Respectful Maternity Care during labour and postpartum in a tertiary hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Respectful maternity care (RMC) is a fundamental human right for women globally. Providing respectful care during labor and postpartum is crucial for the health and well-being of both mothers and newborns. The interactions between healthcare providers and women play a significant role in shaping their future healthcare decisions. Therefore, this research aims to evaluate the prevalence of RMC during labor and postpartum from the patient's perspective at a tertiary care center. METHODS: We conducted a descriptive cross-sectional study at a tertiary center from February 20, 2023, to September 30, 2023. Ethical approval was obtained from the Institutional Review Committee of the same institution. A total of 217 patients were included using consecutive sampling techniques. Data were collected through interviews using a structured questionnaire on respectful maternity care. The point estimate was calculated with a 95% Confidence Interval. RESULTS: The prevalence of overall respectful maternity care (RMC) score was 81%. The score for right to confidentiality and privacy during labor was 91.7%, treated with dignity and respect was 90.87%, received equitable care free of discrimination was 86.41%, protection from physical harm and ill treatment was 84.02%, while protection of right to information/informed consent and choice'preference was 72.55%. CONCLUSIONS: This study demonstrated a high prevalence of respectful maternity care, with most patients experiencing protection of confidentiality, dignity, equitable treatment, safety, and informed consent, indicating effective implementation of RMC practices at our tertiary care center.\ Keywords: labour; maternity care; postpartum; prevalence; tertiary hospital.

Evaluating the Adoption of mHealth Technologies by Community Health Workers to Improve the Use of Maternal Health Services in Sub-Saharan Africa: Systematic Review.

BACKGROUND: Limited information exists on the impact of mobile health (mHealth) use by community health workers (CHWs) on improving the use of maternal health services in sub-Saharan Africa (SSA). OBJECTIVE: This systematic review addresses 2 objectives: evaluating the impact of mHealth use by CHWs on antenatal care (ANC) use, facility-based births, and postnatal care (PNC) use in SSA; and identifying facilitators and barriers to mHealth use by CHWs in programs designed to increase ANC use, facility-based births, and PNC use in SSA using a sociotechnical system approach. METHODS: We searched for articles in 6 databases (MEDLINE, CINAHL, Web of Science, Embase, Scopus, and Africa Index Medicus) from inception up to September 2022, with additional articles identified from Google Scholar. After article selection, 2 independent reviewers performed title and abstract screening, full-text screening, and data extraction using Covidence software (Veritas Health Innovation Ltd). In addition, we manually screened the references lists of the included articles. Finally, we performed a narrative synthesis of the outcomes. RESULTS: Among the 2594 records retrieved, 10 (0.39%) studies (n=22, 0.85% articles) met the inclusion criteria and underwent data extraction. The studies were published between 2012 and 2022 in 6 countries. Of the studies reporting on ANC outcomes, 43% (3/7) reported that mHealth use by CHWs increased ANC use. Similarly, of the studies reporting on facility-based births, 89% (8/9) demonstrated an increase due to mHealth use by CHWs. In addition, in the PNC studies, 75% (3/4) showed increased PNC use associated with mHealth use by CHWs. Many of the studies reported on the importance of addressing factors related to the social environment of mHealth-enabled CHWs, including the perception of CHWs by the community, trust, relationships, digital literacy, training, mentorship and supervision, skills, CHW program ownership, and the provision of incentives. Very few studies reported on how program goals and culture influenced mHealth use by CHWs. Providing free equipment, accessories, and internet connectivity while addressing ongoing challenges with connectivity, power, the ease of using mHealth software, and equipment maintenance support allowed mHealth-enabled CHW programs to thrive. CONCLUSIONS: mHealth use by CHWs was associated with an increase in ANC use, facility-based births, and PNC use in SSA. Identifying and addressing social and technical barriers to the use of mHealth is essential to ensure the success of mHealth programs. TRIAL REGISTRATION: PROSPERO CRD42022346364; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=346364.

Standards-based audit to improve quality of maternal and newborn care-A stepped-wedge cluster randomised trial in Malawi.

BACKGROUND: Audit is a quality improvement approach used in maternal and newborn health. Our objective was to introduce the practice of standards-based audit at healthcare facility level, and to examine if this would improve quality of care assessed by compliance with standards developed and agreed with healthcare providers. Our focus was on emergency obstetric and newborn care (EmONC). METHODS: A multidimensional incomplete stepped-wedge cluster randomised trial with 8 steps was conducted in 44 healthcare facilities in Malawi. A total of 25 standards of care were developed. At each healthcare facility one (health centres) or two (hospitals) standards were audited per cycle with two consecutive audit cycles conducted. Each cycle consisted of five steps: (i) select standard to be audited, (ii) measure compliance with standard (measurement 1), (iii) review findings and identify what changes are required to increase compliance (iv) implement changes, (v) re-measure compliance (measurement 2). Each compliance measurement assessed 25 women. Multilevel mixed effects logistic regression models were used to analyse data for all standards. RESULTS: The crude overall compliance rate rose from 45% in the control phase (measurement 1) to 63% in the intervention phase (measurement 2) (from 51.6% to70.6% at Basic and from 34.5% to 50.8% at Comprehensive EmONC healthcare facilities. When adjusted for standard, facility type, month, and healthcare facility by month, the adjusted OR (95% CI) was 2.80 (1.65, 4.76). Actions taken to improve compliance with standards included improving staff performance of clinical duties and general conduct through re-orientation and staff meetings as well as improved supervision, and, ensuring basic equipment and consumables were available on site (thermometers, rapid diagnostic tests, partograph). CONCLUSION: The introduction of standards-based audit helped healthcare providers identify problems with service provision, which when addressed, resulted in a measurable and significant improvement in quality of care. TRIAL REGISTRATION: ISRCTN registration number: 59931298.

Evaluation of the structure of primary maternal and infant healthcare in the state of Roraima, the North region of Brazil, and Brazil, 2012-2017. / Avaliação de estrutura da atenção primária à saúde materno-infantil. Roraima, região Norte e Brasil, 2012-2017.

Primary healthcare is the main gateway and priority for healthcare management in Brazil. However, there are significant challenges in the quality of care, particularly for those most vulnerable, especially maternal and infant healthcare. This fact is exacerbated by regional inequalities, which have historically left the North and Northeast regions at a relative disadvantage. The study involves an analysis of the resources available for maternal and infant healthcare in the state of Roraima, the North region, and Brazil as a whole in 2012, 2014, and 2017, using data from Module I of the National Program for the Improvement of Access and Quality of Primary Care (PMAQ-AB). There was a significant improvement in physical infrastructure indicators (e.g., ventilation and air conditioning) as well as improvement in the distribution of supplies and equipment needed for maternal and infant care between 2014 and 2017. However, the availability of medicines and the number of human resources and hours worked diminished. The study offers a crucial longitudinal analysis, comparing the situation in Roraima and Brazil, whose findings could contribute to the development of programs and public policymaking for reproductive rights and maternal and infant health.

A atenção primária à saúde é a principal porta de entrada e prioridade na gestão de saúde no Brasil. Contudo, existem desafios importantes na qualidade da atenção, em particular aos mais vulneráveis, especificamente na rede de saúde materna-infantil (RASMI). Esse fato é agravado pelas já conhecidas desigualdades regionais, que historicamente afetam mais as regiões Norte e Nordeste. O objetivo é avaliar no espaço-tempo a estrutura da RASMI em Roraima, na região Norte e no Brasil nos anos de 2012, 2014 e 2017. Para isso, a fonte de dados será o Programa Nacional de Melhoria do Acesso e Qualidade da Atenção Básica (PMAQ-AB), Módulo I. Observou-se melhoria significativa nos indicadores de infraestrutura física, como ambiência/climatização; e na distribuição de insumos/equipamentos necessários à assistência materno-infantil, percebeu-se um crescimento progressivo entre 2014 e 2017. Por outro lado, notou-se piora na disponibilidade de medicamentos e diminuição de quantidade/carga-horária de recursos humanos. O estudo configurou uma importante análise longitudinal, comparativa entre a realidade estadual e nacional, que contribui para a formulação de políticas e programas relativos aos direitos reprodutivos e à assistência materno-infantil.

'I am happy to be listened to': co-creation of a simple tool to measure women's experiences of respectful maternity care in urban Tanzania.

BACKGROUND: Rights-based Respectful Maternity Care (RMC) is crucial for quality of care and improved birth outcomes, yet RMC measurements are rarely included in facility improvement initiatives. We aimed to (i) co-create a routine RMC measurement tool (RMC-T) for congested maternity units in Dar es Salaam, Tanzania, and (ii) assess the RMC-T's acceptability among women and healthcare stakeholders. METHOD: We employed a participatory approach utilizing multiple mixed methods. This included a scoping review, stakeholder engagement involving postnatal women, healthcare providers, health leadership, and global researchers through interviews, focus groups, and two surveys involving 201 and 838 postnatal women. Cronbach's alpha and factor analysis were conducted for validation using Stata 15. Theories of social practice and Thematic Framework of Acceptability guided the assessment of stakeholder priorities and tool acceptability. RESULTS: The multi-phased iterative co-creation process produced the 25-question RMC-T that measures satisfaction, communication, mistreatment (including physical, verbal, and sexual abuse; neglect; discrimination; lack of privacy; unconsented care; post-birth clean-up; informal payments; and denial of care), supportive care (such as food intake and mobility), birth companionship, post-procedure pain relief, bed-sharing, and newborn respect. The pragmatic validation process prioritized stakeholder feedback over strict statistics, lowering Cronbach's alpha from 0.70 in version 1 to 0.57 for the RMC-T. Women valued the opportunity to share their experiences. CONCLUSIONS: The RMC-T is contextualized, validated, and acceptable for measuring women's experiences of RMC. Routine use in facility-based quality improvement initiatives, along with targeted actions to address gaps, will advance rights-based RMC. Further validation and community-based studies are needed.

• Main findings: This study describes the participatory approach involving postnatal women, healthcare providers, health leadership, and global researchers to co-create and validate a tool for measuring women's experiences of respectful maternity care in Dar es Salaam's urban health facilities.• Added knowledge: The iterative process produced a concise, 25-item Respectful Maternity Care Measurement tool that is user-friendly, administered in 15­20 minutes and addresses all mistreatment domains. The tool reflects women's priorities and is well accepted by postnatal women and health leaders.• Global health impact for policy and action: Regular use of the tool can enhance awareness of childbirth rights and drive actions to improve and normalize respectful maternity care in low-resource urban settings.

Researchers' perspectives of self-agency within a context of violence and harm in maternity care.

PROBLEM: There is an increasing awareness of the prevalence of obstetric violence within maternity care and that some women and birthing people are at greater risk of experiencing violence and harm. BACKGROUND: Supporting self-agency for women and birthing people in maternity care may be a way of addressing the disparities in vulnerability to violence and harm. AIM: To explore researchers' perspectives of self-agency for women from different backgrounds, what inhibits and prevents self-agency, and how self-agency can be enabled. METHODS: A qualitative research design was undertaken underpinned by a reproductive justice framework. Group interviews were held with researchers working with perinatal women/birthing people with histories and experiences of violence and abuse. Reflexive thematic analysis using Bronfenbrenner's ecological systems theory was undertaken. FINDINGS: 12 participants took part in two group interviews. Two themes were developed: 'defining self-agency' and 'ecological influences on self-agency'. DISCUSSION: The findings identify how self-agency should not be perceived as an intrinsic attribute, but rather is underpinned by exogenous and endogenous influences. Whether and how self-agency is enacted is determined by interacting factors that operate on a micro, meso and macro level perspective. Self-agency is undermined by factors including immigration policies and sociocultural perspectives that can lead to under-resourced and judgemental care, other intersectional factors can also lead to some individuals being more vulnerable to violence and harm. CONCLUSION: Implications from this work include strategies that emphasise woman-centred care, staff training and meaningful organisational change to optimise positive health and wellbeing.

Investigating the role of women's education status and empowerment on accessing skilled birth attendance in Bangladesh: A structural equation modelling approach.

BACKGROUND: The objective of this study was to investigate the associations between women's education and access to skilled birth attendant (SBA) services mediated by factors of women's empowerment and sociodemographic characteristics using a path analysis through a structural equation (SEM) modelling approach. METHODS: A sample of 4946 mothers from the most recent Bangladesh Demographic and Health Survey of 2017-18 was used in the SEM analysis. Accessing SBA service at childbirth was operationalized as utilizing SBA during last childbirth. After extracting the relevant variables and cleaning the original survey data, a subsample of 4,946 women were eligible for analysis in the current study. RESULTS: The SEM model revealed strong evidence of direct, indirect, and mediating effects of both education and empowerment of women in accessing SBA services. Educated women have more autonomy in decision making and are less susceptible to family violence and consequently are more likely to access SBA services during childbirth (ß = 0.094, p < 0.001). In addition, age at first marriage, media exposure, husband's education, healthcare accessibility, decision marking, and household wealth index mediated the relationship between education and SBA service use. CONCLUSION: Bangladesh, a country that needs to improve several societal and health indices to achieve the Sustainable Development Goals, need to prioritize women's education to increase accessibility to maternal healthcare services. Health education and mass-media-driven awareness may be potential interventions for LMICs to increase SBA coverage.

Shared decision-making in maternity care in Saudi Arabia: A cross-sectional study.

BACKGROUND: Shared decision-making (SDM) in maternity care involves women actively in decisions, thereby reducing decisional conflicts and enhancing satisfaction with care. AIM: To investigate SDM and the factors associated with it, and its correlation with respect in maternity care in Saudi Arabia. METHODS: A comprehensive, nationwide online questionnaire-based study was conducted between January to May 2023, involving women aged 18 years and above who were either pregnant or had experienced pregnancy/childbirth in the past 12 months. The Mothers' Autonomy in Decision-Making (MADM) scale and the Mothers of Respect Index (MORi) were used. Low to very low SDM was defined as a score of ≤ 24 on the MADM and low to very low respected was defined as a score of ≤ 49 on the MORi. RESULTS: A total of 505 women completed the survey. Low to very low SDM was reported by 137 (34.1 %, 95 confidence interval (CI), 29.6 % - 38.9 %) women. Factors significantly associated with low to very low SDM included seeing different obstetricians of different gender at each visit (adjusted odds ratio (AOR) 2.0, 95 % CI, 1.0 - 3.9), not meeting the same obstetrician throughout the pregnancy (AOR 2.6, 95 % CI, 1.2 - 5.6) and having an instrumental vaginal birth (AOR 6.67, 95 % CI, 1.6 - 28.1). There was a positive association between low to very SDM and feeling of low to very low respect ((χ2 = 83.8173, p < 0.001). CONCLUSION: More than one-third of women experienced low to very low SDM in maternity care. This should alert healthcare providers to the importance of continuity of care in Saudi Arabia.

Effect of health education provided to couples on maternal knowledge, attitude and use of maternity waiting homes in rural Ethiopia: A cluster-randomized trial.

BACKGROUND: Maternity waiting home (MWH) has been advocated as an approach to improve women's access to obstetric services in low-resource settings; however, its use remains low. This study investigated the effectiveness of couple-based health education on maternal knowledge, attitudes, and use of MWHs in rural Ethiopia. METHODS: A total of 320 couples from 16 clusters were allocated to the intervention and control groups using restricted randomization. Participants in the intervention group received group health education, home visits, and information flyers along with usual care, whereas those in the control group received usual care. Statistical differences were estimated using the chi-squared test. The impact of the intervention was evaluated using generalized linear regression and difference-in-differences models. RESULTS: Baseline and endline data were collected from the 320 couples. The intervention increased knowledge by 37.5 % (95 % CI: 32.2 % - 42.8 %), attitude by 33.8 % (95 % CI: 28.8 %-39.2 %), and utilization of MWH by 32.9 % (95 % CI: 27.9 %-38.2 %) among women. In addition, compared to those in the control group, women in the intervention group were almost six times more likely to have increased knowledge of MWH (AOR 5.74, 95 % CI: 3.51-9.38), four times more likely to have improved attitudes of MWH (AOR 4.45, 95 % CI: 2.78 -7.13), and four times more likely to stay at MWH (AOR 4.45, 95 % CI: 2.78 -7.12). CONCLUSION: Providing health education to couples can improve maternal knowledge, attitudes, and the use of MWHs. Policymakers and healthcare cadres can use the current intervention strategy to enhance maternal health services, particularly MWHs, in rural Ethiopia.

Strengthening open disclosure in maternity services in the English NHS: the DISCERN realist evaluation study.

Background: There is a policy drive in NHS maternity services to improve open disclosure with harmed families and limited information on how better practice can be achieved. Objectives: To identify critical factors for improving open disclosure from the perspectives of families, doctors, midwives and services and to produce actionable evidence for service improvement. Design: A three-phased, qualitative study using realist methodology. Phase 1: two literature reviews: scoping review of post-2013 NHS policy and realist synthesis of initial programme theories for improvement; an interview study with national stakeholders in NHS maternity safety and families. Phase 2: in-depth ethnographic case studies within three NHS maternity services in England. Phase 3: interpretive forums with study participants. A patient and public involvement strategy underpinned all study phases. Setting: National recruitment (study phases 1 and 3); three English maternity services (study phase 2). Participants: We completed n = 142 interviews, including 27 with families; 93 hours of ethnographic observations, including 52 service and family meetings over 9 months; and interpretive forums with approximately 69 people, including 11 families. Results: The policy review identified a shift from viewing injured families as passive recipients to active contributors of post-incident learning, but a lack of actionable guidance for improving family involvement. The realist synthesis found weak evidence of the effectiveness of open disclosure interventions in the international maternity literature, but some improvements with organisation-wide interventions. Recent evidence was predominantly from the United Kingdom. The research identified and explored five key mechanisms for open disclosure: meaningful acknowledgement of harm; involvement of those affected in reviews/investigations; support for families' own sense-making; psychological safely of skilled clinicians (doctors and midwives); and knowing that improvements to care have happened. The need for each family to make sense of the incident in their own terms is noted. The selective initiatives of some clinicians to be more open with some families is identified. The challenges of an adversarial medicolegal landscape and limited support for meeting incentivised targets is evidenced. Limitations: Research was conducted after the pandemic, with exceptional pressure on services. Case-study ethnography was of three higher performing services: generalisation from case-study findings is limited. No observations of Health Safety Investigation Branch investigations were possible without researcher access. Family recruitment did not reflect population diversity with limited representation of non-white families, families with disabilities and other socially marginalised groups and disadvantaged groups. Conclusions: We identify the need for service-wide systems to ensure that injured families are positioned at the centre of post-incident events, ensure appropriate training and post-incident care of clinicians, and foster ongoing engagement with families beyond the individual efforts made by some clinicians for some families. The need for legislative revisions to promote openness with families across NHS organisations, and wider changes in organisational family engagement practices, is indicated. Examination of how far the study's findings apply to different English maternity services, and a wider rethinking of how family diversity can be encouraged in maternity services research. Study registration: This study is registered as PROSPERO CRD42020164061. The study has been assessed following RAMESES realist guidelines. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research Programme (NIHR award ref: 17/99/85) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 22. See the NIHR Funding and Awards website for further award information.

This study describes the experiences of families and healthcare professionals involved in incidents in NHS maternity care. The incidents caused harm-like injury or death to the baby or woman. We wanted to know whether services involved families in investigations and reviews and how this was done, what worked well, what did not work well and why. To do this, we first looked at what had already been written about 'open disclosure' or OD. Open disclosure is when the NHS admits to families that the care they provided has directly caused harm. After open disclosure occurs, families should be involved in making sure that the NHS learns so it can deliver better care for families in the future. In our reading, we found that families want a meaningful apology, to be involved in reviews or investigations, to know what happened to their loved one, to be cared for by knowledgeable doctors and midwives who are supported in providing open disclosure and to know things have changed because of what happened. Recommendations for involving families in open disclosure have improved, but there is still work to be done to make sure families are involved. Next, we talked to over 100 healthcare professionals involved in government policy for open disclosure in maternity services and 27 families who experienced harm. We spent 9 months observing the work of clinicians at three maternity services to watch open disclosure. We shared early findings with families, doctors, midwives and managers, and included their views. We found that services need to provide dedicated time, education and emotional support for staff who provide open disclosure. Services need to ensure that families have ongoing support and better communication about incidents. Finally, families must be involved in the review process if they want to be with their experiences reflected in reports and kept informed of ongoing improvements.

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.

The maternal and newborn health eCohort to track longitudinal care quality: study protocol and survey development.

The MNH eCohort was developed to fill gaps in maternal and newborn health (MNH) care quality measurement. In this paper, we describe the survey development process, recruitment strategy, data collection procedures, survey content and plans for analysis of the data generated by the study. We also compare the survey content to that of existing multi-country tools on MNH care quality. The eCohort is a longitudinal mixed-mode (in-person and phone) survey that will recruit women in health facilities at their first antenatal care (ANC) visit. Women will be followed via phone survey until 10-12 weeks postpartum. User-reported information will be complemented with data from physical health assessments at baseline and endline, extraction from MNH cards, and a brief facility survey. The final MNH eCohort instrument is centered around six key domains of high-quality health systems including competent care (content of ANC, delivery, and postnatal care for the mother and newborn), competent systems (prevention and detection, timely care, continuity, integration), user experience, health outcomes, confidence in the health system, and economic outcomes. The eCohort combines the maternal and newborn experience and, due to its longitudinal nature, will allow for quality assessment according to specific risks that evolve throughout the pregnancy and postpartum period. Detailed information on medical and obstetric history and current health status of respondents and newborns will allow us to determine whether women and newborns at risk are receiving needed care. The MNH eCohort will answer novel questions to guide health system improvements and to fill data gaps in implementing countries.

Added knowledge: The MNH eCohort will answer novel questions and provide information on undermeasured dimensions of MNH care quality included continuity of care, system competence, and user experience.Global health impact for policy and action: The data generated will inform policy makers to develop strategies to improve adherence to standards of care and quality for mothers and newborns.

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.

"Letting themselves go during care" - exploring patient autonomy during co-designed intrapartum care in a Beninese maternity ward.

BACKGROUND: Patient autonomy is central to the provision of respectful maternity care. Enabling women to make decisions free of discrimination and coercion, and respecting their privacy and confidentiality can contribute to positive childbirth experiences. This study aimed to deepen the understanding of how patient autonomy is reflected through social practices during intrapartum care in Benin. METHODS: Semi-structured interviews with women and midwives, a focus-group discussion with women's birth companions, and non-participant observations in the delivery room were conducted within the frame of the ALERT research project. This study analysed data through a reflexive thematic analysis approach, in line with Braun and Clarke. RESULTS: We identified two themes and five sub-themes. Patient autonomy was systemically suppressed over the course of birth as a result of the conditions of care provision, various forms of coercion and women's surrendering of their autonomy. Women used other care practices, such as alternative medicine and spiritual care, to counteract experiences of limited autonomy during intrapartum care. CONCLUSIONS: The results pointed to women's experiences of limited patient autonomy and their use of alternative and spiritual care practices to reclaim their patient autonomy. This study identified spiritual autonomy as an emergent dimension of patient autonomy. Increasing women's autonomy during childbirth may improve their experiences of childbirth, and the provision of quality and respectful maternity care.

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.