Extended Paid Maternity Leave Associated With Improved Maternal Mental Health In Hong Kong.

In July 2020, Hong Kong extended statutory paid maternity leave from ten weeks to fourteen weeks to align with International Labour Organization standards. We used the policy enactment as an observational natural experiment to assess the mental health implications of this policy change on probable postnatal depression (Edinburgh Postnatal Depression Scores of 10 or higher) and postpartum emotional well-being. Using an opportunistic observational study design, we recruited 1,414 survey respondents with births before (August 1-December 10, 2020) and after (December 11, 2020-July 18, 2022) policy implementation. Participants had a mean age of thirty-two, were majority primiparous, and were mostly working in skilled occupations. Our results show that the policy was associated with a 22 percent decrease in mothers experiencing postnatal depressive symptoms and a 33 percent decrease in postpartum emotional well-being interference. Even this modest change in policy, an additional four weeks of paid leave, was associated with significant mental health benefits. Policy makers should consider extending paid maternity leave to international norms to improve mental health among working mothers and to support workforce retention.

Accountability for maternal and newborn health: Why measuring and monitoring broader social, political, and health system determinants matters.

This article offers four key lessons learned from a set of seven studies undertaken as part of the collection entitled, "Improving Maternal Health Measurement to Support Efforts toward Ending Preventable Maternal Mortality". These papers were aimed at validating ten of the Ending Preventable Maternal Mortality initiative indicators that capture information on distal causes of maternal mortality. These ten indicators were selected through an inclusive consultative process, and the research designs adhere to global recommendations on conducting indicator validation studies. The findings of these papers are timely and relevant given growing recognition of the role of macro-level social, political, and economic factors in maternal and newborn survival. The four key lessons include: 1) Strengthen efforts to capture maternal and newborn health policies to enable global progress assessments while reducing multiple requests to countries for similar data; 2) Monitor indicator "bundles" to understand degree of policy implementation, inconsistencies between laws and practices, and responsiveness of policies to individual and community needs; 3) Promote regular monitoring of a holistic set of human resource metrics to understand how to effectively strengthen the maternal and newborn health workforce; and 4) Develop and disseminate clear guidance for countries on how to assess health system as well as broader social and political determinants of maternal and newborn health. These lessons are consistent with the Kirkland principles of focus, relevance, innovation, equity, global leadership, and country ownership. They stress the value of indicator sets to understand complex phenomenon related to maternal and newborn health, including small groupings of complementary indicators for measuring policy implementation and health workforce issues. They also stress the fundamental ethos that maternal and newborn health indicators should only be tracked if they can drive actions at global, regional, national, or sub-national levels that improve lives.

Knowledge and practice of health workers towards maternal and child health in the Democratic Republic of the Congo: a cross-sectional study.

BACKGROUND: The burden of maternal and child mortality is high in the Democratic Republic of the Congo (DRC). While health workers (HWs) with adequate knowledge and practice of maternal and child health (MCH) are crucial to reduce this burden, the skill level of HWs in charge of MCH in the DRC is currently insufficient. This study aimed to assess the knowledge and practice of HWs towards MCH in Kasai and Maniema, two DRC provinces with very high maternal mortality ratios and under-5 mortality rates. METHODS: This cross-sectional study was conducted in 96 health facilities of Kasai and Maniema provinces in 2019. All HWs in charge of MCH were eligible for the study. Data were collected using a structured questionnaire containing 76 questions on knowledge and practice of MCH. Analyses were performed using the Wilcoxon-Mann-Whitney test, Kendall's correlation test, and a multivariate linear mixed regression model. RESULTS: Among participating HWs, 42.6% were A2 nurses (lowest qualification), 81.9% had no up-to-date training in MCH, and 48.4% had only 1-5 years of experience in MCH. In the two provinces combined, about half of HWs had poor knowledge (50.6%) and poor practice (53.3%) of MCH. Knowledge and practice scores were higher in Maniema than in Kasai (P < 0.001). Good knowledge and practice scores were significantly associated with high qualification (P = 0.001), continuing up-to-date training in MCH (P = 0.009), and 6 years of experience or more in MCH (P = 0.01). CONCLUSION: In Maniema and Kasai provinces, about half of HWs had poor knowledge and poor practice of MCH. The conversion of A1 nurses into midwives as well as the provision of up-to-date training in MCH, supervision, and mentorship could improve the skill level of HWs and could thus reduce the burden of MCH in the DRC.

This study assessed the knowledge and practice of health workers (HWs) towards maternal and child health (MCH) in Kasai and Maniema, two provinces of the Democratic Republic of the Congo (DRC) with very high maternal and child mortality rates. About half of surveyed HWs had poor knowledge and poor practice of MCH. Good knowledge and good practice were associated with high qualification, up-to-date training, and 6 years of experience or more in MCH. The conversion of A1 nurses into midwives as well as the provision of up-to-date training in MCH, supervision, and mentorship could improve the skill level of HWs and could thus reduce the burden of MCH in the DRC.

Alliance for Innovation on Maternal Health: Evolution of a program to address maternal morbidity and mortality.

The Alliance for Innovation on Maternal Health program is a national investment in promoting safe care for every birth in the United States and lowering rates of preventable maternal mortality and severe maternal morbidity. Through its work with state and jurisdiction-based teams on patient safety bundle implementation, the program supports data-driven quality improvement. This paper details key aspects of the Alliance for Innovation on Maternal Health including patient safety bundles, technical assistance, implementation resource development, data support, and partnerships while providing an overview of the program's evolution, reach, impact, and future opportunities.

Understanding the language barriers to translating informed consent documents for maternal health trials in Zambia: a qualitative study.

OBJECTIVE: Providing comprehensible information is essential to the process of valid informed consent. Recruitment materials designed by sponsoring institutions in English-speaking, high-income countries are commonly translated for use in global health studies in other countries; however, key concepts are often missed, misunderstood or 'lost in translation'. The aim of this study was to explore the language barriers to informed consent, focusing on the challenges of translating recruitment materials for maternal health studies into Zambian languages. DESIGN: We used a qualitative approach, which incorporated a multistakeholder workshop (11 participants), in-depth interviews with researchers and translators (8 participants) and two community-based focus groups with volunteers from community advisory boards (20 participants). Content analysis was used to identify terms commonly occurring in recruitment materials prior to the workshop. The framework analysis approach was used to analyse interview data, and a simple inductive thematic analysis approach was used to analyse focus group data. SETTING: The study was based in Lusaka, Zambia. RESULTS: The workshop highlighted difficulties in translating research terms and pregnancy-specific terms, as well as widespread concern that current templates are too long, use overly formal language and are designed with little input from local teams. Framework analysis of in-depth interviews identified barriers to participant understanding relating to design and development of recruitment materials, language, local context and communication styles. Focus group participants confirmed these findings and suggested potential solutions to ensure the language and content of recruitment materials can be better understood. CONCLUSION: Our findings demonstrate that the way in which recruitment materials are currently designed, translated and disseminated may not enable potential trial participants to fully understand the information provided. Instead of using overly complex institutional templates, recruitment materials should be created through an iterative and interactive process that provides truly comprehensible information in a format appropriate for its intended participants.

Effectiveness of trained religious leaders' engagement in maternal health education on improving maternal health service utilizations: Protocol of cluster randomized controlled trial in Hadiya Zone, Southern Ethiopia.

BACKGROUND: Despite the many supply- and demand-side interventions aimed at increasing uptake of maternal health service utilizations, the maternal and new-born health service utilizations remains low. Religious leaders have the power to inhibit or facilitate effective adoption of maternal health service utilizations to promote maternal health. However, evidence on the roles of religious leaders in promoting maternal health in developing world is not fully known. Therefore this cluster-randomized trial is designed to evaluate the effects of trained religious leaders' engagement in maternal health education in improving maternal health service utilization and knowledge of obstetric danger signs. METHODS: A community based cluster randomized control trial in which the study kebeles are randomly assigned into intervention and control groups will be conducted. The sample size is calculated using stata software. Three hundred six pregnant mothers will be enrolled in each group. A baseline study will be conducted before the intervention and post-intervention evaluation will be conducted after four months of intervention. Religious leaders will be selected and trained to lead participatory sessions on maternal health. Data on maternal health service utilizations, knowledge about obstetric danger signs, attitude towards skilled delivery service utilization and perception of pregnancy risk will be collected from a repeated cross sectional household survey. Effect of intervention will be assessed using multivariable logistic regression with generalized estimating equation model. Data will be analyzed using STATA software. For qualitative study, coded transcripts will be further analyzed and summarized in narratives for each theme and sub-themes. DISCUSSION: This is one of the first trials to evaluate the effectiveness of trained religious leaders' engagement in maternal health education and will provide much needed evidence to policy makers about aspects of functionality and the religious leaders engagement required as they scale-up this programme in Ethiopia.

Maternal cardiovascular health in early pregnancy and the risk of congenital heart defects in offspring.

BACKGROUND: Congenital heart disease (CHD) is the predominant birth defect. This study aimed to explore the association between maternal cardiovascular health (CVH) and the CHD risk in offspring. METHODS: We used the prospective data from the Fujian Birth Cohort Study, collected from March 2019 to December 2022 on pregnant women within 14 weeks of gestation. Overall maternal CVH was assessed by seven CVH metrics (including physical activity, smoking, sleep duration, body mass index, blood pressure, total cholesterol, and fasting plasma glucose), with each metric classified as ideal, intermediate or poor with specific points. Participants were further allocated into high, moderate and low CVH categories based on the cumulative CVH score. The association with offspring CHD was determined with log-binominal regression models. RESULTS: A total of 19810 participants aged 29.7 (SD: 3.9) years were included, with 7846 (39.6%) classified as having high CVH, 10949 (55.3%) as having moderate CVH, and 1015 (5.1%) as having low CVH. The average offspring CHD rate was 2.52%, with rates of 2.35%, 2.52% and 3.84% across the high, moderate and low CVH categories, respectively (P = 0.02). Adjusted relative risks (RRs) of having offspring CHD were 0.64 (95% CI: 0.45-0.90, P = 0.001) for high CVH and 0.67 (95% CI: 0.48-0.93, P = 0.02) for moderate CVH compared to low CVH. For individual metrics, only ideal total cholesterol was significantly associated with lower offspring CHD (RR: 0.73, 95% CI: 0.59-0.83, P = 0.002). CONCLUSIONS: Pregnant women of high or moderate CVH categories in early pregnancy had reduced risks of CHD in offspring, compared to those of low CVH. It is important to monitor and improve CVH during pre-pregnancy counseling and early prenatal care.

Supporting the Development of Grassroots Maternal and Childhood Health Leaders through a Public-Health-Informed Training Program.

The purpose of this research was to assess leadership growth (i.e., changes in personal capacity and social capital) among women living in high-risk infant mortality zip codes who completed a grassroots maternal and childhood health leadership (GMCHL) training program. We used semi-structured qualitative interviews and thematic analysis. Three major themes associated with the training program experience were identified: (1) building personal capacity and becoming community brokers; (2) linking and leveraging through formal organizations; and (3) how individual change becomes community change. Although many of the grassroots leaders were already brokers (i.e., connecting individuals to information/services), they were able to become community brokers by gaining new skills and knowledge about strategies to reduce adverse birth outcomes in their community. In particular, joining and participation in formal organizations aimed at improving community health led to the development of linking or vertical ties (e.g., "people in high places"). The grassroots leaders gained access to people in power, such as policymakers, which enabled leaders to access more resources and opportunities for themselves and their social networks. We outline the building blocks for supporting potential grassroots leaders by enhancing personal capacity and social capital, thus leading to increases in collective efficacy and collective action.

Use of qualitative research in World Health Organisation guidelines: a document analysis.

BACKGROUND: Guidelines depend on effect estimates, usually derived from randomised controlled trials, to inform their decisions. Qualitative research evidence may improve decisions made but where in the process and the methods to do this have not been so clearly established. We sought to describe and appraise how qualitative research has been used to inform World Heath Organization guidance since 2020. METHODS: We conducted a document analysis of WHO guidelines from 2020 to 2022. We purposely sampled guidelines on the topics of maternal and newborn health (MANH) and infectious diseases, as most of the qualitative synthesis to date has been conducted on these topics, likely representing the 'best case' scenario. We searched the in-built repository feature of the WHO website and used standardised search terms to identify qualitative reporting. Using deductive frameworks, we described how qualitative evidence was used to inform guidelines and appraised the standards of this use. RESULTS: Of the 29 guidelines, over half used qualitative research to help guide decisions (18/29). A total of 8 of these used qualitative research to inform the guideline scope, all 18 to inform recommendations, and 1 to inform implementation considerations. All guidelines drew on qualitative evidence syntheses (QES), and five further supplemented this with primary qualitative research. Qualitative findings reported in guidelines were typically descriptive, identifying people's perception of the benefits and harms of interventions or logistical barriers and facilitators to programme success. No guideline provided transparent reporting of how qualitative research was interpreted and weighed used alongside other evidence when informing decisions, and only one guideline reported the inclusion of qualitative methods experts on the panel. Only a few guidelines contextualised their recommendations by indicating which populations and settings qualitative findings could be applied. CONCLUSIONS: Qualitative research frequently informed WHO guideline decisions particularly in the field of MANH. However, the process often lacked transparency. We identified unmet potential in informing implementation considerations and contextualisation of the recommendations. Use in these areas needs further methods development.

Reproductive and Social Policies, Sociopolitical Stress, and Implications for Maternal and Child Health Equity.

PURPOSE OF REVIEW: Although many environmental exposures (e.g., air pollution) are geographically patterned and persist as a result of historic economic policies (e.g., redlining), the impact of reproductive and social policies on maternal and child health remains incompletely understood. Reproductive and social policies are increasingly important for maternal and child health equity, particularly following the 2022 US Supreme Court decision in Dobbs v Jackson Women's Health Organization ("Dobbs decision"), which restricted access to abortion. Here, we summarize the literature from original research studies examining influences of reproductive and social policy on maternal and child health, focusing on impacts on adverse birth outcomes and policies as sources of stress. RECENT FINDINGS: Several studies suggest that those most impacted by the Dobbs decision are younger, non-white, socioeconomically disadvantaged, and living in states with less access to government safety net programs, all of which are compounded by environmental injustices. Further, studies conducted in the wake of the Dobbs decision find elevated stress levels among women of reproductive age. This may represent one pathway leading to adverse birth outcomes, as epidemiologic studies demonstrate that preterm birth rates increased following the 2016 election, a period of heightened stress. Reproductive and social policies are understudied contributors to adverse outcomes for reproductive-aged women and their children. This has important implications for maternal and child health equity, as those who will be the most impacted by reproductive and social policies already experience the highest rates of adverse birth outcomes and environmental toxicant exposure.

Patient navigation in women's health care for maternal health and noncancerous gynecologic conditions: a scoping review.

PURPOSE: This study investigated the scope of patient navigation studies on women's health care for maternal health and noncancerous gynecologic conditions and aimed to report the characteristics of the identified patient navigation programs. METHODS: A scoping review was conducted following Arksey and O'Malley's framework. Five electronic databases were searched for relevant studies published in English: PubMed, Embase, Cochrane Library, CINAHL, and PsycInfo. There were no restrictions on the publication date and the search was completed in July 2023. RESULTS: This scoping review included 14 studies, which collectively examined seven patient navigation programs. All selected studies were related to maternal health issues (e.g., perinatal health problems and contraception for birth spacing). Close to two-thirds of the patient navigation services were provided by women (n=9, 64.3%) and half by lay navigators (n=7, 50.0%). The majority incorporated the use of mobile health technologies (n=11, 78.6%). All of the patient navigation programs included in the review coordinated the necessary clinical and social support services to improve women's access to care. CONCLUSION: Patient navigation appears to be in its nascent phase in the field of maternal health. The results of this study suggest that the implementation of patient navigation services could potentially improve access to care for socially disadvantaged women and families. Furthermore, providing patient navigation services that are specifically tailored to meet women's needs could improve the quality of maternity care.

Severe Maternal Morbidity and Mental Health Hospitalizations or Emergency Department Visits.

Importance: Severe maternal morbidity (SMM) can have long-term health consequences for the affected mother. The association between SMM and future maternal mental health conditions has not been well studied. Objective: To assess the association between SMM in the first recorded birth and the risk of hospitalization or emergency department (ED) visits for a mental health condition over a 13-year period. Design, Setting, and Participants: This population-based retrospective cohort study used data from postpartum individuals aged 18 to 55 years with a first hospital delivery between 2008 and 2021 in 11 provinces and territories in Canada, except Québec. Data were analyzed from January to June 2023. Exposure: SMM, defined as a composite of conditions, such as septic shock, severe preeclampsia or eclampsia, severe hemorrhage with intervention, or other complications, occurring after 20 weeks' gestation and up to 42 days after a first delivery. Main Outcomes and Measures: The main outcome was a hospitalization or ED visit for a mental health condition, including mood and anxiety disorders, substance use, schizophrenia, and other psychotic disorder, or suicidality or self-harm event, arising at least 43 days after the first birth hospitalization. Cox regression models generated hazard ratios with 95% CIs, adjusted for baseline maternal comorbidities, maternal age at delivery, income quintile, type of residence, hospital type, and delivery year. Results: Of 2 026 594 individuals with a first hospital delivery, 1 579 392 individuals (mean [SD] age, 30.0 [5.4] years) had complete ED and hospital records and were included in analyses; among these, 35 825 individuals (2.3%) had SMM. Compared with individuals without SMM, those with SMM were older (mean [SD] age, 29.9 [5.4] years vs 30.7 [6.0] years), were more likely to deliver in a teaching tertiary care hospital (40.8% vs 51.1%), and to have preexisting conditions (eg, ≥2 conditions: 1.2% vs 5.3%), gestational diabetes (8.2% vs 11.7%), stillbirth (0.5% vs 1.6%), preterm birth (7.7% vs 25.0%), or cesarean delivery (31.0% vs 54.3%). After a median (IQR) duration of 2.6 (1.3-6.4) years, 1287 (96.1 per 10 000) individuals with SMM had a mental health hospitalization or ED visit, compared with 41 779 (73.2 per 10 000) individuals without SMM (adjusted hazard ratio, 1.26 [95% CI, 1.19-1.34]). Conclusions and Relevance: In this cohort study of postpartum individuals with and without SMM in pregnancy and delivery, there was an increased risk of mental health hospitalizations or ED visits up to 13 years after a delivery complicated by SMM. Enhanced surveillance and provision of postpartum mental health resources may be especially important after SMM.

Prioritization of maternal and newborn health policies and their implementation in the eastern conflict affected areas of the Democratic Republic of Congo: a political economy analysis.

BACKGROUND: Maternal and neonatal mortality remains a major concern in the Democratic Republic of Congo (DRC), and the country's protracted crisis context exacerbates the problem. This political economy analysis examines the maternal and newborn health (MNH) prioritization in the DRC, focussing specifically on the conflict-affected regions of North and South Kivu. The aim is to understand the factors that facilitate or hinder the prioritization of MNH policy development and implementation by the Congolese government and other key actors at national level and in the provinces of North and South Kivu. METHODS: Using a health policy triangle framework, data collection consisted of in-depth interviews with key actors at different levels of the health system, combined with a desk review. Qualitative data were analysed using inductive and then deductive approaches, exploring the content, process, actor dynamics, contextual factors and gender-related factors influencing MNH policy development and implementation. RESULTS: The study highlighted the challenges of prioritizing policies in the face of competing health and security emergencies, limited resources and governance issues. The universal health coverage policy seems to offer hope for improving access to MNH services. Results also revealed the importance of international partnerships and global financial mechanisms in the development of MNH strategies. They reveal huge gender disparities in the MNH sector at all levels, and the need to consider cultural factors that can positively or negatively impact the success of MNH policies in crisis zones. CONCLUSIONS: MNH is a high priority in DRC, yet implementation faces hurdles due to financial constraints, political influences, conflicts and gender disparities. Addressing these challenges requires tailored community-based strategies, political engagement, support for health personnel and empowerment of women in crisis areas for better MNH outcomes.

Parto domiciliar planeado em Portugal: Assistência e desafios na prática do enfermeiro especialista em enfermagem de saúde materna e obstétrica / Planned home birth in Portugal: Assistance and challenges in the practice of nurses specialising in maternal health and obstetric nursing

Enquadramento: No âmbito da unidade curricular "Estágio com Relatório," integrada no X Curso de Mestrado em Enfermagem de Saúde Materna e Obstétrica, foi elaborado um relatório final que engloba uma descrição e reflexão acerca da componente de estágio, bem como uma abordagem à componente de investigação. No que concerne à vertente investigativa, o estudo teve como tema o "Parto Domiciliário Planeado em Portugal: Assistência e Desafios na Prática do Enfermeiro Especialista em Enfermagem de Saúde Materna e Obstétrica." Objetivos: Conhecer a prática profissional dos EEESMO em contexto de PDP; identificar as motivações dos EEESMO perante a opção de exercerem em contexto de PDP e descrever os desafios e obstáculos que os EEESMO enfrentaram na sua prática profissional em contexto de PDP. Metodologia: Trata-se de um estudo exploratório e descritivo com abordagem qualitativa. Participaram da pesquisa oito (8) profissionais com cédula profissional EEESMO em Portugal, que atuam em contexto de PDP há pelo menos um ano. Os dados foram coletados por meio de entrevistas semiestruturadas, e a análise foi conduzida seguindo a metodologia de análise de conteúdo proposta por Minayo (2007). Resultados: O estudo revelou a experiência profissional das EEESMO em contexto do parto domiciliar planeado. Foram explorados temas relacionados à acessibilidade das utentes ao serviço, medidas de segurança, material clínico para assistência ao parto, emergências e transferência para o hospital, bem como os contributos da entidade reguladora da profissão (Ordem dos Enfermeiros) para a prática profissional nesse contexto. Além disso, foram identificadas as motivações iniciais das participantes que optaram exercer a sua prática profissional no âmbito do parto domiciliar planeado, categorizadas em desejo de infância, desde a formação de EEESMO, experiência do seu parto no domicílio e preferência por um modelo de assistência diferente do hospitalar. No que concerne aos desafios e obstáculos enfrentados pelas participantes no contexto do PDP, ficou evidente que estes são diversos e abrangem várias esferas. Esses desafios foram categorizados nos âmbitos da formação, social, profissional e pessoal. Conclusão: Conclui-se que os desafios expostos pelas participantes revelam a complexidade do trabalho no contexto do PDP, ressaltando a importância de promover mudanças nesse contexto. A superação desses desafios contribuirá para uma prática mais segura, valorizada e efetiva no cuidado às mulheres e seus bebés durante o parto domiciliário. Considera-se que este estudo contribui de forma significativa para enriquecer a reflexão e o debate em torno desse tema, especialmente no meio acadêmico, ao estimular o desenvolvimento de estudos aprofundados relacionados à assistência das EEESMO no contexto do PDP.

Recomendaciones para la atención de las principales emergencias obstétricas

Esta edición de Recomendaciones para la atención de las principales emergencias obstétricas incluye la actualización de los capítulos Estados hipertensivos del embarazo, Hemorragia postparto, Reanimación cardiovascular en el embarazo, Sistema de alerta temprano y equipos de respuesta rápida en Obstetricia. Siguiendo el sistema GRADE para definir la calidad de la evidencia y la fortaleza de la recomendación se plantean recomendaciones para el abordaje del tromboembolismo pulmonar y embarazo, embolismo de líquido amniótico, Covid-19 y embarazo, influenza y embarazo y sepsis materna. Con esta publicación se busca apoyar los esfuerzos para lograr la concretización de la meta 3.1 de los ODS de reducir la tasa mundial de mortalidad materna a menos de 70 por cada 100.00 nacidos vivos hasta el 2030.

Women's autonomy and maternal health decision making in Kenya: implications for service delivery reform - a qualitative study.

BACKGROUND: Maternal and neonatal outcomes in, Kakamega County is characterized by a maternal mortality rate of 316 per 100,000 live births and a neonatal mortality rate of 19 per 1,000 live births. In 2018, approximately 70,000 births occurred in the county, with 35% at home, 28% in primary care facilities, and 37% in hospitals. A maternal and child health service delivery redesign (SDR) that aims to reorganize maternal and newborn health services is being implemented in Kakamega County in Kenya to improve the progress of these indicators. Research has shown that women's ability to make decisions (voice, agency, and autonomy) is critical for gender equality, empowerment and an important determinant of access and utilization. As part of the Kakamega SDR process evaluation, this study sought to understand women's processes of decision-making in seeking maternal health care and how these affect women's ability to access and use antenatal, delivery, and post-natal services. METHODS: We adapted the International Centre for Research on Women (ICRW) conceptual framework for reproductive empowerment to focus on the interrelated concepts of "female autonomy", and "women's agency" with the latter incorporating 'voice', 'choice' and 'power'. Our adaptation did not consider the influence of sexual relationships and leadership on SRH decision-making. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men in Kakamega County. A thematic analysis approach was used to analyze the data in NVivo 12. RESULTS: The results revealed notable findings across three dimensions of agency. Women with previous birthing experiences, high self-esteem, and support from their social networks exhibited greater agency. Additionally, positive previous birthing experiences were associated with increased confidence in making reproductive health choices. Women who had control over financial resources and experienced respectful communication with their partners exhibited higher levels of agency within their households. Distance relational agency demonstrated the impact of health system factors and socio-cultural norms on women's agency and autonomy. Finally, women who faced barriers such as long waiting times or limited staff availability experienced reduced agency in seeking healthcare. CONCLUSIONS: Individual agency, immediate relational agency, and distance relational agency all play crucial roles in shaping women's decision-making power and control over their utilization of maternal health services. This study offers valuable insights that can guide the ongoing implementation of an innovative service delivery redesign model, emphasizing the critical need for developing context-specific strategies to promote women's voices for sustained use.

Realist evaluation of maternity waiting home intervention models in Inhambane, Mozambique: protocol for a comparative embedded case study, the Mozambique-Canada Maternal Health Project.

INTRODUCTION: This is a study protocol that tests and refines realist theories regarding the uptake and scale-up of the linked maternity waiting home (hereafter MWH) and facility birth intervention in the Mozambican context. The theories were developed through a realist review of MWH-facility birth literature from low-income and middle-income countries. The aim of the proposed study is to contribute to a contextually refined understanding of the causal chains underlying MWH-facility birth adoption by pregnant women and their families, communities, the health system and donors. METHODS AND ANALYSIS: The overarching methodology is mixed-methods realist evaluation. The study will adopt a comparative embedded case study design comparing three new masonry MWHs built by the Mozambique-Canada Maternal Health Project in Inhambane province with three older MWHs selected based on variation in the built environment. Baseline data on participating MWH-facility birth interventions will be collected through observations, reviews of routine data and analysis of statistics and reports from provincial and district health authorities and the Mozambique-Canada Maternal Health project. Realist interviews will be conducted with MWH users and non-users, companions of MWH users and non-users, partners of MWH users and non-users, and stakeholders within the health system and the non-governmental organisation sector. Realist focus groups will be used to collect data from community-level implementers. The analysis will be retroductive and use the context-mechanism-outcome configuration heuristic tool to represent generative causation. We will analyse data from intervention and comparator MWHs independently and compare the resulting refined programme theories. Data analysis will be done in NVivo 12. ETHICS AND DISSEMINATION: Ethics approval for the project has been obtained from the Mozambique National Bioethics Committee (CNBS-Comité Nacional de Bioética para a Saúde) and the University of Saskatchewan Bioethical Research Ethics Board. The evaluation will adhere to the International Ethical Guidelines for Biomedical Research Involving Human Subjects and the African adaptation of evaluation ethics and principles. Evaluation results will be disseminated to stakeholders' practice audiences through peer-reviewed publications, plain-language briefs, theory validation/feedback meetings and conference presentations.