Mobile health-delivered narrative intervention to increase cervical cancer screening among Malawian women living with HIV: A pilot randomized controlled trial.

Objective: This study aimed to develop and evaluate a mobile health (mHealth)-delivered, theory-guided, culturally tailored storytelling narrative (STN) intervention to increase cervical cancer screening among Malawian women living with human immunodeficiency virus (HIV). Methods: This study involved two phases: Phase 1: development of a theory-guided and culturally adapted STN intervention and Phase 2: a pilot randomized controlled trial was conducted. Participants were randomly assigned to one of three arms: Arm 1: tablet-based video (mHealth) with STN (n = 60); Arm 2: mHealth with a video of nonnarrative educational materials (n = 59); and Arm 3: control group with only reading nonnarrative educational materials in person (n = 60). Cervical cancer screening was measured using visual inspection with acetic acid (VIA) uptakes by self-report and health passport record review at 2 and 6 months after intervention. Results: Both arms 1 and 2 had nearly twice the rate of VIA uptakes than those in Arm 3 (51.0% and 50.0%, respectively, vs. 35.0%, P = 0.01) at 2 months follow-up, but there were no differences among groups from 2- to 6-month follow-ups. All groups demonstrated significant improvement of knowledge about risk factors, intention, and VIA uptakes. Conclusions: The findings demonstrate the preliminary effectiveness of the intervention on cervical cancer screening behavior and the feasibility of the study regarding recruitment, retention, treatment fidelity, and acceptability of the single 30-min session. The feasibility and the preliminary results of the effectiveness of the proposed study indicate scaling up the STN intervention to a larger population of women to increase cervical cancer screening uptake to prevent deaths due to cervical cancer in Malawi.

Many Cooks in the Kitchen: Iterating a Qualitative Analysis Process Across Multiple Countries, Sites, and Teams.

Establishing and proving methodological rigor has long been a challenge for qualitative researchers where quantitative methods prevail, but much published literature on qualitative analysis assumes a relatively small number of researchers working in relative proximity. This is particularly true for research conducted with a grounded theory approach. Different versions of grounded theory are commonly used, but this methodology was originally developed for a single researcher collecting and analyzing data in isolation. Although grounded theory has evolved since its development, little has been done to reconcile this approach with the changing nature and composition of international research teams. Advances in technology and an increased emphasis on transnational collaboration have facilitated a shift wherein qualitative datasets have been getting larger and the teams collecting and analyzing them more diverse and diffuse. New processes and systems are therefore required to respond to these conditions. Data for this article are drawn from the experiences of the Innovations for Choice and Autonomy (ICAN) Research Consortium. ICAN aims to understand how self-injectable contraceptives can be implemented in ways that best meet women's needs in Kenya, Uganda, Malawi, and Nigeria. We found that taking a structured approach to analysis was important for maintaining consistency and making the process more manageable across countries. However, it was equally important to allow for flexibility within this structured approach so that teams could adapt more easily to local conditions, making data collection and accompanying analysis more feasible. Meaningfully including all interested researchers in the analysis process and providing support for learning also increased rigor. However, competing priorities in a complex study made it difficult to adhere to planned timelines. We conclude with recommendations for both funders and study teams to design and conduct global health studies that ensure more equitable contributions to analysis while remaining logistically feasible and methodologically sound.

Effectiveness of a training intervention in increasing the use of misoprostol in postabortion care in Malawi: a quasi-experimental study.

OBJECTIVES: The study was conducted to determine effectiveness of a training intervention in increasing use of misoprostol in management of incomplete abortions. DESIGN: A quasi-experimental study with training intervention on use of misoprostol in treatment of incomplete abortion. SETTING: Five secondary-level public hospitals in Malawi, one in urban and four in semiurban settings. Three intervention and two control sites. PARTICIPANTS: Records of women treated for first-trimester incomplete abortion from March to May 2020 (baseline) and April to June 2021 (endline). Clinical data were collected from 865 records, 421 before and 444 after the intervention in all study sites. INTERVENTION: Three-hour theoretical training sessions for 81 healthcare workers were conducted in July 2020 at the three intervention sites. PRIMARY AND SECONDARY OUTCOME MEASURES: Proportion of women with incomplete abortion treated with misoprostol before and after the intervention. The proportion of women treated with sharp curettage at the study sites. RESULTS: At the intervention sites, there was a significant increase in use of misoprostol from 22.8% (95% CI 17.9% to 28.0%) to 35.9% (95% CI 30.5% to 41.6%) and significant reduction in use of sharp curettage from 48.1% (95% CI 41.9% to 54.3%) to 39.4% (95% CI 35.3% to 42.6%) p<0.01 at baseline and endline, respectively. The use of misoprostol was significantly higher at the intervention sites with OR of 5.02 (95% CI 1.7 to 14.7) p<0.05 compared with control sites at the endline in multivariable models, and there was a difference in the difference of 14.4% ((95% CI 10.4% to 18.2%) p<0.001) between the intervention and control sites after the intervention. CONCLUSIONS: A training intervention effectively increased the use of misoprostol in the treatment of incomplete abortions. Increasing misoprostol use will make treatment of incomplete abortion cheaper, easier and more easily accessible. Making quality postabortion care accessible to more women may reduce maternal morbidity and mortality. Further training interventions are recommended.

Experiences of Using Misoprostol in the Management of Incomplete Abortions: A Voice of Healthcare Workers in Central Malawi.

Complications after abortion are a major cause of maternal death. Incomplete abortions are common and require treatment with surgical or medical uterine evacuation. Even though misoprostol is a cheaper and safer option, it is rarely used in Malawi. To improve services, an intervention was performed to increase the use of misoprostol in post-abortion care. This study explored healthcare providers' perceptions and experiences with misoprostol in the Malawian setting and their role in achieving effective implementation of the drug. A descriptive phenomenological study was conducted in three hospitals in central Malawi. Focus group discussions were conducted with healthcare workers in centres where the training intervention was offered. Participants were purposefully sampled, and thematic analysis was done. Most of the healthcare workers were positive about the use of misoprostol, knew how to use it and were confident in doing so. The staff preferred misoprostol to surgical treatment because it was perceived safe, effective, easy to use, cost-effective, had few complications, decreased hospital congestion, reduced workload, and saved time. Additionally, misoprostol was administered by nurses/midwives, and not just physicians, thus enhancing task-shifting. The results showed acceptability of misoprostol in post-abortion care among healthcare workers in central Malawi, and further implementation of the drug is recommended.

Working lives of maternity healthcare workers in Malawi: an ethnography to identify ways to improve care.

BACKGROUND: Maternal mortality in East Africa is high with a maternal mortality rate of 428 per 100,000 live births. Malawi, whilst comparing favourably to East Africa as a whole, continues to have a high maternal mortality rate (349 per 100,000 live births) despite it being reduced by 53% since 2000. To make further improvements in maternal healthcare, initiatives must be carefully targeted and evaluated to achieve maximum influence. The Malawian Government is committed to improving maternal health; however, to achieve this goal, the quality of care must be high. Furthermore, such a goal requires enough staff with appropriate training. There are not enough midwives in Malawi; therefore, focusing on staff working lives has the potential to improve care and retain staff within the system. OBJECTIVE: This study aimed to identify ways in which working lives of maternity healthcare workers could be enhanced to improve clinical care. STUDY DESIGN: We conducted a 1-year ethnographic study of 3 district-level hospitals in Malawi. Data were collected through observations and discussions with staff and analyzed iteratively. The ethnography focused on the interrelationships among staff as these relationships seemed most important to working lives. The field jottings were transcribed into electronic documents and analyzed using NVivo. The findings were discussed and developed with the research team, participants, and other researchers and healthcare workers in Malawi. To understand the data, we developed a conceptual model, "the social order of the hospital," using Bourdieu's work on political sociology. The social order was composed of the social structure of the hospital (hierarchy), rules of the hospital (how staff in different staff groups behaved), and precedent (following the example of those before them). RESULTS: We used the social order to consider the different core areas that emerged from the data: processes, clinical care, relationships, and context. The Malawian system is underresourced with staff unable to provide high-quality care because of the lack of infrastructure and equipment. However, some processes hinder them on national and local level, for example staff rotations and poorly managed processes for labeling drugs. The staff are aware of the clinical care they should provide; however, they sometimes do not provide such care because they are working with the predefined system and they do not want to disrupt it. Within all of this, there are hierarchical relationships and a desire to move to the next level of the system to ensure a better life with more benefits and less direct clinical work. These elements interact to keep care at its most basic as disruption to the "usual" way of doing things is challenging and creates more work. CONCLUSION: To improve the working lives of the Malawian maternity staff, it is necessary to focus on improving the working culture, relationships, and environment. This may help the next generation of Malawian maternity staff to be happier at work and to better provide respectful, comprehensive, high-quality care to women.

Use of mHealth tools to register birth outcomes in low-income and middle-income countries: a scoping review.

OBJECTIVE: Accurate reporting of birth outcomes in low-income and middle-income countries (LMICs) is essential. Mobile health (mHealth) tools have been proposed as a replacement for conventional paper-based registers. mHealth could provide timely data for individual facilities and health departments, as well as capture deliveries outside facilities. This scoping review evaluates which mHealth tools have been reported to birth outcomes in the delivering room in LMICs and documents their reported advantages and drawbacks. DESIGN: A scoping review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Joanna Briggs Institute guidelines for scoping reviews and the mHealth evidence reporting and assessment checklist for evaluating mHealth interventions. DATA SOURCES: PubMed, CINAHL and Global Health were searched for records until 3 February 2022 with no earliest date limit. ELIGIBILITY CRITERIA: Studies were included where healthcare workers used mHealth tools in LMICs to record birth outcomes. Exclusion criteria included mHealth not being used at the point of delivery, non-peer reviewed literature and studies not written in English. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers screened studies and extracted data. Common themes among studies were identified. RESULTS: 640 records were screened, 21 of which met the inclusion criteria, describing 15 different mHealth tools. We identified six themes: (1) digital tools for labour monitoring (8 studies); (2) digital data collection of specific birth outcomes (3 studies); (3) digital technologies used in community settings (6 studies); (4) attitudes of healthcare workers (10 studies); (5) paper versus electronic data collection (3 studies) and (6) infrastructure, interoperability and sustainability (8 studies). CONCLUSION: Several mHealth technologies are reported to have the capability to record birth outcomes at delivery, but none were identified that were designed solely for that purpose. Use of digital delivery registers appears feasible and acceptable to healthcare workers, but definitive evaluations are lacking. Further assessment of the sustainability of technologies and their ability to integrate with existing health information systems is needed.

Systematic review and narrative synthesis of the impact of Appreciative Inquiry in healthcare.

BACKGROUND: Appreciative Inquiry is a motivational, organisational change intervention, which can be used to improve the quality and safety of healthcare. It encourages organisations to focus on the positive and investigate the best of 'what is' before thinking of 'what might be', deciding 'what should be' and experiencing 'what can be'. Its effects in healthcare are poorly understood. This review seeks to evaluate whether Appreciative Inquiry can improve healthcare. METHODS: Major electronic databases and grey literature were searched. Two authors identified reports of Appreciative Inquiry in clinical settings by screening study titles, abstracts and full texts. Data extraction, in duplicate, grouped outcomes into an adapted Kirkpatrick model: participant reaction, attitudes, knowledge/skills, behaviour change, organisational change and patient outcomes. RESULTS: We included 33 studies. One randomised controlled trial, 9 controlled observational studies, 4 qualitative studies and 19 non-controlled observational reports. Study quality was generally poor, with most having significant risk of bias. Studies report that Appreciative Inquiry impacts outcomes at all Kirkpatrick levels. Participant reaction was positive in the 16 studies reporting it. Attitudes changed in the seventeen studies that reported them. Knowledge/skills changed in the 14 studies that reported it, although in one it was not universal. Behaviour change occurred in 12 of the 13 studies reporting it. Organisational change occurred in all 23 studies that reported it. Patient outcomes were reported in eight studies, six of which reported positive changes and two of which showed no change. CONCLUSION: There is minimal empirical evidence to support the effectiveness of Appreciative Inquiry in improving healthcare. However, the qualitative and observational evidence suggests that Appreciative Inquiry may have a positive impact on clinical care, leading to improved patient and organisational outcomes. It is, therefore, worthy of consideration when trying to deliver improvements in care. However, high-quality studies are needed to prove its effects. PROSPERO REGISTRATION NUMBER: CRD42015014485.

Research priorities in maternal and neonatal health in Africa: results using the Child Health and Nutrition Research Initiative method involving over 900 experts across the continent.

Background: Africa will miss the maternal and neonatal health (MNH) Sustainable Development Goals (SDGs) targets if the current trajectory is followed. The African Academy of Sciences has formed an expert maternal and newborn health group to discuss actions to improve MNH SDG targets. The team, among other recommendations, chose to implement an MNH research prioritization exercise for Africa covering four grand challenge areas. Methods: The team used the Child Health and Nutrition Research Initiative (CHNRI) research prioritization method to identify research priorities in maternal and newborn health in Africa. From 609 research options, a ranking of the top 46 research questions was achieved. Research priority scores and agreement statistics were calculated, with sub-analysis possible for the regions of East Africa, West Africa and those living out of the continent.  Results: The top research priorities generally fell into (i) improving identification of high-risk mothers and newborns, or diagnosis of high-risk conditions in mothers and newborns to improve health outcomes; (ii) improving access to treatment through improving incentives to attract and retain skilled health workers in remote, rural areas, improving emergency transport, and assessing health systems' readiness; and (iii) improving uptake of proven existing interventions such as Kangaroo Mother Care. Conclusions: The research priorities emphasized building interventions that improved access to quality healthcare in the lowest possible units of the provision of MNH interventions. The lists prioritized participation of communities in delivering MNH interventions. The current burden of disease from MNCH in Africa aligns well with the list of priorities listed from this exercise but provides extra insights into current needs by African practitioners. The MNCH Africa expert group believes that the recommendations from this work should be implemented by multisectoral teams as soon as possible to provide adequate lead time for results of the succeeding programmes to be seen before 2030.

Assessing the impact of a motivational intervention to improve the working lives of maternity healthcare workers: a quantitative and qualitative evaluation of a feasibility study in Malawi.

BACKGROUND: Globally too many mothers and babies die during childbirth; 98% of maternal deaths are avoidable. Skilled clinicians can reduce these deaths; however, there is a world-wide shortage of maternity healthcare workers. Malawi has enough to deliver 20% of its maternity care. A motivating work environment is important for healthcare worker retention. To inform a future trial, we aimed to assess the feasibility of implementing a motivational intervention (Appreciative Inquiry) to improve the working lives of maternity healthcare workers and patient satisfaction in Malawi. METHODS: Three government hospitals participated over 1 year. Its effectiveness was assessed through: a monthly longitudinal survey of working life using psychometrically validated instruments (basic psychological needs, job satisfaction and work-related quality of life); a before and after questionnaire of patient satisfaction using a patient satisfaction tool validated in low-income settings with a maximum score of 80; and a qualitative template analysis encompassing ethnographic data, semi-structured interviews and focus groups with staff. RESULTS: The intervention was attended by all 145 eligible staff, who also participated in the longitudinal study. The general trend was an increase in the scores for each scale except for the basic psychological needs score in one site. Only one site demonstrated strong evidence for the intervention working in the work-related quality of life scales. Pre-intervention, 162 postnatal women completed the questionnaire; post-intervention, 191 postnatal women participated. Patient satisfaction rose in all three sites; referral hospital 4.41 rise (95% CI 1.89 to 6.95), district hospital 10.22 (95% CI 7.38 to 13.07) and community hospital 13.02 (95% CI 10.48 to 15.57). The qualitative data revealed that staff felt happier, that their skills (especially communication) had improved, behaviour had changed and systems had developed. CONCLUSIONS: We have shown that it is possible to implement Appreciative Inquiry in government facilities in Malawi, which has the potential to change the way staff work and improve patient satisfaction. The mixed methods approach revealed important findings including the importance of staff relationships. We have identified clear implementation elements that will be important to measure in a future trial such as implementation fidelity and inter-personal relationship factors.

Determinants of maternal near-miss cases at two selected central hospitals in Malawi.

Background: Maternal near-miss cases occur in larger numbers than maternal deaths hence they require comprehensive analysis when studied. However, there is scarcity of information on determinants of maternal near-miss cases in Malawi. Therefore, this study aimed at establishing the determinants of maternal near-miss cases at two selected central hospitals in Malawi. Methods: This was a case control study that utilized a quantitative approach. A random sample of 458 case files comprising maternal near-miss cases (161) and non-cases (297) was drawn using a ratio of 1:1.8. Data were analyzed using Stata 14 to generate descriptive statistics, Chi Square values to describe the data and determine associations among variables and logistic regression was conducted to determine the determinants of maternal near-miss. Results: We found significant differences between demographic characteristics (marital status, occupation, admission mode, means of transport and age) of maternal near-miss cases and the non-cases (P<0.05). Age and mode of birth were found to be significantly associated (P<0. 05) with maternal near-miss. Women aged 31-35 years were 3.14 times more likely to experience maternal near-miss [OR=3.14, 95% CI: 1.09, 9.02, p=0.03] compared to those aged less than 20 years. Furthermore, emergency caesarean [OR=4.08, 95% CI: 2.34, 7.09, p=0.001] and laparotomy for uterine rupture [OR=83.49, 95% CI: 10.49, 664.55, P=0.001] were significantly associated with maternal near-miss. Conclusion: Among pregnant women, health workers need to pay close attention to factors such as age and mode of birth for them to implement targeted maternal health services in order to reduce incidence of maternal near-miss cases.

Harnessing the Power of Networks of Care for Universal Health Coverage.

On the global health agenda, Universal Health Coverage has been displaced by the COVID-19 pandemic while disparities in COVID-19 outcomes have exposed stark gaps in quality, access, equity, and financial risk protection. These disparities highlight the importance of the core goals of Universal Health Coverage and the need for innovative approaches to working toward them. The newly codified concept of "Networks of Care" offers a promising option for implementation. The articles in this special issue present the Networks of Care lexicon and framework and demonstrate the development of leadership, responsibility, intra- and inter-facility cooperation, and dynamic cycles of quality improvement. These elements are associated with better access to services and better health outcomes, the ultimate goals of Universal Health Coverage. Increases in poverty, food insecurity, and deleterious impact on the status of women secondary to the COVID-19 pandemic add urgency to Universal Health Coverage, while the economic impact of pandemic mitigation may reduce availability of resources for years to come. The need for Universal Health Coverage and efficiency and flexibility in health spending, including the ability to contract directly, has become even more important. Countries where Universal Health Coverage efforts have yet to carry through to provision of good quality, accessible and equitable service delivery could potentially benefit from concurrent Networks of Care implementation. Documentation of Networks of Care in the context of Universal Health Coverage should be prioritized to understand how Networks of Care can be used to help realize the goals of Universal Health Coverage around the world.

Seeing the Forest for the Trees: A Set of Descriptive Case Studies Presented with the Networks of Care Framework.

Durable solutions for daunting problems in global health can be elusive. The global health literature tends to present aggregated data and highlight clinical outcomes but fails to describe the systems that buttress the interventions. The common idiom about "missing the forest for the trees" is apropos: by focusing on individual examples, we may miss the bigger picture. How implementation of policies and innovations plays out on the front lines of service delivery often goes uncommunicated. The Networks of Care scoping study takes a different approach, looking at diverse programs to seek out common patterns. Using the four domains of the Networks of Care framework to structure descriptions of six operational programs reveals commonalities in their designs and shows the utility of the framework's components. The commonalities increase our conviction that the framework can be used as a practical approach to strengthen service-level health systems. The case studies are followed by a commentary about the potential synergy of Networks of Care with Universal Health Coverage efforts, to deliver on the core promises to increase access and quality of care for all, especially the persistently underserved. These case studies help define a practical toolkit to promote enduring positive changes, forging a path for the Networks of Care framework to move anecdotes of individual successes to health policy and broader implementation, enabling global health practitioners at all levels to keep the big picture in focus while working toward ensuring healthy lives and well-being for all.

Developing a Common Understanding of Networks of Care through a Scoping Study.

The phrase "Networks of Care" seems familiar but remains poorly defined. A health system that exemplifies effective Networks of Care (NOC) purposefully and effectively interconnects service delivery touch points within a catchment area to fill critical service gaps and create continuity in patient care. To more fully elaborate the concept of Networks of Care, we conducted a multi-method scoping study that included a literature review, stakeholder interviews, and descriptive case studies from five low- and middle-income countries. Our extended definition of a Network of Care features four overlapping and interdependent domains of activity at multiple levels of health systems, characterized by: 1) Agreement and Enabling Environment, 2) Operational Standards, 3) Quality, Efficiency and Responsibility, and 4) Learning and Adaptation. There are a series of key interrelated themes within each domain. Creating a common understanding of what characterizes and fosters an effective Network of Care can drive the evolution and strengthening of national health programs, especially those incorporating universal health coverage and promoting comprehensive care and integrated services. An understanding of the Networks of Care model can help guide efforts to move health service delivery toward goals that can benefit a diversity of stakeholders, including a variety of health system actors, such as health care workers, users of health systems, and the wider community at large. It can also contribute to improving poor health outcomes and reducing waste originating from fragmented services and lack of access.

Examining coverage, content, and impact of maternal nutrition interventions: the case for quality-adjusted coverage measurement.

BACKGROUND: Reductions in neonatal mortality remain stagnant, despite gains in health care access and utilization. Nutrition interventions during antenatal care (ANC) and in the immediate postpartum period are associated with improved neonatal outcomes. Adjusting coverage estimates for the quality of care provided yields greater insight into health system performance and potential population health benefits of accessing care. In this cross-sectional study, we adjust maternity care coverage measures for quality of nutrition interventions to determine the impact on infant birth weight and breastfeeding. METHODS: We used household data from the Malawi 2013-2014 Multiple Indicator Cluster Survey to assess use of maternal health services and direct observations of ANC and delivery from the 2013 Service Provision Assessment to measure nutrition interventions provided. We adjusted coverage measures combining self-reported utilization of care with the likelihood of receipt of nutrition interventions. Using adjusted log-linear regression, we estimated the associations of these nutrition quality-adjusted metrics with infant birthweight and immediate breastfeeding. RESULTS: Health facility data provided over 2500 directly observed clinical encounters and household data provided 7385 individual reports of health care utilization and outcomes. Utilization of ANC and facility-delivery was high. Women received nutrition-related interventions considerably less often than they sought care: over the course of ANC women received a median of 1.6 interventions on iron, 1 instance of nutrition counseling, and 0.06 instances of breastfeeding counseling. Nutrition quality-adjusted ANC coverage was associated with a reduced risk of low birthweight (adjusted relative risk [ARR] 0.87, 95% confidence interval (CI) = 0.79, 0.96) and increased likelihood of immediate breastfeeding (ARR = 1.04, 95% CI = 1.02, 1.07); nutrition quality-adjusted post-delivery care was also associated with greater uptake of immediate breastfeeding (ARR = 1.08, 95% CI = 1.02, 1.14). Based on these models, delivering nutrition interventions consistently within the existing level of coverage would decrease population prevalence of low birthweight from 13.7% to 10.8% and increase population prevalence of immediate breastfeeding from 75.9% to 86.0%. CONCLUSIONS: Linking household survey data to health service provision assessments demonstrates that despite high utilization of maternal health services in Malawi, low provision of nutrition interventions is undermining infant health. Substantial gains in newborn health are possible in Malawi if quality of existing services is strengthened.

Variation in competent and respectful delivery care in Kenya and Malawi: a retrospective analysis of national facility surveys.

OBJECTIVE: Although substantial progress has been made in increasing access to care during childbirth, reductions in maternal and neonatal mortality have been slower. Poor-quality care may be to blame. In this study, we measure the quality of labour and delivery services in Kenya and Malawi using data from observations of deliveries and explore factors associated with levels of competent and respectful care. METHODS: We used data from nationally representative health facility assessment surveys. A total of 1100 deliveries in 392 facilities across Kenya and Malawi were observed and quality was assessed using two indices: the quality of the process of intrapartum and immediate postpartum care (QoPIIPC) index and a previously validated index of respectful maternity care. Data from standardised observations of care were analysed using descriptive statistics and multivariable random-intercept regression models to examine factors associated with variation in quality of care. We also quantified the variance in quality explained by each domain of covariates (patient-, provider- and facility-level and subnational divisions). RESULTS: Only 61-66% of basic elements of competent and respectful care were performed. In adjusted models, better-staffed facilities, private hospitals and morning deliveries were associated with higher levels of competent and respectful care. In Malawi, younger, primipara and HIV-positive women received higher-quality care. Quality also differed substantially across regions in Kenya, with a 25 percentage-point gap between Nairobi and the Coast region. Quality was also higher in higher-volume facilities and those with caesarean section capacity. Most of the explained variance in quality was due to regions in Kenya and to facility, and patient-level characteristics in Malawi. CONCLUSIONS: Our findings suggest considerable scope for improvement in quality. Increasing staffing and shifting births to higher-volume facilities - along with promotion of respectful care in these facilities - should be considered in sub-Saharan Africa to improve outcomes for mothers and newborns.

OBJECTIF: Bien que des progrès substantiels aient été accomplis dans l'amélioration de l'accès aux soins pendant l'accouchement, les réductions de la mortalité maternelle et néonatale ont été plus lentes. Des soins de mauvaise qualité peuvent être à blâmer. Dans cette étude, nous mesurons la qualité de la main-d'œuvre et des services d'accouchement au Kenya et au Malawi en utilisant les données des observations des accouchements et explorons les facteurs associés aux niveaux de la compétence et du respect dans les soins. MÉTHODES: Nous avons utilisé les données d'enquêtes d'évaluation des établissements de santé représentatives au niveau national. 1100 accouchements dans 392 établissements au Kenya et au Malawi ont été observés et la qualité a été évaluée à l'aide de deux indices: l'indice de qualité du processus de soins intra-partum et postpartum immédiat (QoPIIPC) et un indice précédemment validé de soins maternels respectueux. Les données des observations normalisées des soins ont été analysées à l'aide de statistiques descriptives et de modèles de régression à interceptions aléatoires multivariables pour examiner les facteurs associés à la variation de la qualité des soins. Nous avons également quantifié la variance de la qualité expliquée par chaque domaine de covariables (divisions au niveau des patients, des prestataires et des établissements, et infranationales). RÉSULTATS: Seuls 61% à 66% des éléments de base de soins compétents et respectueux ont été réalisés. Dans les modèles ajustés, des établissements mieux dotés en personnel, des hôpitaux privés et des accouchements le matin étaient associés à des niveaux plus élevés de soins compétents et respectueux. Au Malawi, les femmes plus jeunes, primipares et VIH positives ont reçu des soins de meilleure qualité. La qualité différait également considérablement d'une région à l'autre au Kenya, avec un écart de 25 points de pourcentage entre Nairobi et la région côtière. La qualité était également plus élevée dans les établissements avec un volume plus élevé et ceux ayant une capacité de césarienne. La majeure partie des raisons de la variance dans la qualité était liée aux régions du Kenya et à l'établissement et aux caractéristiques des patients au Malawi. CONCLUSIONS: Nos résultats suggèrent une marge considérable pour l'amélioration de la qualité. L'augmentation du personnel et le déplacement des naissances vers des établissements de plus grand volume - ainsi que la promotion de soins respectueux dans ces établissements - devraient être envisagés en Afrique subsaharienne pour améliorer les résultats pour les mères et les nouveau-nés.

Exploring Complicity of Cervical Cancer Screening in Malawi: The Interplay of Behavioral, Cultural, and Societal Influences.

OBJECTIVE: Cervical cancer is preventable, and early diagnosis is possible using low-cost technologies, but a scant number of women receive cancer screening in Malawi. This study aims to identify facilitators and barriers that influence the uptakes of cervical cancer screening behavior in Malawi. METHODS: A rapid ethnographic approach with the goal of optimizing planning for a future intervention study was utilized. Data were collected from three focus groups and seven individual interviews with adults in their communities, stakeholders, and health-care providers. RESULTS: Three categories (sociocultural influences, access to the health-care system, and individual factors) have emerged as facilitators or barriers to cervical cancer screening among Malawian women. The findings also showed that cervical cancer screening behavior is situated socially through cultural and health-care services of a given community. CONCLUSIONS: Cancer screenings are only sought when illness symptoms persist or worsen. Awareness and knowledge of cervical cancer and cervical cancer screening is low among both health-care providers and the general population. Health-care systems are donor driven and focus on a single disease, health-care access is the greatest challenge to cervical cancer screening, and health-care providers are not adequately prepared to work for rapid increase in the prevalence of cervical cancer. Integrating cervical cancer screening into the existing health-care system is sustainable way forward, and nurses prepared to handle cervical cancer management can play an essential role to promote cervical cancer screening in a health resource-constrained setting.

High quality health systems in the SDG era: Country-specific priorities for improving quality of care.

Hannah Leslie and co-authors discuss priorities in individual countries for health system reform.