Implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing in family planning: a protocol for a mixed-methods systematic review.

BACKGROUND: Ensuring access to quality family planning (FP) services is fundamental to achieving the Sustainable Development Goals (SDG) targets 3.1, 3.7, and 5.6, including universal access to reproductive health services. However, barriers such as health workforce shortages and restrictive policies on the role of mid and lower-level health workforce cadres limit access to contraceptives and FP in many settings. Workforce reorganization makes more efficient use of human resources. Consequently, the World Health Organization (WHO) recommends task-sharing for FP by different cadres. Evidence on the implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing could inform financing, implementation approaches, and technical assistance of national and global FP task-sharing programs. Therefore, this study aims to describe and assess the quality of the evidence on implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing in FP and the outcome of the scale-up/sustainability interventions. METHODS: This systematic review protocol was developed using relevant guidelines, including the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols (PRISMA-P). A search of five databases, namely CINAHL (EBSCOhost), EMBASE (OvidSP), Global Health (OvidSP), MEDLINE (OvidSP), and Scopus ( www.scopus.com ), and gray literature resources will be conducted. Two independent reviewers will screen and select studies, assess their quality using the "Mixed Methods Appraisal Tool," and extract data from eligible studies. Publications or articles are eligible if they report implementation strategies, facilitators, or barriers to scaling up/sustainability of task-sharing in FP/contraception or the outcomes of the scale-up/sustainability interventions. A convergent synthesis that integrates qualitative, quantitative, descriptive, and mixed-methods data into one dataset will be used for analysis based on an a priori framework-the Cochrane Effective Practice and Organization of Care (EPOC) taxonomy of the health system framework. Two independent reviewers will assess the quality of evidence using the GRADE-CERQual guideline. DISCUSSION: To our knowledge, this systematic review of implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing in family planning is the first in this area. Our rigorous methodology based on up-to-date guidelines can help generate relevant recommendations to support interventions to scale up and sustain task-sharing in family planning. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022339885.

Mistreatment of women during childbirth and postpartum depression: secondary analysis of WHO community survey across four countries.

BACKGROUND: Postpartum depression (PPD) is a leading cause of disability globally with estimated prevalence of approximately 20% in low-income and middle-income countries. This study aims to determine the prevalence and factors associated with PPD following mistreatment during facility-based childbirth. METHOD: This secondary analysis used data from the community survey of postpartum women in Ghana, Guinea, Myanmar and Nigeria for the WHO study, 'How women are treated during facility-based childbirth'. PPD was defined using the Patient Health Questionnaire (PHQ-9) tool. Inferential analyses were done using the generalised ordered partial proportional odds model. RESULTS: Of the 2672 women, 39.0% (n=1041) developed PPD. 42.2% and 5.2% of mistreated women developed minimal/mild PPD and moderate/severe PPD, respectively. 43.0% and 50.6% of women who experienced verbal abuse and stigma/discrimination, respectively developed minimal/mild PPD. 46.3% of women who experienced physical abuse developed minimal/mild PPD while 7.6% of women who experienced stigma/discrimination developed moderate/severe PPD. In the adjusted model, women who were physically abused, verbally abused and stigma/discrimination compared with those who were not were more likely to experience any form of PPD ((OR: 1.57 (95% CI 1.19 to 2.06)), (OR: 1.42 (95% CI 1.18 to 1.69)) and (OR: 1.69 (95% CI 1.03 to 2.78))), respectively. Being single and having higher education were associated with reduced odds of experiencing PPD. CONCLUSION: PPD was significantly prevalent among women who experienced mistreatment during childbirth. Women who were single, and had higher education had lower odds of PPD. Countries should implement women-centred policies and programmes to reduce mistreatment of women and improve women's postnatal experiences.

Implementation strategies to scale up self-administered depot medroxyprogesterone acetate subcutaneous injectable contraception: a scoping review.

BACKGROUND: Self-administered depot medroxyprogesterone acetate subcutaneous injectable contraception (DMPA-SC) is registered in many countries. It shows great potential for improving contraceptive access, continuation, and autonomy. However, there are challenges in rolling out this new efficacious intervention, and major implementation problems have been encountered during scale-up. OBJECTIVE: To describe the implementation strategies to scale up self-administered DMPA-SC and the barriers, facilitators, and outcomes of these programs. METHOD: Recent guidelines, including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews, were used to design and report this review. An article or report was eligible for inclusion if it reported interventions that could scale up self-administered DMPA-SC implementation or its facilitators, barriers, or outcomes. We searched six electronic databases and the grey literature for eligible articles and reports. Two reviewers independently screened the document titles, abstracts, and full texts to identify eligible documents. Data were extracted using structured forms. Using the Effective Practice and Organization of Care (EPOC) taxonomy of health systems framework for thematic analysis, data were presented in a narrative approach. RESULTS: Of the 755 retrieved documents, 34 were included in this review. Most of the documents included were multi-country reports (n = 14), and all documents were published within the last 5 years (2018-2021). This review identified documents that reported interventions in all EPOC domains. The most-reported interventions were: task-sharing amongst health workforce cadres, engaged leadership, encouraging policies, training and education, DMPA-SC demand generation, integration into existing programs, improved funding mechanisms, collaboration with development partners, and supply chain strengthening. The main barriers were suboptimal funding, inadequate human resources, and poor logistics supply of DMPA-SC. There was minimal evidence of scale-up outcomes. CONCLUSION: This scoping review reported a wide range of interventions employed by countries and programs to scale up DMPA-SC self-administration but minimal evidence of the scale-up outcomes. Evidence from this review can help design better programs that improves access to quality family planning services to achieve the Sustainable Development Goals (SDG) targets 3.7. However, efforts should focus on rigorous implementation research that assess scaled up self-administered DMPA-SC interventions and report their outcomes. REGISTRATION: The protocol for this review was registered in the protocols.io repository ( https://www.protocols.io/view/a-protocol-for-a-scoping-review-of-implementation-x54v9yemmg3e/v1 ).

Comparing observed occurrence of mistreatment during childbirth with women's self-report: a validation study in Ghana, Guinea and Nigeria.

BACKGROUND: There has been substantial progress in developing approaches to measure mistreatment of women during childbirth. However, less is known about the differences in measurement approaches. In this study, we compare measures of mistreatment obtained from the same women using labour observations and community-based surveys in Ghana, Guinea and Nigeria. METHODS: Experiences of mistreatment during childbirth are person-centred quality measures. As such, we assessed individual-level and population-level accuracy of labour observation relative to women's self-report for different types of mistreatment. We calculated sensitivity, specificity, percent agreement and population-level inflation factor (IF), assessing prevalence of mistreatment in labour observation divided by 'true' prevalence in women's self-report. We report the IF degree of bias as: low (0.75

The impact of a universal late third-trimester scan for fetal growth restriction on perinatal outcomes in term singleton births: A prospective cohort study.

OBJECTIVE: To investigate perinatal mortality, morbidity and obstetric intervention following the introduction of a universal late third-trimester ultrasound scan for growth restriction. DESIGN: Prospective cohort study. SETTING: Oxfordshire (OUH), UK. POPULATION: Women with a non-anomalous singleton pregnancy undergoing pregnancy care and term delivery at OUH with an estimated due date (EDD) of birth between 1 January 2014 and 30 September 2019. METHODS: Universal ultrasound for fetal growth restriction between 35+0 and 36+6 weeks was introduced in 2016. The outcomes of the next 18 631 eligible term pregnancies were compared, adjusting for covariates and time, with the previous 18 636 who had clinically indicated ultrasounds only. 'Screen-positives' for growth restriction were managed according to a pre-determined protocol which included non-intervention for some small-for-gestational-age babies. MAIN OUTCOME MEASURES: Extended perinatal mortality, a composite of mortality or encephalopathy Grade II-III, and expedited birth. Other outcomes included composite adverse outcomes used elsewhere, detection of low birthweight and birth from 37+0 to 38+6 weeks. RESULTS: Extended perinatal deaths decreased 27% and severe morbidity decreased 33% but neither change was statistically significant (adjusted odd ratio [aOR] 0.53, 95% confidence interval [C1] 00.18-1.56 and aOR 0.71, 95% CI 0.31-1.63). Expedited births changed from 35.2% to 37.7% (aOR 0.99, 95% CI 0.92-1.06). Birthweight (<10th centile) detection using fetal biometry alone was 31.4% and rose to 40.5% if all abnormal scan parameters were used. CONCLUSION: Improvements in mortality and severe morbidity subsequent to introducing a universal ultrasound for growth restriction are encouraging but remain unclear. Little change in intervention is possible. The antenatal detection of low birthweight remains poor but improves where markers of growth restriction are used.

Antenatal and Postnatal Care.

Optimal care during the antenatal and postnatal phases of the life cycle is a potentially positive determinant of health elsewhere in the continuum. A successful transition from the antenatal to the postnatal period requires early detection, optimal management, and prevention of disease; health promotion; birth preparedness; and complication readiness. Women, their babies, and families need appropriate evidence-based care based on their dignity and human rights before, during, and after birth. In this review, we present an overview of the components of antenatal and postnatal care needed to provide women a culturally sensitive and positive pregnancy and postnatal experience. The challenge of antenatal and postnatal care is determining their core components and underpinning them with evidence without overmedicalizing their practice.

Late pregnancy ultrasound parameters identifying fetuses at risk of adverse perinatal outcomes: a protocol for a systematic review of systematic reviews.

INTRODUCTION: Stillbirths and neonatal deaths are leading contributors to the global burden of disease and pregnancy ultrasound has the potential to help decrease this burden. In the absence of high-Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence on universal obstetric ultrasound screening at or close to term, many different screening strategies have been proposed. Systematic reviews have rapidly increased over the past decade owing to the diverse nature of ultrasound parameters and the wide range of possible adverse perinatal outcomes. This systematic review will summarise the evidence on key ultrasound parameters in the published literature to help develop an obstetric ultrasound protocol that identifies pregnancies at risk of adverse perinatal outcomes at or close to term. METHODS: This study will follow the recent Cochrane guidelines for a systematic review of systematic reviews. A comprehensive literature search will be conducted using Embase (OvidSP), Medline (OvidSP), CDSR, CINAHL (EBSCOhost) and Scopus. Systematic reviews evaluating at least one ultrasound parameter in late pregnancy to detect pregnancies at risk of adverse perinatal outcomes will be included. Two independent reviewers will screen, assess the quality including the risk of bias using the ROBIS tool, and extract data from eligible systematic reviews that meet the study inclusion criteria. Overlapping data will be assessed and managed with decision rules, and study evidence including the GRADE assessment of the certainty of results will be presented as a narrative synthesis as described in the Cochrane guidelines for an overview of reviews. ETHICS AND DISSEMINATION: This research uses publicly available published data; thus, an ethics committee review is not required. The findings will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42021266108.

Adolescent experiences of mistreatment during childbirth in health facilities: secondary analysis of a community-based survey in four countries.

INTRODUCTION: Pregnancy and childbearing among adolescents-especially younger adolescents-is associated with health complications and lost opportunities for education and personal development. In addition to established challenges adolescents and young women face in sexual and reproductive healthcare, evidence suggests that they also face mistreatment during childbirth. METHODS: This is a secondary analysis of the WHO study 'How women are treated during facility-based childbirth' cross-sectional community survey in Ghana, Guinea, Myanmar and Nigeria. We used descriptive analysis to assess experiences of mistreatment among adolescents (15-19 years) and young women (20-24 years) and multivariable logistic regression models to assess the association between experiences of mistreatment and satisfaction with care during childbirth. RESULTS: 862 participants are included (15-19 years: 287, 33.3%; 20-24 years: 575, 66.7%). The most common mistreatment was verbal abuse (15-19 years: 104/287, 36.2%; 20-24 years: 181/575, 31.5%). There were high levels of poor communication (15-19 years: 92/287, 32.1%; 20-24 years: 171/575, 29.7%), lack of supportive care (15-19 years: 22/287, 42.5%; 20-24 years: 195/575, 33.9%) and lack of privacy (15-19 years: 180/287, 62.7%; 20-24 years: 395/575, 68.7%). Women who were verbally abused were less likely to report satisfaction with care (adjusted OR (AOR): 0.19, 95% CI: 0.12 to 0.31) and less likely to recommend the facility (AOR: 0.24, 95% CI: 0.15 to 0.38). There were similar reports among those who were physically abused, had long waiting time, did not mobilise and did not give consent for vaginal examinations. CONCLUSION: Our study shows that adolescents and young women mistreatment during childbirth, contributing to low satisfaction with care. It is critical to recognise adolescents and young women's unique needs in maternal healthcare and how their needs may intersect with social stigma around sex and pregnancy.

Scoping review of maternal and newborn health interventions and programmes in Nigeria.

OBJECTIVE: To systematically scope and map research regarding interventions, programmes or strategies to improve maternal and newborn health (MNH) in Nigeria. DESIGN: Scoping review. DATA SOURCES AND ELIGIBILITY CRITERIA: Systematic searches were conducted from 1 June to 22 July 2020 in PubMed, Embase, Scopus, together with a search of the grey literature. Publications presenting interventions and programmes to improve maternal or newborn health or both in Nigeria were included. DATA EXTRACTION AND ANALYSIS: The data extracted included source and year of publication, geographical setting, study design, target population(s), type of intervention/programme, reported outcomes and any reported facilitators or barriers. Data analysis involved descriptive numerical summaries and qualitative content analysis. We summarised the evidence using a framework combining WHO recommendations for MNH, the continuum of care and the social determinants of health frameworks to identify gaps where further research and action may be needed. RESULTS: A total of 80 publications were included in this review. Most interventions (71%) were aligned with WHO recommendations, and half (n=40) targeted the pregnancy and childbirth stages of the continuum of care. Most of the programmes (n=74) examined the intermediate social determinants of maternal health related to health system factors within health facilities, with only a few interventions aimed at structural social determinants. An integrated approach to implementation and funding constraints were among factors reported as facilitators and barriers, respectively. CONCLUSION: Using an integrated framework, we found most MNH interventions in Nigeria were aligned with the WHO recommendations and focused on the intermediate social determinants of health within health facilities. We determined a paucity of research on interventions targeting the structural social determinants and community-based approaches, and limited attention to pre-pregnancy interventions. To accelerate progress towards the sustainable development goal MNH targets, greater focus on implementing interventions and measuring context-specific challenges beyond the health facility is required.

Neonatal and postneonatal tetanus at a referral hospital in Kamsar, Guinea: a retrospective audit of paediatric records (2014-2018).

BACKGROUND: Tetanus is a vaccine-preventable disease caused by the bacterium Clostridium tetani. In 2018, all of Guinea was considered to be at risk of the disease and the country is currently in the elimination phase. METHODS: A 5-y audit (1 January 2014-31 December 2018) of all admissions to the neonatal and general paediatric units of Kamsar Hospital (Western Guinea) was undertaken to identify cases of neonatal tetanus (NNT) and postneonatal tetanus (PNNT). RESULTS: There were 5670 admissions during the study period, of which 39 (0.7%) were due to tetanus (22 NNT and 17 PNNT). Among NNT patients, the bacterial entry site was the umbilical cord (n=20) or wound following circumcision (n=2). For PNNT, the entry site was surface wound (n=12), limb fracture (n=1) or could not be established (n=4). A majority of the patients (36/39, 92.3%) were born to unvaccinated mothers or those who received suboptimal vaccination during pregnancy. Overall, 21 (53.8%) children died within 7 d of admission with a higher mortality observed among neonates (16/22, 72.7%) compared with postneonates (5/17, 29.4%). CONCLUSIONS: Tetanus was a rare cause of admission at Kamsar Hospital with a very high case fatality rate. The disease primarily occurred among children born to mothers who were unvaccinated/inadequately vaccinated during pregnancy.

Vaginal examinations and mistreatment of women during facility-based childbirth in health facilities: secondary analysis of labour observations in Ghana, Guinea and Nigeria.

BACKGROUND: Previous research on mistreatment of women during childbirth has focused on physical and verbal abuse, neglect and stigmatisation. However, other manifestations of mistreatment, such as during vaginal examinations, are relatively underexplored. This study explores four types of mistreatment of women during vaginal examinations: (1) non-consented care, (2) sharing of private information, (3) exposure of genitalia and (4) exposure of breasts. METHODS: A secondary analysis of data from the WHO multicountry study 'How Women Are Treated During Childbirth' was conducted. The study used direct, continuous labour observations of women giving birth in facilities in Ghana, Guinea and Nigeria. Descriptive and multivariable logistic regression analyses were used to describe the different types of mistreatment of women during vaginal examinations and associated privacy measures (ie, availability of curtains). RESULTS: Of the 2016 women observed, 1430 (70.9%) underwent any vaginal examination. Across all vaginal examinations, 842/1430 (58.9%) women were observed to receive non-consented care; 233/1430 (16.4%) women had their private information shared; 397/1430 (27.8%) women had their genitalia exposed; and 356/1430 (24.9%) had their breasts exposed. The observed prevalence of mistreatment during vaginal examinations varied across countries. There were country-level differences in the association between absence of privacy measures and mistreatment. Absence of privacy measures was associated with sharing of private information (Ghana: adjusted OR (AOR) 3.8, 95% CI 1.6 to 8.9; Nigeria: AOR 4.9, 95% CI 1.9 to 12.7), genitalia exposure (Ghana: AOR 6.7, 95% CI 2.9 to 14.9; Nigeria: AOR 6.5, 95% CI 2.9 to 14.5), breast exposure (Ghana: AOR 5.9, 95% CI 2.8 to 12.9; Nigeria: AOR 2.7, 95% CI 1.3 to 5.9) and non-consented vaginal examination (Ghana: AOR 2.5, 95% CI 1.4 to 4.7; Guinea: AOR 0.21, 95% CI 0.12 to 0.38). CONCLUSION: Our results highlight the need to ensure better communication and consent processes for vaginal examination during childbirth. In some settings, measures such as availability of curtains were helpful to reduce women's exposure and sharing of private information, but context-specific interventions will be required to achieve respectful maternity care globally.

Women's experiences of mistreatment during childbirth and their satisfaction with care: findings from a multicountry community-based study in four countries.

INTRODUCTION: Experiences of care and satisfaction are intrinsically linked, as user's experiences of care may directly impact satisfaction, or indirectly impact user's expectations and values. Both experiences of care and satisfaction are important to measure so that quality can be monitored and improved. Globally, women experience mistreatment during childbirth at facilities; however, there is limited evidence exploring the mistreatment and women's satisfaction with care during childbirth. METHODS: This is a secondary analysis of a cross-sectional survey within the WHO study 'How women are treated during facility-based childbirth' exploring the mistreatment of women during childbirth in Ghana, Guinea, Myanmar and Nigeria. Women's experiences of mistreatment and satisfaction with care during childbirth was explored. Multivariable logistic regression modelling was conducted to evaluate the association between mistreatment, women's overall satisfaction with the care they received, and whether they would recommend the facility to others. RESULTS: 2672 women were included in this analysis. Despite over one-third of women reporting experience of mistreatment (35.4%), overall satisfaction for services received and recommendation of the facility to others was high, 88.4% and 90%, respectively. Women who reported experiences of mistreatment were more likely to report lower satisfaction with care: women were more likely to be satisfied if they did not experience verbal abuse (adjusted OR (AOR) 4.52, 95% CI 3.50 to 5.85), or had short waiting times (AOR 5.12, 95% CI 3.94 to 6.65). Women who did not experience any physical or verbal abuse or discrimination were more likely to recommend the facility to others (AOR 3.89, 95% CI 2.98 to 5.06). CONCLUSION: Measuring both women's experiences and their satisfaction with care are critical to assess quality and provide actionable evidence for quality improvement. These measures can enable health systems to identify and respond to root causes contributing to measures of satisfaction.

Determinants and outcome of fetal macrosomia in a Nigerian tertiary hospital.

BACKGROUND: To determine the incidence and risk factors of fetal macrosomia and maternal and perinatal outcome. PATIENTS AND METHODS: This was a 1-year prospective case-control study of singleton pregnancies in a Nigerian tertiary hospital. Only women who gave consent were recruited for the study. The maternal and perinatal outcomes in women who delivered macrosomic infants (birth weight ≥ 4000 g) were compared with the next consecutive delivery of normal birth weight (2500-3999 g) infants. RESULTS: The total deliveries for the study period were 2437, of which 135 were macrosomic babies. The incidence of fetal macrosomia was 5.5%. The mean birth weights of macrosomic and nonmacrosomic babies were 4.26 ± 0.29 kg and 3.20 ± 0.38 kg, respectively, P = 0.000. Mothers with macrosomic babies were more likely to be older (P = 0.047), of higher parity (0.001), taller (P = 0.007), and weighed more at delivery (P = 0.000). Previous history of fetal macrosomia (P = 0.000) and maternal diabetes (P = 0.007) were factors strongly associated with the delivery of macrosomic infants. Pregnancies associated with fetal macrosomia had increased duration of labor (P = 0.007), interventional deliveries (P = 0.000), shoulder dystocia, and genital laceration (P = 0.000). There was no significant difference in the incidence of primary postpartum hemorrhage (P = 0.790), birth asphyxia, and perinatal mortality (P = 0.197). CONCLUSION: Fetal macrosomia is associated with maternal and fetal morbidities. The presence of the observed risk factors should elicit the suspicion of a macrosomic fetus and the need for appropriate management to reduce maternal and fetal morbidities.