Exploring and prioritising strategies for improving uptake of postnatal care services in Thyolo, Malawi: A qualitative study.

Although postnatal care services form a critical component of the cascade of care in maternal, newborn, and child health the uptake of these services has remained low worldwide. This study explored and prioritised the strategies for optimising the uptake of postnatal care (PNC) services in Malawi. A qualitative descriptive study followed by nominal group techniques was conducted at three health facilities in Malawi from July to December 2020 and in October 2021. We conducted focus group discussions among postnatal mothers, fathers, healthcare workers, elderly women, and grandmothers. We conducted in-depth interviews with midwives and key health managers. Nominal group techniques were used to prioritise the main strategies for the provision of PNC. The demand strategies include appointment date reminders, provision of free health passport books, community awareness campaigns, and involvement of men in the services. The supply strategies included training health providers, improving clinic operations: task-shifting and hours of operation, having infrastructure for the services, and linkage to other services. Having services delivered near end-user residences was a crosscutting strategy. Refresher training and improvement in the clinic operations especially on hours of operation, appointment date reminders, and linkage to care were the prioritised strategies. There is a need to use acceptable and contextualised strategies to optimise the uptake and delivery of postnatal care services. Educating the healthcare workers and the community on postnatal services is key to increasing the demand and supply of the services.

Implementing maternal and newborn health quality of care standards in healthcare facilities to improve the adoption of respectful maternity care in Bangladesh, Ghana and Tanzania: a controlled before and after study.

INTRODUCTION: Many women worldwide cannot access respectful maternity care (RMC). We assessed the effect of implementing maternal and newborn health (MNH) quality of care standards on RMC measures. METHODS: We used a facility-based controlled before and after design in 43 healthcare facilities in Bangladesh, Ghana and Tanzania. Interviews with women and health workers and observations of labour and childbirth were used for data collection. We estimated difference-in-differences to compare changes in RMC measures over time between groups. RESULTS: 1827 women and 818 health workers were interviewed, and 1512 observations were performed. In Bangladesh, MNH quality of care standards reduced physical abuse (DiD -5.2;-9.0 to -1.4). The standards increased RMC training (DiD 59.0; 33.4 to 84.6) and the availability of policies and procedures for both addressing patient concerns (DiD 46.0; 4.7 to 87.4) and identifying/reporting abuse (DiD 45.9; 19.9 to 71.8). The control facilities showed greater improvements in communicating the delivery plan (DiD -33.8; -62.9 to -4.6). Other measures improved in both groups, except for satisfaction with hygiene. In Ghana, the intervention improved women's experiences. Providers allowed women to ask questions and express concerns (DiD 37.5; 5.9 to 69.0), considered concerns (DiD 14.9; 4.9 to 24.9), reduced verbal abuse (DiD -8.0; -12.1 to -3.8) and physical abuse (DiD -5.2; -11.4 to -0.9). More women reported they would choose the facility for another delivery (DiD 17.5; 5.5 to 29.4). In Tanzania, women in the intervention facilities reported improvements in privacy (DiD 24.2; 0.2 to 48.3). No other significant differences were observed due to improvements in both groups. CONCLUSION: Institutionalising care standards and creating an enabling environment for quality MNH care is feasible in low and middle-income countries and may facilitate the adoption of RMC.

In uncharted territory "together each achieves more": a United Nations interagency collaboration for continuity of maternal and newborn health services during the coronavirus pandemic in the Eastern and Southern Africa region.

The frangible collaboration between three United Nations agencies (UNICEF, UNFPA and WHO) in the Eastern and Southern Africa Region was strengthened by the outbreak of the coronavirus pandemic. The aim was to combine existing resources and expertise to support countries to respond to the pandemic more effectively and efficiently regarding the provision of maternal and newborn health services. Three kinds of activities were conducted: 15 webinars on a variety of topics and issues impacted by the pandemic; virtual training on maternal and perinatal death surveillance and response as well as on quality improvement; and the development of online e-learning modules for continuous professional development. Key dimensions of the collaboration included: a common vision; commitment to the process; dialogue; building relationships and trust; communication and information sharing; sharing of technical and financial resources and expertise; mobilization of additional resources; celebration of intermediate outcomes; facilitative leadership; and institutional design. Start-up lessons revolved around shared risk taking, while retaining agency autonomy. Collaboration lessons included forming a "united front", harnessing technology to accelerate results, and mitigating adverse structural and contextual factors. There are widespread perceptions that collaborative initiatives tend to yield minimum results in terms of increased efficiency or effectiveness. This particular collaborative effort demonstrated elements of feasibility, value addition, synergy, cost effectiveness and demonstrable results where UN agencies delivered as one. The emergency in healthcare as a ripple effect of the coronavirus pandemic has caused a rethink of collaboration models and levels of engagement.

Perspectives of stakeholders regarding the value of maternal and newborn health interventions and practices supported by UNICEF and other partners in the West Nile region of Uganda: a qualitative study.

INTRODUCTION: Uganda has high maternal, neonatal, and under-five mortality rates. This study documents stakeholder perspectives on best practices in a maternal and newborn health (MNH) quality-improvement programme implemented in the West Nile region of Uganda to improve delivery and utilisation of MNH services. METHODS: This exploratory cross-sectional qualitative study, conducted at the end of 2021, captured the perspectives of stakeholders representing the different levels of the healthcare system. Data were collected in four districts through: interviews with key informants working at all levels of the health system; focus group discussions with parents and caretakers and with community health workers; and interviews with individual community members whose lives had been impacted by the MNH programme. The initial content analysis was followed by a deductive synthesis pitched according to the different levels of the health system and the health-systems building blocks. RESULTS: The findings are summarised according to the health-systems building blocks and an account is given of three of the interventions most valued by participants: (1) data use for evidence-based decision making (with regard to human resources, essential reproductive health commodities, and financing); (2) establishment of special newborn care units and high-dependency maternity units at district hospitals and training of the health workforce (also with reference to other infrastructural improvements such as the provision of water, sanitation and hygiene facilities at health facilities); and (3) community referral of pregnant women through a commercial motorcycle voucher referral system. CONCLUSION: The MNH programme in the West Nile region adopted a holistic and system-wide approach to addressing the key bottlenecks in the planning, delivery, and monitoring of quality MNH services. There was general stakeholder appreciation across the board that the interventions had the potential to improve quality of care and newborn and maternal health outcomes. However, as the funding was largely donor-driven, questions about government ownership and sustainability in the context of limited resources remain.

Uptake of, barriers and enablers to the utilization of postnatal care services in Thyolo, Malawi.

BACKGROUND: Postnatal care (PNC) ensures early assessments for danger signs during the postpartum period and is to be provided within 24 h of birth, 48-72 h, 7-14 days, and six weeks after birth. This study assessed the uptake of and the barriers and facilitators to receiving PNC care among mothers and babies. METHODS: A concurrent mixed-method study employing a retrospective register review and a qualitative descriptive study was conducted in Thyolo from July to December 2020. Postnatal registers of 2019 were reviewed to estimate the proportion of mothers and newborns that received PNC respectively. Focus Group Discussions (FGDs) among postnatal mothers, men, health care workers, and elderly women and in-depth interviews with midwives, and key health care workers were conducted to explore the barriers and enablers to PNC. Observations of the services that mothers and babies received within 24 h of birth, at 48-72 h, 7-14 days, and six weeks after birth were conducted. Descriptive statistics were tabulated for the quantitative data using Stata while the qualitative data were managed using NVivo and analysed following a thematic approach. RESULTS: The uptake of PNC services was at 90.5%, 30.2%, and 6.1% among women and 96.5%, 78.8%, and 13.7% among babies within 48 h of birth, 3 to 7 and 8 to 42 days respectively. The barriers to PNC services included the absence of a baby or mother, limited understanding of PNC services, lack of male involvement, and economic challenges. Cultural and religious beliefs, advice from community members, community activities, distance, lack of resources, and poor attitude of health care workers also impeded the utilisation of PNC services. The enablers included the mother's level of education, awareness of the services, economic resources, community-based health support, adequacy and attitude of health workers, seeking treatment for other conditions, and other clinic activities. CONCLUSION: Optimisation of uptake and utilization of PNC services for mothers and neonates will require the involvement of all stakeholders. The success of PNC services lies in the communities, health services, and mothers understanding the relevance, time points, and services that need to be delivered to create demand for the services. There is a need to assess the contextual factors for a better response in improving the uptake of PNC services and in turn inform the development of strategies for optimizing the uptake of PNC services.

Institutionalising maternal and newborn quality-of-care standards in Bangladesh, Ghana and Tanzania: a quasi-experimental study.

INTRODUCTION: Facility interventions to improve quality of care around childbirth are known but need to be packaged, tested and institutionalised within health systems to impact on maternal and newborn outcomes. METHODS: We conducted cross-sectional assessments at baseline (2016) and after 18 months of provider-led implementation of UNICEF/WHO's Every Mother Every Newborn Quality Improvement (EMEN-QI) standards (preceding the WHO Standards for improving quality of maternal and newborn care in health facilities). 19 hospitals and health centres (2.8M catchment population) in Bangladesh, Ghana and Tanzania were involved and 24 from adjoining districts served for 'comparison'. We interviewed 43 facility managers and 818 providers, observed 1516 client-provider interactions, reviewed 12 020 records and exit-interviewed 1826 newly delivered women. We computed a 39-criteria institutionalisation score combining clinical, patient rights and cross-cutting domains from EMEN-QI and used routine/District Health Information System V.2 data to assess the impact on perinatal and maternal mortality. RESULTS: EMEN-QI standards institutionalisation score increased from 61% to 80% during EMEN-QI implementation, exceeding 75% target. All mortality indicators showed a downward trajectory though not all reached statistical significance. Newborn case-fatality rate fell significantly by 25% in Bangladesh (RR=0·75 (95% CI=0·59 to 0·96), p=0·017) and 85% in Tanzania (RR=0.15 (95% CI=0.08 to 0.29), p<0.001), but not in Ghana. Similarly, stillbirth (RR=0.64 (95% CI=0.45 to 0.92), p<0.01) and perinatal mortality in Tanzania reduced significantly (RR=0.59 (95% CI=0.40 to 0.87), p=0.007). Institutional maternal mortality ratios generally reduced but were only significant in Ghana: 362/100 000 to 207/100 000 livebirths (RR=0.57 (95% CI=0.33 to 0.99), p=0.046). Routine mortality data from comparison facilities were limited and scarce. Systematic death audits and clinical mentorship drove these achievements but challenges still remain around human resource management and equipment maintenance systems. CONCLUSION: Institutionalisation of the UNICEF/WHO EMEN-QI standards as a package is feasible within existing health systems and may reduce mortality around childbirth. Critical gaps around sustainability must be fundamental considerations for scale-up.

Mental health and psychosocial support concerns among frontline workers within the Eastern and Southern Africa COVID-19 response.

We carried out a mental health assessment survey of frontline workers in Eastern and Southern Africa regarding COVID-19 pandemic in the region. A total of 723 people responded to the anonymous survey which was available in English, French and Portuguese. Two thirds of respondents felt overwhelmed and the remaining one third expressed fear of the pandemic. Concern about self and one´s wellbeing was associated with the feeling of being supported by one´s supervisor. Frontline workers that acknowledged supervisor support also expressed a significantly better wellbeing than others that did not receive supportive supervision. It is important to strengthen supervisors´ capacity for psychological support to their subordinates. It is also necessary to emphasise the importance of giving attention to staff mental health concerns. Supervisors should provide information on referral opportunities and encourage their staff to take advantage of them when in need of specialised services. While frontline workers have been celebrated worldwide for their efforts during the COVID-19 pandemic, reports also indicate that some of them are exposed to stigma, discrimination and even violence within their communities, at workplace and surroundings. Further studies will improve current understanding of the mental health and psychological concerns other categories of professional caregivers experienced while responding to the pandemic.

Continuity of essential health services in the context of COVID-19: the Eastern and Southern Africa Regional continuity of essential services sub-working group.

COVID-19 cases have continued to increase globally putting intense pressure on health systems, including in the East and Southern African (ESA) region, which bears the brunt of the continent´s cases, and where many health systems are already weak or overstretched. Evidence from the West Africa Ebola disease outbreak and early estimates for COVID-19 show that indirect impacts due to disruptions in access to essential health services can result in even higher mortality than that directly related to the outbreak. In March 2020, World Health Organisation (WHO) established a coordination mechanism to support ESA countries to enhance their response to COVID-19. Technical working groups were established, including a subgroup addressing continuity of essential health services. In this article, the development, activities and achievements of the subgroup over the past six months are reviewed and presented as a model for collaborative action for optimal service delivery in the context of COVID-19 and potentially, during other infectious disease outbreak responses.

Mental health problems and service gaps experienced by pregnant adolescents and young women in Sub-Saharan Africa: A systematic review.

BACKGROUND: Pregnant adolescent girls and young women (AGYW, aged 12-24 years) are at high risk for mental health problems, particularly in the Sub-Saharan African (SSA) region. METHODS: We performed a systematic review of mental health studies among pregnant AGYW in SSA published between January 1, 2007 and December 31, 2020 in PubMed, Embase, CINAHL, PsycInfo, and Global Index Medicus following PRISMA guidelines (PROSPERO: CRD42021230980). We used Bronfenbrenner's bioecological model to frame and synthesize results from included studies. FINDINGS: Our search yielded 945 articles from which 18 studies were included (N = 8 quantitative, N = 9 qualitative, N = 1 case report). The most frequently studied mental health problem was depression (N = 9 studies); the most frequently utilized measurement tool was the Edinburgh Postnatal Depression Scale (N = 3). Studies reported life course factors, individual, microsystem, exosystem, macrosystem, and chronosystem-level factors associated with mental health problems. Gaps in mental health service delivery for pregnant AGYW included lack of confidentiality, judgmental healthcare worker attitudes, and lack of services tailored to their unique needs. INTERPRETATION: Gaps remain in research and services for mental health among pregnant AGYW in SSA. Integration of mental health services within school, community, and healthcare settings that are tailored to pregnant AGYW could strengthen health systems within SSA. FUNDING: Author contributions were supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (F31HD101149 to AL) and the Fogarty International Center (K43TW010716 to MK). The funding agencies had no role in the writing of the manuscript or the decision to submit it for publication. The project itself was not funded.

A Four-Component Framework Toward Patient-Centered, Integrated Mental Healthcare in Kenya.

Background: How can we fast-track the global agenda of integrated mental healthcare in low- and middle-income countries (LMICs) such as Kenya? This is a question that has become increasingly important for individuals with lived experiences, policymakers, mental health advocates and health care providers at the local and international levels. Discussion: This narrative synthesis and perspective piece encompasses an overview of mental health care competencies, best practices and capacity building needed to fast track patient responsive services. In that vein we also review key policy developments like UHC to make a case for fast-tracking our four-step framework. Results: While there is an increasingly global impetus for integrated mental healthcare, there is a lack of clarity around what patient-responsive mental healthcare services should look like and how to measure and improve provider readiness appropriately. Here, our collaborative team of local and international experts proposes a simple four-step approach to integrating responsive mental healthcare in Kenya. Our recommended framework prioritizes a clear understanding and demonstration of multidimensional skills by the provider. The four steps are (1) provider sensitization, (2) continuous supervision, (3) continuous professional training, and (4) leadership empowerment. Conclusion: Our proposed framework can provide pointers to embracing patient-centered and provider empowerment focused quality of care improvements. Though elements of our proposed framework are well-known, it has not been sufficiently intertwined and therefore not been integrated. We think in the current times our integrated framework offers an opportunity to "building back better" mental health for all.

Mental Health Consequences for Healthcare Workers During the COVID-19 Pandemic: A Scoping Review to Draw Lessons for LMICs.

Background: The COVID-19 pandemic has had a significant impact on the mental health of healthcare workers (HCWs) particularly in low and middle-income countries (LMICs). This scoping review provides a summary of current evidence on the mental health consequences of COVID on HCWs. Methods: A scoping review was conducted searching PubMed and Embase for articles relevant to mental health conditions among HCWs during COVID-19. Relevant articles were screened and extracted to summarize key outcomes and findings. Results: A total of fifty-one studies were included in this review. Depressive symptoms, anxiety symptoms, psychological trauma, insomnia and sleep quality, workplace burnout and fatigue, and distress were the main outcomes reviewed. Most studies found a high number of symptoms endorsed for depression, anxiety, and other conditions. We found differences in symptoms by sex, age, and HCW role, with female, younger-aged, frontline workers, and non-physician workers being affected more than other subgroups. Conclusion: This review highlights the existing burden of mental health conditions reported by HCWs during COVID-19. It also demonstrates emerging disparities among affected HCW subgroups. This scoping review emphasizes the importance of generating high quality evidence and developing informed interventions for HCW mental health with a focus on LMICs.

Basic maternal health care coverage among adolescents in 22 sub-Saharan African countries with high adolescent birth rate.

BACKGROUND: In the sub-Saharan Africa region, the adolescent birth rate is the highest in the world, estimated at 100.5 births per 1000 women aged 15 to 19 years, and 2.4 times greater than the global average. This analysis examines coverage levels and gaps in basic maternal health care for adolescent mothers living in this region. METHODS: We used data from national Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) conducted between 2010 and 2016 in 22 of the sub-Saharan African Countdown to 2030 priority countries with adolescent birth rates above 100 in 2016. We analyzed 11 indicators of coverage of key services provided during the pre-pregnancy, pregnancy, delivery and postnatal period. We described the coverage level among adolescent girls aged 15-19 and women aged 20-49 for basic indicators in the continuum of care. We conducted a multilevel random effect logistic regression to quantify the association between the receipt of basic package of maternal care and woman's socio-demographic and socio-economic characteristics. RESULTS: The median coverage of the basic package of maternal care among adolescents was extremely low, at 9.3%. Adolescent mothers who were in the highest household wealth quintile (odds ratio OR = 2.44, 95% confidence interval (CI) = 2.23-2.68), living in an urban area (OR = 1.25, 95% CI = 1.18-1.33) and having secondary education (OR = 1.61, 95% CI = 1.50-1.73) had greater odds of receiving the basic package of maternal health care as compared to those in the lowest wealth quintile, living in rural areas, and with no education respectively. Adolescent girls aged 15-17 and 18-19 had respectively 26% (OR = 0.74, 95% CI = 0.67-0.82) and 9% (OR = 0.91, 95% CI = 0.84-0.98) lower odds of receiving the basic package compared to women 20-49 years old. Child brides had 12% (OR = 0.88, 95% CI = 0.84-0.93) lower odds of receiving the basic package compared to women who were married after the age of 18. CONCLUSION: Coverage of basic maternal health care for adolescent mothers is inadequate in the countries with the highest adolescent birth rates in the world. Addressing the reproductive and maternal health needs of adolescents in sub-Saharan Africa is of critical importance, especially given projections that this region will experience the highest increases in adolescent births in the coming decades.

Mental Distress and Human Rights Violations During COVID-19: A Rapid Review of the Evidence Informing Rights, Mental Health Needs, and Public Policy Around Vulnerable Populations.

Background: COVID-19 prevention and mitigation efforts were abrupt and challenging for most countries with the protracted lockdown straining socioeconomic activities. Marginalized groups and individuals are particularly vulnerable to adverse effects of the pandemic such as human rights abuses and violations which can lead to psychological distress. In this review, we focus on mental distress and disturbances that have emanated due to human rights restrictions and violations amidst the pandemic. We underscore how mental health is both directly impacted by the force of pandemic and by prevention and mitigation structures put in place to combat the disease. Methods: We conducted a review of relevant studies examining human rights violations in COVID-19 response, with a focus on vulnerable populations, and its association with mental health and psychological well-being. We searched PubMed and Embase databases for studies between December 2019 to July 2020. Three reviewers evaluated the eligibility criteria and extracted data. Results: Twenty-four studies were included in the systematic inquiry reporting on distress due to human rights violations. Unanimously, the studies found vulnerable populations to be at a high risk for mental distress. Limited mobility rights disproportionately harmed psychiatric patients, low-income individuals, and minorities who were at higher risk for self-harm and worsening mental health. Healthcare workers suffered negative mental health consequences due to stigma and lack of personal protective equipment and stigma. Other vulnerable groups such as the elderly, children, and refugees also experienced negative consequences. Conclusions: This review emphasizes the need to uphold human rights and address long term mental health needs of populations that have suffered disproportionately during the pandemic. Countries can embed a proactive psychosocial response to medical management as well as in existing prevention strategies. International human rights guidelines are useful in this direction but an emphasis should be placed on strengthening rights informed psychosocial response with specific strategies to enhance mental health in the long-term. We underscore that various fundamental human rights are interdependent and therefore undermining one leads to a poor impact on the others. We strongly recommend global efforts toward focusing both on minimizing fatalities, protecting human rights, and promoting long term mental well-being.

Midwifery retention and coverage and impact on service utilisation in Afghanistan.

OBJECTIVE: to measure the rate of and determine factors associated with community midwifery education (CME) graduate retention in public sector health care in Afghanistan. DESIGN: cross-sectional. SETTING: performed in public health facilities of 11 Afghan provinces purposively selected by geographic location and security conditions, between October 2011 and April 2012. Facilities were selected by one of two criteria: either a registered deployment site for a CME graduate or randomly selected through population-proportionate sampling. PARTICIPANTS: facility managers and midwives employed in public facilities at the time of data collection. MEASUREMENTS: three quantitative instruments were used: a facility checklist assessed staffing and service volume, and two separate questionnaires for midwives and facility managers, which measured employment duration and perceived barriers to midwife retention. FINDINGS: at 456 surveyed facilities, 570 midwives were interviewed. Overall, 61.3% (n=209/341) of CME graduates deployed in surveyed provinces were working in public sector facilities, whereas 36.8% were working at their assigned site. Facilities without midwife staff had lower average monthly volumes of antenatal care visits (14.6 (SD ± 22.7) versus 71.5 (SD ± 72.5)), family planning visits (10.4 (SD+13.9) versus 56.8 (SD+85.0)), or facility-based deliveries (0.55 (SD ± 2.2) versus 15.7 (SD ± 18.7)). Perceived reasons for leaving employment were insecurity (civil unrest/armed conflict) (46.4%), family disagreement (28.1%), increased workload without compensation (9.9%), and lack of appropriate housing (7.8%). KEY CONCLUSIONS: CME graduate retention in public sector positions was relatively low and significantly impacted by insecurity and cultural issues related to women working outside the home. IMPLICATIONS FOR PRACTICE: culturally appropriate measures are needed to attract and retain skilled female health care providers for rural public facilities in Afghanistan and similar settings. Advocacy to encourage family and community support for midwives working in rural facilities and providing amenities such as housing, education for children, and employment for the accompanying male family member are measures most likely to improve midwife retention.

Factors influencing the retention of midwives in the public sector in Afghanistan: a qualitative assessment of midwives in eight provinces.

OBJECTIVE: to examine factors that affect retention of public sector midwives throughout their career in Afghanistan. DESIGN: qualitative assessment using semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs). SETTING: health clinics in eight provinces in Afghanistan, midwifery education schools in three provinces, and stakeholder organisations in Kabul. PARTICIPANTS: purposively sampled midwifery profession stakeholders in Kabul (n=14 IDIs); purposively selected community midwifery students in Kabul (n=3 FGDs), Parwan (n=1 FGD) and Wardak (n=1 FGD) provinces (six participants per FGD); public sector midwives, health facility managers, and community health workers from randomly selected clinics in eight provinces (n=48 IDIs); midwives who had left the public sector midwifery service (n=5 IDIs). MEASUREMENTS AND FINDINGS: several factors affect a midwife throughout her career in the public sector, including her selection as a trainee, the training itself, deployment to her pre-assigned post, and working in clinics. Overall, appropriate selection is the key to ensuring deployment and retention later on in a midwife's career. Other factors that affect retention of midwives include civil security concerns in rural areas, support of family and community, salary levels, professional development opportunities and workplace support, and inefficient human resources planning in the public sector. KEY CONCLUSIONS: Factors affecting midwife retention are linked to problems within the community midwifery education (CME) programme and those reflecting the wider Afghan context. Civil insecurity and traditional attitudes towards women were major factors identified that negatively affect midwifery retention. IMPLICATIONS FOR PRACTICE: Factors such as civil insecurity and traditional attitudes towards women require a multisectoral response and innovative strategies to reduce their impact. However, factors inherent to midwife career development also impact retention and may be more readily modified.