Role of men in women's health service utilisation in northern Nigeria: a qualitative study of women, men and provider perspectives.

BACKGROUND: The 2018 Nigeria Demographic and Health Survey shows poor maternal health in northern Nigeria. Contraceptive use remains low and maternal mortality high. Studies show that cultural norms related to men's decision-making role in the family significantly contribute to this phenomenon. OBJECTIVES: The assessment was designed to identify barriers to service delivery and utilisation of maternal-health and family-planning services in three northern Nigerian states, focusing on aspects of service delivery affected by husband involvement. DESIGN: Qualitative design included 16 focus group discussions and 12 in-depth interviews with facility clients, and 16 in-depth interviews with healthcare providers, in each of the three states. SETTING: Primary healthcare facilities in three northern Nigeria states: Bauchi, Kebbi and Sokoto. PARTICIPANTS: Women who came to the facility for family-planning services (n=233 in 24 focus groups); women who came for antenatal care (n=97 in 12 focus groups); men married to women who either received antenatal care or delivered in a facility (n=96 in 12 focus groups); mothers of newborns who delivered in a facility (n=36) and healthcare providers (n=48). RESULTS: We found gender barriers to contraceptive use and to obtaining maternal healthcare, with some women requiring their husband's permission to use services, even in emergencies. Several supply-side barriers exacerbate the situation. Many healthcare providers would not provide women with a family-planning method without their husbands' presence or approval; some male providers would not admit a woman to deliver in a facility if her husband objected to her being treated by a man and there was no female provider present and some facilities do not have the infrastructure to accommodate men. CONCLUSION: Despite years of programming, barriers to women's family-planning and maternal-health service utilisation persist. State governments in northern Nigeria should invest in additional provider training, improving infrastructure and hiring more female healthcare providers.

Challenges and coping strategies for providing maternal health care services among health care professionals in rural health facilities in Wolaita Zone, Southern Ethiopia: a qualitative study.

BACKGROUND: Many factors can decrease job productivity and cause physical and psychological complications for health care professionals providing maternal care. Information on challenges and coping strategies among healthcare professionals providing maternal healthcare services in rural communities is crucial. However, there needs to be more studies, especially qualitative research, to explore challenges and coping strategies for providing maternal health care services in Ethiopia among health care professionals, particularly in the Wolaita zone. OBJECTIVE: To explore the challenges and coping strategies of professionals providing maternal health care in rural health facilities in Wolaita Zone, Southern Ethiopia, in 2023. METHOD: A phenomenological qualitative study design was applied from May 20 to June 20, 2023. The study was conducted in rural areas of the Wolaita Zone, southern Ethiopia. Healthcare professionals from rural areas were selected using purposive sampling, and in-depth interviews were conducted. A qualitative thematic analysis was employed to analyze the data. Field notes were read, recordings were listened to, and each participant's interview was written word for word and analyzed using ATLAS.ti 7 software. RESULT: Five main themes emerged from the data analysis. These themes included inadequate funding from the government, societal barriers to health and access to health care, professionals' personal life struggles, infrastructure related challenges and health system responsiveness, and coping strategies. Reporting to responsible bodies, teaching mothers about maternal health care services, and helping poor mothers from their pockets were listed among their coping strategies. CONCLUSION: Healthcare professionals have a crucial role in supporting women in delivering babies safely. This study revealed that they are working under challenging conditions. So, if women's lives matter, then this situation requires a call to action.

Exploring the factors behind socioeconomic inequalities in Antenatal Care (ANC) utilization across five South Asian natiaons: A decomposition approach.

Maternal and child mortality rates remain a significant concern in South Asian countries, primarily due to limited access to maternal care services and socioeconomic disparities. While previous studies have examined the factors influencing the utilization of antenatal care (ANC) services in individual countries, there is a lack of comparative analysis across South Asian nations. This study aims to investigate the factors affecting ANC utilization among women aged 15-49 in Bangladesh, India, Nepal, Maldives, and Pakistan using the latest Demographic and Health Survey data. The study utilized a total weighted sample size of 262,531 women. Simple bivariate statistics and binary logistic regression were employed to identify potential factors influencing ANC utilization. Decomposition analysis and concentration curve (Lorenz curve) were used to assess inequality in ANC service utilization. The prevalence of ANC utilization varied across the countries, with Maldives having the highest (96.83%) and Bangladesh the lowest (47.01%). Women's and husbands' education, household wealth status, BMI, and urban residence were found to significantly influence maternal healthcare services utilization. Higher education levels, affluent wealth quintiles, and urban living were identified as significant contributors to socioeconomic disparities in accessing ANC services. This study highlights the crucial role of socioeconomic factors in the utilization of maternal healthcare services in South Asian countries. Governments should focus on improving healthcare infrastructure, addressing cultural barriers, and promoting education to address these disparities. Identifying context-specific causes of maternal healthcare utilization is essential to inform targeted interventions and policies aimed at improving access to ANC services and reducing maternal mortality rates.

Women's experiences in institutional childbirth care in times of the first and second waves of COVID in Mexico. / Experiencias de mujeres en la atención del parto institucional en tiempos de la primera y segunda ola de COVID en México.

This is a qualitative study that explores the perspectives and experiences of a group of Mexican women who experienced institutionalized childbirth care in the first and second waves of the COVID-19 pandemic. Through a semi-structured script, nine women who experienced childbirth care were interviewed between March and October 2020 in public and private hospitals in the city of San Luis Potosí, Mexico. Under the Grounded Theory analysis proposal, it was identified that the health strategies implemented during the pandemic brought with them a setback in the guarantee of humanized childbirth. Women described themselves as distrustful of the protocols that personnel followed to attend to their births in public sector hospitals and very confident in those implemented in the private sector. The intervention of cesarean sections without a clear justification emerged as a constant, as did early dyad separation. Healthcare personnel's and institutions' willingness and conviction to guarantee, protect and defend the right of women to experience childbirth free of violence remain fragile. Resistance persists to rethink childbirth care from a non-biomedicalizing paradigm.

Estudio de tipo cualitativo que explora las perspectivas y experiencias de un grupo de mujeres mexicanas que vivieron la atención institucionalizada del parto en la primera y segunda ola de la pandemia por COVID-19. A través de un guión semiestructurado se entrevistó a nueve mujeres que vivieron la experiencia de la atención del parto entre marzo y octubre de 2020, en hospitales públicos y privados de la ciudad de San Luis Potosí, en México. Bajo la propuesta de análisis de la teoría fundamentada, se identificó que las estrategias sanitarias implementadas en el marco de la pandemia, trajeron consigo un retroceso en la garantía del parto humanizado, las mujeres se narraron desconfiadas en los protocolos que siguió el personal para la atención de sus partos en los hospitales del sector público y muy confiadas en los que se implementaron en el sector privado. La realización de cesáreas sin una justificación clara emergió como una constante, igual que la separación temprana de los binomios. Continúa frágil la disposición y el convencimiento del personal sanitario y las instituciones para garantizar, proteger y defender el derecho de las mujeres a vivir el parto libre de violencia. Persisten resistencias para repensar la atención del parto desde un paradigma no biomédicalizante.

Preliminary findings on the experiences of care for women who suffered early pregnancy losses during the COVID-19 pandemic: a qualitative study.

BACKGROUND: Women who suffer an early pregnancy loss require specific clinical care, aftercare, and ongoing support. In the UK, the clinical management of early pregnancy complications, including loss is provided mainly through specialist Early Pregnancy Assessment Units. The COVID-19 pandemic fundamentally changed the way in which maternity and gynaecological care was delivered, as health systems moved to rapidly reconfigure and re-organise services, aiming to reduce the risk and spread of SARS-CoV-2 infection. PUDDLES is an international collaboration investigating the pandemic's impact on care for people who suffered a perinatal bereavement. Presented here are initial qualitative findings undertaken with UK-based women who suffered early pregnancy losses during the pandemic, about how they navigated the healthcare system and its restrictions, and how they were supported. METHODS: In-keeping with a qualitative research design, in-depth semi-structured interviews were undertaken with an opportunity sample of women (N = 32) who suffered any early pregnancy loss during the COVID-19 pandemic. Data were analysed using a template analysis to understand women's access to services, care, and networks of support, during the pandemic following their pregnancy loss. The thematic template was based on findings from parents who had suffered a late-miscarriage, stillbirth, or neonatal death in the UK, during the pandemic. RESULTS: All women had experienced reconfigured maternity and early pregnancy services. Data supported themes of: 1) COVID-19 Restrictions as Impractical & Impersonal; 2) Alone, with Only Staff to Support Them; 3) Reduction in Service Provision Leading to Perceived Devaluation in Care; and 4) Seeking Their Own Support. Results suggest access to early pregnancy loss services was reduced and pandemic-related restrictions were often impractical (i.e., restrictions added to burden of accessing or receiving care). Women often reported being isolated and, concerningly, aspects of early pregnancy loss services were reported as sub-optimal. CONCLUSIONS: These findings provide important insight for the recovery and rebuilding of health services in the post-pandemic period and help us prepare for providing a higher standard of care in the future and through any other health system shocks. Conclusions made can inform future policy and planning to ensure best possible support for women who experience early pregnancy loss.

Barriers and facilitators of access to maternity care for African-born women living in Australia: a meta-synthesis of qualitative evidence.

BACKGROUND: Adverse perinatal health outcomes are notably high among African-born women living in Australia. This problem is partly attributed to their lower engagement in maternity care services as compared to Australian-born women. Various barriers might limit African-born women's access to and use of services; however, these barriers are not well documented. Therefore, this review aimed to synthesise current qualitative evidence on barriers and facilitators of access to maternity care for African-born women living in Australia. METHODS: The search was conducted in MEDLINE, CINAHL, Embase, PsychInfo, and Maternity and Infant Care databases on 16 April 2023. All articles retrieved were meticulously screened for eligibility by two independent reviewers with any disagreements resolved through discussion. The quality of the included articles was evaluated using the Mixed Methods Appraisal Tool. Studies were screened in Covidence and analysed in NVivo. The findings were organised and presented using Levesque's framework of healthcare access. RESULTS: Out of 558 identified papers, 11 studies comprising a total of 472 participants met the eligibility criteria. The review highlighted provider-side barriers such as shortage of information, unmet cultural needs, long waiting times, low engagement of women in care, discrimination, and lack of continuity of care. User-side barriers identified include communication issues, difficulty navigating the health system, and lack of trustful relationships with healthcare providers. In contrast, the review pinpointed provider-side facilitators including positive staff attitudes, service availability, and the proximity of facilities to residential homes, while user-side facilitators such as cultural assimilation and feeling valued by healthcare providers were noted. CONCLUSIONS: This review identified barriers and facilitators of access to maternity care for African-born women living in Australia. Empirical evidence that would inform potential changes to policy and practice to address African-born women's unique health needs was highlighted. Designing and implementing a culturally safe service delivery model could remove the identified access barriers and improve African-born women's engagement in maternity care. Moreover, reinforcing factors associated with positive healthcare experiences is essential for improving maternity care access for this priority population. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42023405458.

Study protocol: a mixed-methods study of the implementation of doula care to address racial health equity in six state Medicaid programs.

BACKGROUND: Racial inequities in severe maternal morbidity (SMM) and mortality constitute a public health crisis in the United States. Doula care, defined as care from birth workers who provide culturally appropriate, non-clinical support during pregnancy and postpartum, has been proposed as an intervention to help disrupt obstetric racism as a driver of adverse pregnancy outcomes in Black and other birthing persons of colour. Many state Medicaid programs are implementing doula programs to address the continued increase in SMM and mortality. Medicaid programs are poised to play a major role in addressing the needs of these populations with the goal of closing the racial gaps in SMM and mortality. This study will investigate the most effective ways that Medicaid programs can implement doula care to improve racial health equity. METHODS: We describe the protocol for a mixed-methods study to understand how variation in implementation of doula programs in Medicaid may affect racial equity in pregnancy and postpartum health. Primary study outcomes include SMM, person-reported measures of respectful obstetric care, and receipt of evidence-based care for chronic conditions that are the primary causes of postpartum mortality (cardiovascular, mental health, and substance use conditions). Our research team includes doulas, university-based investigators, and Medicaid participants from six sites (Kentucky, Maryland, Michigan, Pennsylvania, South Carolina and Virginia) in the Medicaid Outcomes Distributed Research Network (MODRN). Study data will include policy analysis of doula program implementation, longitudinal data from a cohort of doulas, cross-sectional data from Medicaid beneficiaries, and Medicaid healthcare administrative data. Qualitative analysis will examine doula and beneficiary experiences with healthcare systems and Medicaid policies. Quantitative analyses (stratified by race groups) will use matching techniques to estimate the impact of using doula care on postpartum health outcomes, and will use time-series analyses to estimate the average treatment effect of doula programs on population postpartum health outcomes. DISCUSSION: Findings will facilitate learning opportunities among Medicaid programs, doulas and Medicaid beneficiaries. Ultimately, we seek to understand the implementation and integration of doula care programs into Medicaid and how these processes may affect racial health equity. Study registration The study is registered with the Open Science Foundation ( https://doi.org/10.17605/OSF.IO/NXZUF ).

Effectiveness of engaging religious leaders in maternal health education for improving maternal health service utilization in Ethiopia: cluster randomized controlled trial.

Introduction: High mortality rates for pregnant women and their new-borns are one of Africa's most intractable public health issues today, and Ethiopia is one of the countries most afflicted. Behavioral interventions are needed to increase maternal health service utilizations to improve outcomes. Hence, this trial aimed to evaluate effectiveness of trained religious leaders' engagement in maternal health education on maternal health service utilization. Methods: The study employed a cluster-randomized controlled community trial that included baseline and end-line measurements. Data on end points were gathered from 593 pregnant mothers, comprising 292 and 301 individuals in the intervention and control groups, respectively. In the intervention group, the trained religious leaders delivered the behavioral change education on maternal health based on intervention protocol. Unlike the other group, the control group only received regular maternal health information and no additional training from religious leaders. Binary generalized estimating equation regression analysis adjusted for baseline factors were used to test effects of the intervention on maternal health service utilization. Results: Following the trial's implementation, the proportion of optimal antenatal care in the intervention arm increased by 21.4% from the baseline (50.90 vs. 72.3, p ≤ 0.001) and the proportion of institutional delivery in the intervention group increased by 20% from the baseline (46.1% vs. 66.1%, p ≤ 0.001). Pregnant mothers in the intervention group significantly showed an increase of proportion of PNC by 22.3% from baseline (26% vs. 48.3%, p ≤ 0.001). A statistically significant difference was observed between in ANC4 (AOR = 2.09, 95% CI: 1.69, 2.57), institutional delivery (AOR = 2.36, 95% CI: 1.94, 2.87) and postnatal care service utilization (AOR = 2.26, 95% CI: 1.79, 2.85) between the intervention and control groups. Conclusion: This research indicated that involving religious leaders who have received training in maternal health education led to positive outcomes in enhancing the utilization of maternal health services. Leveraging the influential position of these religious leaders could be an effective strategy for improving maternal health service utilization. Consequently, promoting maternal health education through religious leaders is advisable to enhance maternal health service utilization.Clinical trial registration: [https://clinicaltrials.gov/], identifier [NCT05716178].

Integrated maternity care: A concept analysis.

INTRODUCTION: Integrated maternity care is strongly promoted in the Netherlands. However, the term 'integrated' and its practical meaning is understood differently by professionals and policy makers. This lack of clarity is also visible in other countries and hinders implementation. In this study, we will examine how the concept of 'integrated maternity care' and its defining attributes are presented in the international literature. METHODS: This study aims to provide a definition and deeper understanding of the concept of integrated maternity care by conducting a concept analysis using Morse's method. We performed a systematic search using Embase and Ebscohost (CINAHL, PsychINFO, SocINDEX, MEDLINE) including records that described integrated maternity care from on organizational perspective. Through a qualitative analysis of the selected research and non-research records, we identified defining attributes, boundaries, antecedents, and consequences of the concept. Subsequently, we constructed a definition of the concept based on the findings. RESULTS: We included 36 records on integrated maternity care in the period from 1978 to 2022. Our search included 21 research and 15 non-research records (e.g. guidelines and policy records). Only half of these had a definition of integrated maternity care. Over time, the definition became more specific. Our concept analysis resulted in three defining attributes of integrated maternity care: collaboration, organizing collaboration and woman-centeredness. We identified role clarity, a culture of collaboration, and clear and timely communication as antecedents of integrated maternity care. A number of consequences were found: continuity of care, improved outcomes, and efficiency. All consequences were described as expected effects of integrated maternity care and not based on evidence. CONCLUSION: We propose the following definition: 'Integrated maternity care is woman-centred care provided by (maternity) care professionals collaborating together within and across different levels of healthcare with a specific focus on organizing seamless care.' Addressing the antecedents is important for the successful implementation of integrated maternity care.

Diversity, Equity, and Inclusion: Obstetrics and Gynecologist Hospitalists' Impact on Maternal Mortality.

Obstetrics and gynecology hospitalists play a vital role in reducing maternal morbidity and mortality by providing immediate access to obstetric care, especially in emergencies. Their presence in hospitals ensures timely interventions and expert management, contributing to better outcomes for mothers and babies. This proactive approach can extend beyond hospital walls through education, advocacy, and community outreach initiatives aimed at improving maternal health across diverse settings.

The Meso-Level in Quality Improvement: Perspectives From a Maternal-Neonatal Health Partnership in South Africa.

BACKGROUND: Sustained implementation of facility-level quality improvement (QI) processes, such as plan-do-study-act cycles, requires enabling meso-level environments and supportive macro-level policies and strategies. Although this is well recognised, there is little systematic empirical evidence on roles and capacities, especially at the immediate meso-level of the system, that sustain QI strategies at the frontline. METHODS: In this paper we report on qualitative research to characterize the elements of a quality and outcome-oriented meso-level, focused on sub/district health systems (DHSs), conducted within a multi-level initiative to improve maternal-newborn health (MNH) in three provinces of South Africa. Drawing on the embedded experience and tacit knowledge of core project partners, obtained through in-depth interviews (39) and project documentation, we analysed thematically the roles, capacities and systems required at the meso-level for sustained QI, and experiences with strengthening the meso-level. RESULTS: Meso-level QI roles identified included establishing and supporting QI systems and strengthening delivery networks. We propose three elements of system capacity as enabling these meso-level roles: (1) leadership stability and capacity, (2) the presence of formal mechanisms to coordinate service delivery processes at sub-district and district levels (including governance, referral and outreach systems), and (3) responsive district support systems (including quality oriented human resource, information, and emergency medical services [EMS] management), embedded within supportive relational eco-systems and appropriate decision-space. While respondents reported successes with system strengthening, overall, the meso-level was regarded as poorly oriented to and even disabling of quality at the frontline. CONCLUSION: We argue for a more explicit orientation to quality and outcomes as an essential district and sub-district function (which we refer to as meso-level stewardship), requiring appropriate structures, processes, and capacities.

Barriers and facilitators when implementing midwifery continuity of carer: a narrative analysis of the international literature.

BACKGROUND: Midwifery continuity of carer (MCoC) is a model of care in which the same midwife or small team of midwives supports women throughout pregnancy, birth and the postnatal period. The model has been prioritised by policy makers in a number of high-income countries, but widespread implementation and sustainability has proved challenging. METHODS: In this narrative review and synthesis of the global literature on the implementation and sustainability of midwifery continuity of carer, we identify barriers to, and facilitators of, this model of delivering maternity care. By mapping existing research evidence onto the Consolidated Framework for Implementation Research (CFIR), we identify factors for organisations to consider when planning and implementing midwifery continuity of carer as well as gaps in the current research evidence. RESULTS: Analysing international evidence using the CFIR shows that evidence around midwifery continuity of carer implementation is patchy and fragmented, and that the impetus for change is not critically examined. Existing literature pays insufficient attention to core aspects of the innovation such as the centrality of on call working arrangements and alignment with the professional values of midwifery. There is also limited attention to the political and structural contexts into which midwifery continuity of carer is introduced. CONCLUSIONS: By synthesizing international research evidence with the CFIR, we identify factors for organisations to consider when planning and implementing midwifery continuity of carer. We also call for more systematic and contextual evidence to aid understanding of the implementation or non-implementation of midwifery continuity of carer. Existing evidence should be critically evaluated and used more cautiously in support of claims about the model of care and its implementation, especially when implementation is occurring in different settings and contexts to the research being cited.

The extent of implementation and perceptions of maternity and social care professionals about two interprofessional programs for care for pregnant women: a mixed methods study.

BACKGROUND: In 2018, the Dutch government initiated the Solid Start program to provide each child with the best start in life. Key program elements are a biopsychosocial perspective on pregnancy and children's development and stimulating local collaborations between social and health domains, with a specific focus on (future) families in vulnerable situations. Two programs for interprofessional collaboration between maternity and social care professionals to optimize care for pregnant women in vulnerable situations were developed and implemented, in Groningen in 2017 and in South Limburg in 2021. This paper describes the extent of implementation of these programs and the perceptions of involved professionals about determinants that influence program implementation. METHODS: We conducted a mixed-methods study in 2021 and 2022 in two Dutch regions, Groningen and South Limburg. Questionnaires were sent to primary care midwives, hospital-based midwives, obstetricians (i.e. maternity care professionals), (coordinating) youth health care nurses and social workers (i.e. social care professionals), involved in the execution of the programs. Semi-structured interviews were held with involved professionals to enrich the quantitative data. Quantitative and qualitative data were collected and analyzed using Fleuren's implementation model. RESULTS: The findings of the questionnaire (n = 60) and interviews (n = 28) indicate that professionals in both regions are generally positive about the implemented programs. However, there was limited knowledge and use of the program in Groningen. Promoting factors for implementation were mentioned on the determinants for the innovation and the user. Maternity care professionals prefer a general, conversational way to identify vulnerabilities that connects to midwives' daily practice. Low-threshold, personal contact with clear agreements for referral and consultation between professionals contributes to implementation. Professionals agree that properly identifying vulnerabilities and referring women to appropriate care is an important task and contributes to better care. On the determinants of the organization, professionals indicate some preconditions for successful implementation, such as clearly described roles and responsibilities, interprofessional training, time and financial resources. CONCLUSIONS: Areas for improvement for the implementation of interprofessional collaboration between maternity care and social care focus mainly on determinants of the organization, which should be addressed both regionally and nationally. In addition, sustainable implementation requires continuous awareness of influencing factors and a process of evaluation, adaptation and support of the target group.

Seldom Heard Voices - Empowering Maternity Services in Wales.

Seldom-heard groups refer to individuals whose voices are often marginalised, underrepresented, or not adequately considered in the digital design process. This case study aims to demonstrate the benefits of taking a user-centred design (UCD) approach to implementing a digital solution for Maternity Services in Wales. Semi-structured interviews were conducted to understand the needs of women and birthing people from seldom-heard groups. The research insights were used to inform the design of a service pattern that could be delivered before and after each maternity appointment. The research shows opportunities to improve the experience for women and birthing people and reduce their anxieties by creating a reliable, accessible digital maternity record that will empower them to make evidence-based decisions. By taking a user-centred design approach and centering the unique needs of those facing the greatest health disparities, Maternity Services' digital transformation aims to positively impact the health and well-being of women and birthing people in Wales.

Health system responsiveness and its associated factors for intrapartum care in conflict affected areas in Amhara region, Ethiopia: a cross-sectional study.

OBJECTIVE: In Ethiopia, information about health system responsiveness (HSR) in conflict-affected areas is limited. No previous local study was conducted on the assessment of HSR at the community level. Hence, the study assessed HSR for intrapartum care in conflict-affected areas in Amhara region, Ethiopia. DESIGN: Community-based cross-sectional study design. SETTING: Wadila, Gayint and Meket districts, Amhara region, Ethiopia. PARTICIPANTS: The participants were 419 mothers who gave birth in conflict-affected areas within the last 6 months. The study included all mothers who gave birth at health facilities but excluded those who delivered at home, critically ill or unable to hear. OUTCOME: HSR was the outcome variable. In this regard, the study assessed how mothers were treated and the situation in which they were cared for in relation to their experience during the conflict. METHODS: We conducted the study in the community, where we analysed eight domains of HSR to identify 30 measurement items related to intrapartum care responsiveness. The domains we looked at were dignity (4), autonomy (4), confidentiality (2), communication (5), prompt attention (5), social support (3), choice (3) and basic amenities (4). We used a multiple linear regression model to analyse the data, and in this model, we used an unstandardized ß coefficient with a 95% CI and a p value of less than 0.05 to determine the factors significantly associated with HSR. RESULTS: The findings of our study revealed that the overall proportion of HSR in intrapartum care was 45.11% (95% CI: 40.38 to 49.92). The performance of responsiveness was the lowest in the autonomy, choice and prompt attention domains at 35.5%, 49.4% and 52.0%, respectively. Mothers living in urban areas (ß=4.28; 95% CI: 2.06 to 6.50), government employees (ß=4.99; 95% CI: 0.51 to 9.48), those mothers stayed at the health facilities before delivery/during conflict (ß=0.22; 95% CI: 0.09 to 0.35), those who were satisfied with the healthcare service (ß=0.69; 95% CI: 0.08 to 1.30) and those who perceived the quality of healthcare favourable (ß=0.96; 95% CI: 0.72 to 1.19) were more likely to rate HSR positively. On the other hand, joint decision-making for health (ß=-2.46; 95% CI: -4.81 to -0.10) and hospital delivery (ß=-3.62; 95% CI: -5.60 to -1.63) were negatively associated with HSR. CONCLUSION: In the Amhara region of Ethiopia, over 50% of mothers living in areas affected by conflict reported that health systems were not responsive with respect to intrapartum care. Therefore, all stakeholders should work together to ensure that intrapartum care is responsive to conflict-affected areas, with a focus on providing women autonomy and choice.

Estimates and determinants of health facility delivery in the Birhan cohort in Ethiopia.

Health facility delivery is one of the critical indicators to monitor progress towards the provision of skilled delivery care and reduction in perinatal mortality. In Ethiopia, utilization of health facilities for skilled delivery care has been increasing but varies greatly by region and among specific socio-demography groups. We aimed to measure the prevalence and determinants of health facility delivery in the Amhara region in Ethiopia. From December 2018 to November 2020, we conducted a longitudinal study from a cohort of 2801 pregnant women and described the location of delivery and the association with determinants. We interviewed a subset of women who delivered in the community and analyzed responses using the three delays model to understand reasons for not using health facility services. A multivariable poisson regression model with robust error variance was used to estimate the presence and magnitude of association between location of delivery and the determinants. Of the 2,482 pregnant women followed through to birth, 73.6% (n = 1,826) gave birth in health facilities, 24.3% (n = 604) gave birth at home and 2.1% (n = 52) delivered on the way to a health facility. Determinants associated with increased likelihood of delivery at a health facility included formal maternal education, shorter travel times to health facilities, primiparity, higher wealth index and having attended at least one ANC visit. Most common reasons mothers gave for not delivering in a health facility were delays in individual/family decision to seek care. The proportion of deliveries occurring in health facilities is increasing but falls below targets. Interventions that focus on the identified social-demographic determinants and delays are warranted.

Delivery and postnatal care among women in 71 low- and middle-income countries: analyzing coverage gaps using household surveys.

BACKGROUND: High levels of maternal morbidity and mortality persist in low- and middle-income countries, despite increases in coverage of facility delivery and skilled assistance at delivery. We compared levels of facility birth to a summary delivery care measure and quantified gaps. METHODS: We approximated a delivery care score from type of delivery (home, lower-level facility, or hospital), skilled attendant at delivery, a stay of 24-or-more-hours after delivery, and a health check within 48-h after delivery. Data were obtained from 333,316 women aged 15-49 who had a live birth in the previous 2 years, and from 71 countries with nationally representative surveys between 2013 and 2020. We computed facility delivery and delivery care coverage estimates to assess the gap. We stratified the analysis by country characteristics, including the national maternal mortality ratio (MMR), to assess the size of coverage gaps, and we assessed missed opportunities through coverage cascades. We looked at the association between MMR and delivery care coverage. RESULTS: Delivery care coverage varied by country, ranging from 24% in Sudan to 100% in Cuba. Median coverage was 70% with an interquartile range of 30 percentage points (55% and 85%). The cascade showed that while 76% of women delivered in a facility, only 41% received all four interventions. Coverage gaps exist across all MMR levels. Gaps between highest and lowest wealth quintiles were greatest in countries with MMR levels of 100 or higher, and the gap narrowed in countries with MMR levels below 100. The delivery care indicator had a negative association with MMR. CONCLUSIONS: In addition to providing high-quality evidenced-based care to women during birth and the postpartum period, there is also a need to address gaps in delivery care, which occur within and between countries, wealth quintiles, and MMR phases.

Structural barriers to maternity care in Cameroon: a qualitative study.

BACKGROUND: The maternal mortality and perinatal mortality rate in Cameroon are among the highest worldwide. To improve these outcomes, we conducted a formative qualitative assessment to inform the adaptation of a mobile provider-to-provider intervention in Cameroon. We explored the complex interplay of structural barriers on maternity care in this low-resourced nation. The study aimed to identify structural barriers to maternal care during the early adaptation of the mobile Medical Information Service via Telephone (mMIST) program in Cameroon. METHODS: We conducted in-depth interviews and focus groups with 56 key stakeholders including previously and currently pregnant women, primary healthcare providers, administrators, and representatives of the Ministry of Health, recruited by purposive sampling. Thematic coding and analysis via modified grounded theory approach were conducted using NVivo12 software. RESULTS: Three main structural barriers emerged: (1) civil unrest (conflict between Ambazonian militant groups and the Cameroonian government in the Northwest), (2) limitations of the healthcare system, (3) inadequate physical infrastructure. Civil unrest impacted personal security, transportation safety, and disrupted medical transport system. Limitations of healthcare system involved critical shortages of skilled personnel and medical equipment, low commitment to evidence-based care, poor reputation, ineffective health system communication, incentives affecting care, and inadequate data collection. Inadequate physical infrastructure included frequent power outages and geographic distribution of healthcare facilities leading to logistical challenges. CONCLUSION: Dynamic inter-relations among structural level factors create barriers to maternity care in Cameroon. Implementation of policies and intervention programs addressing structural barriers are necessary to facilitate timely access and utilization of high-quality maternity care.

Increasing the number of midwives is necessary but not sufficient: using global data to support the case for investment in both midwife availability and the enabling work environment in low- and middle-income countries.

BACKGROUND: Most countries are off-track to achieve global maternal and newborn health goals. Global stakeholders agree that investment in midwifery is an important element of the solution. During a global shortage of health workers, strategic decisions must be made about how to configure services to achieve the best possible outcomes with the available resources. This paper aims to assess the relationship between the strength of low- and middle-income countries' (LMICs') midwifery profession and key maternal and newborn health outcomes, and thus to prompt policy dialogue about service configuration. METHODS: Using the most recent available data from publicly available global databases for the period 2000-2020, we conducted an ecological study to examine the association between the number of midwives per 10,000 population and: (i) maternal mortality, (ii) neonatal mortality, and (iii) caesarean birth rate in LMICs. We developed a composite measure of the strength of the midwifery profession, and examined its relationship with maternal mortality. RESULTS: In LMICs (especially low-income countries), higher availability of midwives is associated with lower maternal and neonatal mortality. In upper-middle-income countries, higher availability of midwives is associated with caesarean birth rates close to 10-15%. However, some countries achieved good outcomes without increasing midwife availability, and some have increased midwife availability and not achieved good outcomes. Similarly, while stronger midwifery service structures are associated with greater reductions in maternal mortality, this is not true in every country. CONCLUSIONS: A complex web of health system factors and social determinants contribute to maternal and newborn health outcomes, but there is enough evidence from this and other studies to indicate that midwives can be a highly cost-effective element of national strategies to improve these outcomes.