Creation of a globally informed and locally relevant KMC implementation model for population-impact in Amhara, Ethiopia.

AIM: As part of a multi-country implementation trial, we tested a regionally specific model of kangaroo mother care (KMC). Effective KMC was defined as ≥8 h of newborn-caregiver skin-to-skin contact daily plus exclusive breast feeding. The study was designed to achieve ≥80+% effective KMC coverage at the population level. METHODS: The Amhara KMC model was designed using global evidence, formative research in the region and input from government officials, clinicians, newborn families and global scientists. We optimised the initial model using continuous quality improvement with process feedback, outcome measurement and collaborative re-design. Outcomes from the evaluation period are reported. RESULTS: At discharge, the final model resulted in a median of 16 h per day of skin-to-skin contact with 63% effective KMC coverage. Fifty-three percent sustained effective KMC to 7 days post-discharge. CONCLUSIONS: It is possible to achieve high coverage (63%), high-quality KMC at public hospitals without prior KMC services using government-owned, multisectoral collaborative design. Targeted co-design, real-time data and customisation of KMC interventions with input from impacted stakeholders was critical in achieving high coverage and sustained quality.

Scaling up Kangaroo Mother Care in Ethiopia and India: a multi-site implementation research study.

OBJECTIVES: Kangaroo Mother Care (KMC), prolonged skin-to-skin care of the low birth weight baby with the mother plus exclusive breastfeeding reduces neonatal mortality. Global KMC coverage is low. This study was conducted to develop and evaluate context-adapted implementation models to achieve improved coverage. DESIGN: This study used mixed-methods applying implementation science to develop an adaptable strategy to improve implementation. Formative research informed the initial model which was refined in three iterative cycles. The models included three components: (1) maximising access to KMC-implementing facilities, (2) ensuring KMC initiation and maintenance in facilities and (3) supporting continuation at home postdischarge. PARTICIPANTS: 3804 infants of birth weight under 2000 g who survived the first 3 days, were available in the study area and whose mother resided in the study area. MAIN OUTCOME MEASURES: The primary outcomes were coverage of KMC during the 24 hours prior to discharge and at 7 days postdischarge. RESULTS: Key barriers and solutions were identified for scaling up KMC. The resulting implementation model achieved high population-based coverage. KMC initiation reached 68%-86% of infants in Ethiopian sites and 87% in Indian sites. At discharge, KMC was provided to 68% of infants in Ethiopia and 55% in India. At 7 days postdischarge, KMC was provided to 53%-65% of infants in all sites, except Oromia (38%) and Karnataka (36%). CONCLUSIONS: This study shows how high coverage of KMC can be achieved using context-adapted models based on implementation science. They were supported by government leadership, health workers' conviction that KMC is the standard of care, women's and families' acceptance of KMC, and changes in infrastructure, policy, skills and practice. TRIAL REGISTRATION NUMBERS: ISRCTN12286667; CTRI/2017/07/008988; NCT03098069; NCT03419416; NCT03506698.

Kangaroo Mother Care implementation research to develop models for accelerating scale-up in India and Ethiopia: study protocol for an adequacy evaluation.

INTRODUCTION: Kangaroo Mother Care (KMC) is the practice of early, continuous and prolonged skin-to-skin contact between the mother and the baby with exclusive breastfeeding. Despite clear evidence of impact in improving survival and health outcomes among low birth weight infants, KMC coverage has remained low and implementation has been limited. Consequently, only a small fraction of newborns that could benefit from KMC receive it. METHODS AND ANALYSIS: This implementation research project aims to develop and evaluate district-level models for scaling up KMC in India and Ethiopia that can achieve high population coverage. The project includes formative research to identify barriers and contextual factors that affect implementation and utilisation of KMC and design scalable models to deliver KMC across the facility-community continuum. This will be followed by implementation and evaluation of these models in routine care settings, in an iterative fashion, with the aim of reaching a successful model for wider district, state and national-level scale-up. Implementation actions would happen at three levels: 'pre-KMC facility'-to maximise the number of newborns getting to a facility that provides KMC; 'KMC facility'-for initiation and maintenance of KMC; and 'post-KMC facility'-for continuation of KMC at home. Stable infants with birth weight<2000 g and born in the catchment population of the study KMC facilities would form the eligible population. The primary outcome will be coverage of KMC in the preceding 24 hours and will be measured at discharge from the KMC facility and 7 days after hospital discharge. ETHICS AND DISSEMINATION: Ethics approval was obtained in all the project sites, and centrally by the Research Ethics Review Committee at the WHO. Results of the project will be submitted to a peer-reviewed journal for publication, in addition to national and global level dissemination. STUDY STATUS: WHO approved protocol: V.4-12 May 2016-Protocol ID: ERC 2716. Study implementation beginning: April 2017. Study end: expected March 2019. TRIAL REGISTRATION NUMBER: Community Empowerment Laboratory, Uttar Pradesh, India (ISRCTN12286667); St John's National Academy of Health Sciences, Bangalore, India and Karnataka Health Promotion Trust, Bangalore, India (CTRI/2017/07/008988); Society for Applied Studies, Delhi (NCT03098069); Oromia, Ethiopia (NCT03419416); Amhara, SNNPR and Tigray, Ethiopia (NCT03506698).

Characterising innovations in maternal and newborn health based on a common theory of change: lessons from developing and applying a characterisation framework in Nigeria, Ethiopia and India.

Government leadership is key to enhancing maternal and newborn survival. In low/middle-income countries, donor support is extensive and multiple actors add complexity. For policymakers and others interested in harmonising diverse maternal and newborn health efforts, a coherent description of project components and their intended outcomes, based on a common theory of change, can be a valuable tool. We outline an approach to developing such a tool to describe the work and the intended effect of a portfolio of nine large-scale maternal and newborn health projects in north-east Nigeria, Ethiopia and Uttar Pradesh in India. Teams from these projects developed a framework, the 'characterisation framework', based on a common theory of change. They used this framework to describe their innovations and their intended outcomes. Individual project characterisations were then collated in each geography, to identify what innovations were implemented where, when and at what scale, as well as the expected health benefit of the joint efforts of all projects. Our study had some limitations. It would have been enhanced by a more detailed description and analysis of context and, by framing our work in terms of discrete innovations, we may have missed some synergistic aspects of the combination of those innovations. Our approach can be valuable for building a programme according to a commonly agreed theory of change, as well as for researchers examining the effectiveness of the combined work of a range of actors. The exercise enables policymakers and funders, both within and between countries, to enhance coordination of efforts and to inform decision-making about what to fund, when and where.

Determinants of perinatal mortality among cohorts of pregnant women in three districts of North Showa zone, Oromia Region, Ethiopia: Community based nested case control study.

BACKGROUND: Statistics indicate that Ethiopia has made remarkable progress in reducing child mortality. It is however estimated that there is high rate of perinatal mortality although there is scarcity of data due to a lack of vital registration in the country. This study was conducted with the purpose of assessing the determinants and causes of perinatal mortality among babies born from cohorts of pregnant women in three selected districts of North Showa Zone, Oromia Region, Ethiopia. The study used community based data, which is believed to provide more representative and reliable information and also aimed to narrow the data gap on perinatal mortality. METHODS: A community based nested case control study was conducted among 4438 (cohorts of) pregnant women. The cohort was followed up between March 2011 to December 2012 in three districts of Oromia region, Ethiopia, until delivery. The World Health Organization verbal autopsy questionnaire for neonatal death was used to collect data. A binary logistic regression model was used to identify determinants of perinatal mortality. Causes of deaths were assigned by a pediatrician and neonatologist. Cases are stillbirths and early neonatal death. Control are live births surviving of the perinatal period' RESULT: A total of 219 newborns (73 cases and 146 controls) were included in the analysis. Perinatal mortality rate was 16.5 per 1000 births. Mothers aged 35 years and above had a higher risk of losing their newborn babies to perinatal deaths than younger mothers [AOR 7.59, (95% CI, 1.91-30.10)]. Babies born to mothers who had a history of neonatal deaths were also more likely to die during the perinatal period than their counterparts [AOR 5.42, (95% CI, 2.27-12.96)]. Preterm births had a higher risk of perinatal death than term babies [AOR 8.58, (95% CI, 2.27-32.38)]. Similarly, male babies were at higher risk than female babies [AOR 5.47, (95% CI, 2.50-11.99)]. Multiple birth babies had a higher chance of dying within the perinatal period than single births [AOR 3.59, (95% CI, 1.20-10.79)]. Home delivery [AOR 0.23, (95% CI, 0.08-0.67)] was found to reduce perinatal deaths. Asphyxia, sepsis and chorioamnionitis were among the leading causes of perinatal deaths. CONCLUSION: This study reported a lower perinatal mortality rate. The main causes of perinatal death identified were often related to maternal factors. There is still a need for greater focus on these interrelated issues for further intervention.

Appropriateness and timeliness of care-seeking for complications of pregnancy and childbirth in rural Ethiopia: a case study of the Maternal and Newborn Health in Ethiopia Partnership.

BACKGROUND: In 2014, USAID and University Research Co., LLC, initiated a new project under the broader Translating Research into Action portfolio of projects. This new project was entitled Systematic Documentation of Illness Recognition and Appropriate Care Seeking for Maternal and Newborn Complications. This project used a common protocol involving descriptive mixed-methods case studies of community projects in six low- and middle-income countries, including Ethiopia. In this paper, we present the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) case study. METHODS: Methods included secondary analysis of data from MaNHEP's 2010 baseline and 2012 end line surveys, health program inventory and facility mapping to contextualize care-seeking, and illness narratives to identify factors influencing illness recognition and care-seeking. Analyses used descriptive statistics, bivariate tests, multivariate logistic regression, and thematic content analysis. RESULTS: Maternal illness awareness increased between 2010 and 2012 for major obstetric complications. In 2012, 45% of women who experienced a major complication sought biomedical care. Factors associated with care-seeking were MaNHEP CMNH Family Meetings, health facility birth, birth with a skilled provider, or health extension worker. Between 2012 and 2014, the Ministry of Health introduced nationwide initiatives including performance review, ambulance service, increased posting of midwives, pregnant women's conferences, user-friendly services, and maternal death surveillance. By 2014, most facilities were able to provide emergency obstetric and newborn care. Yet in 2014, biomedical care-seeking for perceived maternal illness occurred more often compared with care-seeking for newborn illness-a difference notable in cases in which the mother or newborn died. Most families sought care within 1 day of illness recognition. Facilitating factors were health extension worker advice and ability to refer upward, and health facility proximity; impeding factors were time of day, weather, road conditions, distance, poor cell phone connectivity (to call for an ambulance), lack of transportation or money for transport, perceived spiritual or physical vulnerability of the mother and newborn and associated culturally determined postnatal restrictions on the mother or newborn's movement outside of the home, and preference for traditional care. Some families sought care despite disrespectful, poor quality care. CONCLUSIONS: Improvements in illness recognition and care-seeking observed during MaNHEP have been reinforced since that time and appear to be successful. There is still need for a concerted effort focusing on reducing identified barriers, improve quality of care and provider counseling, and contextualize messaging behavior change communications and provider counseling.

Community economic status and intimate partner violence against women in bangladesh: compositional or contextual effects?

In this research, we used a multi-level contextual-effects analysis to disentangle the household- and community-level associations between income and intimate partner violence (IPV) against women in Bangladesh. Our analyses of data from 2,668 women interviewed as part of the World Health Organization (WHO) multi-country study on women's health and domestic violence against women showed that household income was negatively associated with women's risk of experiencing IPV. Controlling for residence in a low-income household, living in a low-income community was not associated with women's risk of experiencing IPV. These results support a household-level, not community-level, relationship between income and IPV in Bangladesh.

A network study exploring factors that promote or erode interaction among diverse community health workers in rural Ethiopia.

Task shifting in response to the health workforce shortage has resulted in community-based health workers taking on increasing responsibility. Community health workers are expected to work collaboratively, though they are often a heterogeneous group with a wide range of training and experience. Interpersonal relationships are at the very core of effective teamwork, yet relational variables have seldom been the focus of health systems research in low resource, rural settings. This article helps fill this knowledge gap by exploring the dyadic level, or relational, characteristics of community maternal and newborn health workers and the individual and collective influence of these characteristics on interaction patterns. Network data were collected from community health workers (N = 194) in seven rural kebeles of Amhara region, Ethiopia from November 2011 to January 2012. Multiple Regression Quadratic Assignment Procedure was used to fit regression models for frequency of work interactions, a proxy for teamwork. Strong and consistent evidence was found in support of Trust and Past training together as important relational factors for work interactions; less consistent evidence was found across sites in support of Homophily, Distance and Shared motivations. Our findings also point to a typology of network structure across sites, where one set of networks was characterized by denser and stronger health worker ties relative to their counterparts. Our results suggest that the development of interventions that promote trust and incorporate cross-cadre training is an important step in encouraging collective action. Moreover, assessing the structure of health worker networks may be an effective means of evaluating health systems strengthening efforts in rural, low-resource settings.

Recognition of and Response to neonatal intrapartum-related complications in home-birth settings in Bangladesh.

Intrapartum-related complications (previously called 'birth asphyxia') are a significant contributor to deaths of newborns in Bangladesh. This study describes some of the perceived signs, causes, and treatments for this condition as described by new mothers, female relatives, traditional birth attendants, and village doctors in three sites in Bangladesh. Informants were asked to name characteristics of a healthy newborn and a newborn with difficulty in breathing at birth and about the perceived causes, consequences, and treatments for breathing difficulties. Across all three sites 'no movement' and 'no cry' were identified as signs of breathing difficulties while 'prolonged labour' was the most commonly-mentioned cause. Informants described a variety of treatments for difficulty in breathing at birth, including biomedical and, less often, spiritual and traditional practices. This study identified the areas that need to be addressed through behaviour change interventions to improve recognition of and response to intrapartum-related complications in Bangladesh.

A qualitative study of attitudes and values surrounding stillbirth and neonatal mortality among grandmothers, mothers, and unmarried girls in rural Amhara and Oromiya regions, Ethiopia: unheard souls in the backyard.

INTRODUCTION: In Ethiopia, neonatal mortality and stillbirth are high and underreported. This study explored values related to neonatal mortality and stillbirth and the visibility of these deaths in rural Ethiopia among 3 generations of women. METHODS: We conducted a qualitative study in 6 rural districts of the Oromiya and Amhara regional states during May 2012. We included 30 focus groups representing grandmothers, married women (mothers), and unmarried girls in randomly selected kebeles (villages). RESULTS: Until the 40th day of life, neonates are considered to be strangers to the community (not human). Their deaths are not talked about; they are buried in the house or in the backyard. Mothers are forbidden to mourn their loss lest they offend God and bring on future neonatal losses. Women who repeatedly lose their neonates may be blamed, mistreated, and dishonored through divorce. Neonatal death and stillbirth are attributed to supernatural powers, although some women and girls associate these deaths with poverty and lack of education. The desire for increased visibility of neonatal death is mixed. Unlike the grandmothers and unmarried girls, most of the married women want death to be visible to draw the attention of policy makers. Women prefer home birth and consider themselves lucky to be able to give birth at home. At present, there is no national vital registration system. DISCUSSION: Neonatal death and stillbirth are hidden and the magnitude is likely underrepresented. The delayed recognition of personhood, attribution of death to supernatural causes, social repercussions for women who experience a pregnancy loss, preference for home birth, and lack of a vital registration system all contribute to the invisibility of perinatal deaths. Increasing the visibility of (and counting) these deaths may require multifaceted behavior-change interventions.

Knowledge and skills retention among frontline health workers: community maternal and newborn health training in rural Ethiopia.

INTRODUCTION: We examined the degree to which the skills and knowledge of health workers in Ethiopia were retained 18 months after initial maternal and newborn health training and sought to identify factors associated with 18-month skills assessment performance. METHODS: A nonexperimental, descriptive design was employed to assess 18-month skills performance on the topics of Prevent Problems Before Baby Is Born and Prevent Problems After Baby Is Born. Assessment was conducted by project personnel who also received the maternal and newborn health training and additional training to reliably assess health worker performance. RESULTS: Among the 732 health workers who participated in maternal and newborn health training in 6 rural districts of the Amhara and Oromia regions of Ethiopia (including pretesting before training and a posttraining posttest), 75 health extension workers (78%) and 234 guide team members (37%) participated in 18-month posttest. Among health extension workers in both regions, strong knowledge retention was noted in 10 of 14 care steps for Prevent Problems Before Baby Is Born and in 14 of 16 care steps of Prevent Problems After Baby Is Born. Lower knowledge retention was observed among guide team members in the Amhara region. Across regions, health workers scored lowest on steps that involved nonaction (eg, do not give oxytocin). Educational attainment and age were among the few variables found to significantly predict test performance, although participants varied substantially by other sociodemographic characteristics. DISCUSSION: Results demonstrated an overall strong retention of knowledge and skills among health extension workers and highlighted the need for improvement among some guide team members. Refresher training and development of strategies to improve knowledge of retention of low-performing steps were recommended.

Factors shaping interactions among community health workers in rural Ethiopia: rethinking workplace trust and teamwork.

INTRODUCTION: Worldwide, a shortage of skilled health workers has prompted a shift toward community-based health workers taking on greater responsibility in the provision of select maternal and newborn health services. Research in mid- and high-income settings suggests that coworker collaboration increases productivity and performance. A major gap in this research, however, is the exploration of factors that influence teamwork among diverse community health worker cadres in rural, low-resource settings. The purpose of this study is to examine how sociodemographic and structural factors shape teamwork among community-based maternal and newborn health workers in Ethiopia. METHODS: A cross-sectional survey was conducted with health extension workers, community health development agents, and traditional birth attendants in 3 districts of the West Gojam Zone in the Amhara region of Ethiopia. Communities were randomly selected from Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) sites; health worker participants were recruited using a snowball sampling strategy. Fractional logit modeling and average marginal effects analyses were carried out to identify the influential factors for frequency of work interactions with each cadre. RESULTS: One hundred and ninety-four health workers participated in the study. A core set of factors-trust in coworkers, gender, and cadre-were influential for teamwork across groups. Greater geographic distance and perception of self-interested motivations were barriers to interactions with health extension workers, while greater food insecurity (a proxy for wealth) was associated with increased interactions with traditional birth attendants. DISCUSSION: Interventions that promote trust and gender sensitivity and improve perceptions of health worker motivations may help bridge the gap in health services delivery between low- and high-resource settings. Inter-cadre training may be one mechanism to increase trust and respect among diverse health workers, thereby increasing collaboration. Large-scale, longitudinal research is needed to understand how changes in trust, gender norms, and perceptions of motivations influence teamwork over time.

The effect of community maternal and newborn health family meetings on type of birth attendant and completeness of maternal and newborn care received during birth and the early postnatal period in rural Ethiopia.

INTRODUCTION: Maternal and newborn deaths occur predominantly in low-resource settings. Community-based packages of evidence-based interventions and skilled birth attendance can reduce these deaths. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) used community-level health workers to conduct prenatal Community Maternal and Newborn Health family meetings to build skills and care-seeking behaviors among pregnant women and family caregivers. METHODS: Baseline and endline surveys provided data on a random sample of women with a birth in the prior year. An intention-to-treat analysis, plausible net effect calculation, and dose-response analysis examined increases in completeness of care (mean percentage of 17 maternal and newborn health care elements performed) over time and by meeting participation. Regression models assessed the relationship between meeting participation, completeness of care, and use of skilled providers or health extension workers for birth care-controlling for sociodemographic and health service utilization factors. RESULTS: A 151% increase in care completeness occurred from baseline to endline. At endline, women who participated in 2 or more meetings had more complete care than women who participated in fewer than 2 meetings (89% vs 76% of care elements; P < .001). A positive dose-response relationship existed between the number of meetings attended and greater care completeness (P < .001). Women with any antenatal care were nearly 3 times more likely to have used a skilled provider or health extension worker for birth care. Women who had additionally attended 2 or more meetings with family members were over 5 times as likely to have used these providers, compared to women without antenatal care and who attended fewer than 2 meetings (odds ratio, 5.19; 95% confidence interval, 2.88-9.36; P < .001). DISCUSSION: MaNHEP's family meetings complemented routine antenatal care by engaging women and family caregivers in self-care and care-seeking, resulting in greater completeness of care and more highly skilled birth care.

Improving coverage of postnatal care in rural Ethiopia using a community-based, collaborative quality improvement approach.

INTRODUCTION: Ethiopia has high maternal and neonatal mortality and low use of skilled maternity care. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP), a 3.5-year learning project, used a community collaborative quality improvement approach to improve maternal and newborn health care during the birth-to-48-hour period. This study examines how the promotion of community maternal and newborn health (CMNH) family meetings and labor and birth notification contributed to increased postnatal care within 48 hours by skilled providers or health extension workers. METHODS: Baseline and endline surveys, monthly quality improvement data, and MaNHEP's CMNH change package, a compendium of the most effective changes developed and tested by communities, were reviewed. Logistic regression assessed factors associated with postnatal care receipt. Monthly postnatal care receipt was plotted with control charts. RESULTS: The baseline (n = 1027) and endline (n = 1019) surveys showed significant increases in postnatal care, from 5% to 51% and from 15% to 47% in the Amhara and Oromiya regions, respectively (both P < .001). Notification of health extension workers for labor and birth within 48 hours was closely linked with receipt of postnatal care. Women with any antenatal care were 1.7 times more likely to have had a postnatal care visit (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.10-2.54; P < .001). Women who had additionally attended 2 or more CMNH meetings with family members and had access to a health extension worker's mobile phone number were 4.9 times more likely to have received postnatal care (OR, 4.86; 95% CI, 2.67-8.86; P < .001). DISCUSSION: The increase in postnatal care far exceeds the 7% postnatal care coverage rate reported in the 2011 Ethiopian Demographic and Health Survey (EDHS). This result was linked to ideas generated by community quality improvement teams for labor and birth notification and cooperation with community-level health workers to promote antenatal care and CMNH family meetings.

Interpretation of national policy regarding community-based use of misoprostol for postpartum hemorrhage prevention in Ethiopia: a tale of two regions.

INTRODUCTION: Postpartum hemorrhage (PPH) is responsible for a significant proportion of maternal mortality in developing countries. The uterotonic drug misoprostol (Cytotec) is a safe and effective means of preventing PPH. However, ministries of health in some countries are still grappling with policy that addresses the implementation of this targeted intervention in community settings and with communicating this policy throughout the health care system. The purpose of this study was to examine understandings of national policy for community-based use of misoprostol to prevent PPH in 2 regions of Ethiopia: Amhara and Oromiya. METHODS: Qualitative in-depth interviews were conducted with a cohort of purposefully selected health officials (N = 51) representing various administrative levels of the Ministry of Health and influential nongovernmental organizations. Broad topics included national policy for PPH prevention, safety and effectiveness of community-based use of misoprostol, and preferences for misoprostol administration. Interview transcripts were analyzed for key concepts both across and within administrative levels. RESULTS: Among all officials, understandings of national policy for community-based PPH prevention using misoprostol were unclear. Officials in Amhara tended to adopt a strict interpretation that reflected fear of misuse and a deep concern for encouraging home birth (thus deviating from the clear national goal to increase facility-based birth). Conversely, Oromiya officials framed policy in terms of the broader national goal to reduce maternal mortality, which allowed them to adopt multiple means of misoprostol distribution. DISCUSSION: The differences observed in regional practice likely stem from an ambiguously perceived national policy within a climate of decentralization that allowed for flexibility in local implementation. A policy that is clear, specific, evidence-based, and systematically communicated may facilitate common understanding of community-based misoprostol for PPH prevention and, thus, increase women's access to this lifesaving intervention.

A regional comparison of distribution strategies and women's awareness, receipt, and use of misoprostol to prevent postpartum hemorrhage in rural Amhara and Oromiya regions of Ethiopia.

INTRODUCTION: In Ethiopia, postpartum hemorrhage is a leading cause of maternal death. The Maternal Health in Ethiopia Partnership (MaNHEP) project developed a community-based model of maternal and newborn health focusing on birth and early postpartum care. Implemented in the Amhara and Oromiya regions, the model included misoprostol to prevent postpartum hemorrhage. This article describes regional trends in women's use of misoprostol; their awareness, receipt, and use of misoprostol at project's endline; and factors associated with its use. METHODS: The authors assessed trends in use of misoprostol using monthly data from MaNHEP's quality improvement database; and awareness, receipt, use, and correct use of misoprostol using data from MaNHEP's endline survey of 1019 randomly sampled women who gave birth during the year prior to the survey. RESULTS: Misoprostol use increased rapidly and was relatively stable over 20 months, but regional differences were stark. At endline, significantly more women in Oromiya were aware of misoprostol compared with women who resided in Amhara (94% vs 59%); significantly more had received misoprostol (80% vs 35%); significantly more had received it during pregnancy (93% vs 48%); and significantly more had received it through varied sources. Most women who received misoprostol used it (> 95%) irrespective of age, parity, or education. Factors associated with use were Oromiya residence (odds ratio [OR] 9.48; 95% confidence interval [CI], 6.78-13.24), attending 2 or more Community Maternal and Newborn Health (CMNH) family meetings (OR 2.62; 95% CI, 1.89-3.63), receiving antenatal care (OR 1.67; 95% CI, 1.08-2.58) and being attended at birth by a skilled provider or trained health extension worker, community health development agent, or traditional birth attendant versus an untrained caregiver or no one. Correct use was associated with having attended 2 or more CMNH family meetings (OR 2.02; 95% CI, 1.35-3.03). DISCUSSION: Multiple distribution channels increase women's access to misoprostol. Most women who have access to misoprostol use it. Early distribution to pregnant women who are educated to use misoprostol appears to be safe and unrelated to choice of birthplace.

Building district-level capacity for continuous improvement in maternal and newborn health.

INTRODUCTION: The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) adapted a collaborative improvement strategy to develop woreda (district) leadership capacity to support and facilitate continuous improvement of community maternal and neonatal health (CMNH) and to provide a model for other woredas, dubbed "lead" woredas. Community-level quality improvement (QI) teams tested solutions to improve CMNH care supported by monthly coaching and regular meetings to share experiences. This study examines the extent of the capacity built to support continuous improvement in CMNH care. METHODS: Surveys and in-depth interviews assessed the extent to which MaNHEP developed improvement capacity. A survey questionnaire evaluated woreda culture, leadership support, motivation, and capacity for improvement activities. Interviews focused on respondents' understanding and perceived value of the MaNHEP improvement approach. Bivariate analyses and multivariate linear regression models were used to analyze the survey data. Interview transcripts were organized by region, cadre, and key themes. RESULTS: Respondents reported significant positive changes in many areas of woreda culture and leadership, including involving a cross-section of community stakeholders (increased from 3.0 to 4.6 on 5-point Likert scale), using improvement data for decision making (2.8-4.4), using locally developed and tested solutions to improve CMNH care (2.5-4.3), demonstrating a commitment to improve the health of women and newborns (2.6-4.2), and creating a supportive environment for coaches and QI teams to improve CMNH (2.6-4.0). The mean scores for capacity were 3.7 and higher, reflecting respondents' agreement that they had gained capacity in improvement skills. Interview respondents universally recognized the capacity built in the woredas. The themes of community empowerment and focused improvement emerged strongly from the interviews. DISCUSSION: MaNHEP was able to build capacity for continuous improvement and develop lead woredas. The multifaceted approach to building capacity was critical for the success in creating lead woredas able to serve as models for other districts.

Low use of contraceptives among rural women in Maitha, Uttar Pradesh, India.

Low contraceptive utilisation and high fertility in rural Uttar Pradesh (UP), India, is a major concern for the world's second most populous country. The association between reasons for low contraceptive utilisation and maternal factors has been inadequately researched. Data from the 'morbidity and performance assessment' study were analysed to explore reasons for low contraceptive utilisation and their association with maternal factors among 308 women in Maitha, rural UP, India. Chi-square, t-test, ANOVA, and logistic regression analyses were conducted. Majority (84.2%) of the rural women in Maitha, UP, India were not using any contraceptives. Upper caste, literate wives, and wives whose husbands were literate were more likely to use contraceptives. About one-third of the women did not want to use a contraceptive because they wanted another child. Large numbers (65.3%) of women wanted to use contraceptives but were unable to do so due to lack of knowledge (38.9%), fear of side-effects (15.5%), husband/family disapproval (15.5%), inconvenience (10.7%), and other reasons (19.1%). Maternal parity, wives' and husband's literacy were significantly associated with the reasons for low contraceptive utilisation (p < 0.05). Contraceptive utilisation can be Improved by taking into consideration such maternal characteristics. All state subsidised contraceptives should be more widely known, understood and made available.

Traditional birth attendant training for improving health behaviours and pregnancy outcomes.

BACKGROUND: Between the 1970s and 1990s, the World Health Organization promoted traditional birth attendant (TBA) training as one strategy to reduce maternal and neonatal mortality. To date, evidence in support of TBA training is limited but promising for some mortality outcomes. OBJECTIVES: To assess the effects of TBA training on health behaviours and pregnancy outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 June 2012), citation alerts from our work and reference lists of studies identified in the search. SELECTION CRITERIA: Published and unpublished randomised controlled trials (RCT), comparing trained versus untrained TBAs, additionally trained versus trained TBAs, or women cared for/living in areas served by TBAs. DATA COLLECTION AND ANALYSIS: Three authors independently assessed study quality and extracted data in the original and first update review. Three authors and one external reviewer independently assessed study quality and two extracted data in this second update. MAIN RESULTS: Six studies involving over 1345 TBAs, more than 32,000 women and approximately 57,000 births that examined the effects of TBA training for trained versus untrained TBAs (one study) and additionally trained TBA training versus trained TBAs (five studies) are included in this review. These studies consist of individual randomised trials (two studies) and cluster-randomised trials (four studies). The primary outcomes across the sample of studies were perinatal deaths, stillbirths and neonatal deaths (early, late and overall).Trained TBAs versus untrained TBAs: one cluster-randomised trial found a significantly lower perinatal death rate in the trained versus untrained TBA clusters (adjusted odds ratio (OR) 0.70, 95% confidence interval (CI) 0.59 to 0.83), lower stillbirth rate (adjusted OR 0.69, 95% CI 0.57 to 0.83) and lower neonatal death rate (adjusted OR 0.71, 95% CI 0.61 to 0.82). This study also found the maternal death rate was lower but not significant (adjusted OR 0.74, 95% CI 0.45 to 1.22).Additionally trained TBAs versus trained TBAs: three large cluster-randomised trials compared TBAs who received additional training in initial steps of resuscitation, including bag-valve-mask ventilation, with TBAs who had received basic training in safe, clean delivery and immediate newborn care. Basic training included mouth-to-mouth resuscitation (two studies) or bag-valve-mask resuscitation (one study). There was no significant difference in the perinatal death rate between the intervention and control clusters (one study, adjusted OR 0.79, 95% CI 0.61 to 1.02) and no significant difference in late neonatal death rate between intervention and control clusters (one study, adjusted risk ratio (RR) 0.47, 95% CI 0.20 to 1.11). The neonatal death rate, however, was 45% lower in intervention compared with the control clusters (one study, 22.8% versus 40.2%, adjusted RR 0.54, 95% CI 0.32 to 0.92).We conducted a meta-analysis on two outcomes: stillbirths and early neonatal death. There was no significant difference between the additionally trained TBAs versus trained TBAs for stillbirths (two studies, mean weighted adjusted RR 0.99, 95% CI 0.76 to 1.28) or early neonatal death rate (three studies, mean weighted adjusted RR 0.83, 95% CI 0.68 to 1.01).  AUTHORS' CONCLUSIONS: The results are promising for some outcomes (perinatal death, stillbirth and neonatal death). However, most outcomes are reported in only one study. A lack of contrast in training in the intervention and control clusters may have contributed to the null result for stillbirths and an insufficient number of studies may have contributed to the failure to achieve significance for early neonatal deaths. Despite the additional studies included in this updated systematic review, there remains insufficient evidence to establish the potential of TBA training to improve peri-neonatal mortality.