Deen (HNID) in Conakry and Hôpital Regional de Mamou (HRM) in Mamou and one neonatology ward: Institut de Nutrition et de Santé de l'Enfant (INSE) in Conakry. We compared indicators of health service utilisation, provision and health outcomes before and during the COVID-19 pandemic periods. An interrupted time-series analysis (ITSA) was performed to assess the relationship between changes in maternal and neonatal health indicators and COVID-19 through cross-correlation. RESULTS: During COVID-19, the mean monthly number (MMN) of deliveries decreased significantly in HNID (p = 0.039) and slightly increased in HRM. In the two maternities, the change in the MMN of deliveries were significantly associated with COVID-19. The ITSA confirmed the association between the increase in the MMN of deliveries and COVID-19 in HRM (bootstrapped F-value = 1.46, 95%CI [0.036-8.047], p < 0.01). We observed an increasing trend in obstetric complications in HNID, while the trend declined in HRM. The MMN of maternal deaths increased significantly (p = 0.011) in HNID, while it slightly increased in HRM. In INSE, the MMN of neonatal admissions significantly declined (p < 0.001) and this decline was associated with COVID-19. The MMN of neonatal deaths significantly decreased (p = 0.009) in INSE and this decrease was related to COVID-19. CONCLUSION: The pandemic negatively affected the maternal and neonatal care provision, health service utilisation and health outcomes in two referral hospitals located in Conakry, the COVID-19 most-affected region.

Where and why do we lose women from the continuum of care in maternal health? A mixed-methods study in Southern Benin.

OBJECTIVE: Continuum of care (CoC) in maternal health is built on evidence suggesting that the integration of effective interventions across pregnancy, childbirth, and the postnatal period leads to better perinatal health outcomes. We explored gaps along the CoC in maternal health in Benin. METHODS: A mixed-methods study triangulating results from a qualitative study in southern Benin with a quantitative analysis of Benin Demographic and Health Survey (BDHS) data on the use of services along the CoC was conducted. RESULTS: Benin Demographic and Health Survey analysis showed that although 89% of women reported at least one antenatal care (ANC) visit, only half initiated ANC in the first trimester and completed 4 or more visits. 85% reported facility-based childbirth and 69% a postnatal check within 48 h after childbirth. Our qualitative study confirms early initiation of ANC and the transition from facility-based childbirth to postnatal care are important gaps along the CoC and reveals late arrival at health facility for childbirth as an additional gap. These gaps interact with spiritual and alternative care practices that aim to safeguard pregnancy and prevent complications. Structural factors related to poverty and disrespectful care in health facilities compounded to limit the utilisation of formal healthcare. CONCLUSIONS: The combined use of BDHS and qualitative data contributed to highlighting critical gaps along the maternal CoC. A lack of integration of spiritual or alternative aspects of care into biomedical services, as well as structural factors, impeded access to healthcare in Benin.

Spatial variation and inequities in antenatal care coverage in Kenya, Uganda and mainland Tanzania using model-based geostatistics: a socioeconomic and geographical accessibility lens.

BACKGROUND: Pregnant women in sub-Saharan Africa (SSA) experience the highest levels of maternal mortality and stillbirths due to predominantly avoidable causes. Antenatal care (ANC) can prevent, detect, alleviate, or manage these causes. While eight ANC contacts are now recommended, coverage of the previous minimum of four visits (ANC4+) remains low and inequitable in SSA. METHODS: We modelled ANC4+ coverage and likelihood of attaining district-level target coverage of 70% across three equity stratifiers (household wealth, maternal education, and travel time to the nearest health facility) based on data from malaria indicator surveys in Kenya (2020), Uganda (2018/19) and Tanzania (2017). Geostatistical models were fitted to predict ANC4+ coverage and compute exceedance probability for target coverage. The number of pregnant women without ANC4+ were computed. Prediction was at 3 km spatial resolution and aggregated at national and district -level for sub-national planning. RESULTS: About six in ten women reported ANC4+ visits, meaning that approximately 3 million women in the three countries had 20,000 women having

Can machine learning models predict maternal and newborn healthcare providers' perception of safety during the COVID-19 pandemic? A cross-sectional study of a global online survey.

BACKGROUND: Maternal and newborn healthcare providers are essential professional groups vulnerable to physical and psychological risks associated with the COVID-19 pandemic. This study uses machine learning algorithms to create a predictive tool for maternal and newborn healthcare providers' perception of being safe in the workplace globally during the pandemic. METHODS: We used data collected between 24 March and 5 July 2020 through a global online survey of maternal and newborn healthcare providers. The questionnaire was available in 12 languages. To predict healthcare providers' perception of safety in the workplace, we used features collected in the questionnaire, in addition to publicly available national economic and COVID-19-related factors. We built, trained and tested five machine learning models: Support Vector Machine (SVM), Random Forest (RF), XGBoost, CatBoost and Artificial Neural Network (ANN) for classification and regression. We extracted from RF models the relative contribution of features in output prediction. RESULTS: Models included data from 941 maternal and newborn healthcare providers from 89 countries. ML models performed well in classification and regression tasks, whereby RF had 82% cross-validated accuracy for classification, and CatBoost with 0.46 cross-validated root mean square error for regression. In both classification and regression, the most important features contributing to output prediction were classified as three themes: (1) information accessibility, clarity and quality; (2) availability of support and means of protection; and (3) COVID-19 epidemiology. CONCLUSION: This study identified salient features contributing to maternal and newborn healthcare providers perception of safety in the workplace. The developed tool can be used by health systems globally to allow real-time learning from data collected during a health system shock. By responding in real-time to the needs of healthcare providers, health systems could prevent potential negative consequences on the quality of care offered to women and newborns.

Perceptions of peer contraceptive use and its influence on contraceptive method use and choice among young women and men in Kenya: a quantitative cross-sectional study.

BACKGROUND: Prior research has established that an individual's social environment may influence his or her reproductive behaviors, yet less is known about peer influence on contraceptive use among young people (ages 15-24). In Kenya, the site of this study, 15% of adolescents ages 15-19 have begun childbearing and 45% of sexually active young women report current use of a modern contraceptive method. This highlights the need to better understand what factors influence young people to use contraception. The objective of this study is to explore the relationship between the perception of peers' use of contraceptives and contraceptive use and method choice among young men and women in Kenya. METHODS: This study utilizes a nationally representative sample of women and men aged 15-24 years from the 2018 and 2019 cross sectional Shujaaz State of the Kenyan Youth annual surveys. Among the sample of sexually experienced young people (59%), multivariable multinomial logistic regression was used to explore the association between the perception of peers' use of contraceptives and the respondent's contraceptive method choice: non-user, condom use or use of any other modern method. Results are presented separately for young men and young women. RESULTS: Our results show that sexually experienced young men and women who perceive that their peers are using contraceptives are more likely to report current use of condoms compared to being a nonuser (RRR = 2.12, p < 0.001, RRR = 2.59, p < 0.001, respectively); they are also more likely to use condoms than another modern method of contraception (RRR = 2.13, p = 0.034, RRR = 1.71, p = 0.014, respectively). Young women are more likely to use another modern method (not including condoms) than be a nonuser when they perceive that their peers' use contraceptives (RRR = 1.51, p = 0.020). CONCLUSIONS: The results of this study highlight the important role of peer influence on young people's contraceptive choices. These findings can be used to develop programs that encourage behavior change communication activities in Kenya that focus on normalizing use of a full range of contraceptive methods among peer groups of sexually experienced young people.

In Kenya, about 15% of women age 15­19 have already had a birth and approximately one third of these women did not want to have a child at that time. Yet about 45% of sexually active women ages 15­24 report that they currently use family planning (FP). Among young people, friends and peers are an important influence on behaviors.This study focused on a representative sample from Kenya of female and male youth (ages 15­24) who ever had sex. Men and women were asked questions about use of FP, if they think their peers use FP and about characteristics such as age and education.The results showed that young women and men who believed their peers use FP were more likely to use FP themselves. Also, young men and women who believed that peers use FP were more likely to use condoms than not use any FP and more likely to use condoms than to use another modern method of FP. Young women who thought their peers use were more likely to use another modern method (not including condoms) than to be a nonuser of FP.Programs targeting young people should include information on a range of FP methods and aim to include groups of peers and encourage open discussion.

Caesarean section rate in Nigeria between 2013 and 2018 by obstetric risk and socio-economic status.

OBJECTIVES: Caesarean section (CS) can be life-saving for both mother and child, but in Nigeria the CS rate remains low, at 2.7% of births. We aimed to estimate the rate of CS and early neonatal mortality in Nigeria according to obstetric risk and socio-economic background and to identify factors associated with CS. METHODS: We used the 2018 Nigeria Demographic and Health Survey, encompassing 33 924 live births within the last 5 years, to estimate the CS rate and early neonatal mortality rate (ENMR) by obstetric risk group, informed by the Robson classification. The CS rate and ENMR were assessed within each Robson group and stratified by socio-economic background. Logistic regression analyses were used to explore determinants of CS. RESULTS: Almost three-quarters (72.4%) of all births were to multiparous women, with a singleton baby of normal birthweight, thus a low-risk group similar to Robson 3, and with a CS rate of 1.0%. CS rates in the two high-risk groups (multiple pregnancy and preterm/low birthweight) were low, 7.1% (95% CI: 5.2-9.7) and 1.8 % (95% CI: 1.4-2.4), respectively. The ENMR was particularly high for multiple pregnancy (175 per 1000 live births; 95% CI: 131-230). Greater number of antenatal visits, unwanted pregnancy, multiple pregnancy, household wealth, maternal education, Christians/Others versus Muslims and referral during childbirth were positively associated with CS. CONCLUSION: Inequitable access to CS is not limited to socio-economic determinants, but also related to obstetric risk factors, calling for increased efforts to improve access to CS for high-risk pregnancies.

Women's progression through the maternal continuum of care in Guinea: Evidence from the 2018 Guinean Demographic and Health Survey.

OBJECTIVE: To examine women's progression through the antenatal, birth, and post-partum maternal care in Guinea in 2018. METHODS: Using the Guinea Demographic and Health Survey of 2018, we analysed data on most recent live births in the 24 months preceding the survey among women aged 15-49 and the determinants (health system, quality of care, reproductive and sociodemographic factors) of women's progression through three steps of the continuum of care, using multivariable logistic regression. RESULTS: In the sample of 3,018 women, 87% reported at least one ANC visit (ANC1) with a health professional and 36% reported ANC4+, at least one of which was with a health professional. In the study, 26% of women reported ANC4+ plus birth in a health facility, and 20% reported ANC4+, birth in a health facility, plus post-partum check-up. Predictors of woman's progression from ANC1 to ANC4+ visits included living in the administrative regions of Kindia (AOR: 1.96, 95% CI: 1.23-3.14) and Nzérékoré (AOR: 0.50, 95% CI: 0.32-0.79) vs. Kankan, being aged 15 to 17 (AOR: 0.55, 95% CI: 0.35-0.86) vs. aged 25 to 34, having primary or more education (AOR: 1.37, 95% CI: 1.09-1.72), and being from a middle (AOR: 1.52, 95% CI: 1.18-1.96) or wealthier (AOR: 2.38, 95% CI: 1.67-3.39) household vs. a poor household. Living in the administrative regions of Nzérékoré (AOR: 6.27, 95% CI: 1.57-25.05) vs. Kankan, in a middle (AOR: 1.64, 95% CI: 1.05-2.57) or wealthier (AOR: 3.23, 95% CI: 1.98-5.29) household vs. a poor household, nulliparity (AOR: 1.75, 95% CI: 1.03-2.97) vs. 2-4 previous births, the distance to health facility perceived as not being a problem (AOR: 1.75, 95% CI: 1.23-2.50), and higher ANC content score (AOR: 1.29, 95% CI: 1.10-1.52) remained independently associated with progression from ANC4+ to birth in a health facility. Predictors of progression from birth in the health facility to post-partum check-up included residing in the administrative regions of Labé (AOR: 0.22, 95% CI: 0.09-0.51) or Faranah (AOR: 0.43, 95% CI: 0.19-0.96) vs. Kankan, higher ANC content score (AOR: 1.76, 95% CI: 1.36-2.28), skin-to-skin contact after birth (AOR: 3.00, 95% CI: 1.70-5.31), and being attended at birth by a health professional (AOR: 17.52, 95% CI: 4.68-65.54). CONCLUSIONS: Removing financial barriers and improving quality of care appear to be important to increase the percentage of women receiving the full maternal continuum of care.