Assessing post-abortion care using the WHO quality of care framework for maternal and newborn health: a cross-sectional study in two African hospitals in humanitarian settings.

BACKGROUND: Abortion-related complications remain a main cause of maternal mortality. There is little evidence on the availability and quality of post-abortion care (PAC) in humanitarian settings. We assessed the quality of PAC in two hospitals supported by an international organization in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR). METHODS: We mapped indicators corresponding to the eleven domains of the WHO Maternal and Newborn Health quality-of-care framework to assess inputs, processes (provision and experience of care), and outcomes of PAC. We measured these indicators in four components of a cross-sectional multi-methods study: 1) an assessment of the hospitals' PAC signal functions, 2) a survey of the knowledge, attitudes, practices, and behavior of 140 Nigerian and 84 CAR clinicians providing PAC, 3) a prospective review of the medical records of 520 and 548 women presenting for abortion complications and, 4) a survey of 360 and 362 of these women who were hospitalized in the Nigerian and CAR hospitals, respectively. RESULTS: Among the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26 in the CAR hospital. In both hospitals, less than 2.5% were treated with dilatation and sharp curettage. Over 80% of women received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients with no documented indication. Among discharged women in CAR, 99% received contraceptive counseling but only 39% did in Nigeria. Over 80% of women in Nigeria reported positive experiences of respect and preservation of dignity. Conversely, in CAR, 37% reported that their privacy was always respected during examination and 62% reported short or very short waiting time before seeing a health provider. In terms of communication, only 15% felt able to ask questions during treatment in both hospitals. The risk of abortion-near-miss happening ≥ 24h after presentation was 0.2% in Nigeria and 1.1% in CAR. Only 65% of women in the Nigerian hospital and 34% in the CAR hospital reported that the staff provided them best care all the time. CONCLUSION: Our comprehensive assessment identified that these two hospitals in humanitarian settings provided lifesaving PAC. However, hospitals need to strengthen the patient-centered approach engaging patients in their own care and ensuring privacy, short waiting times and quality provider-patient communication. Health professionals would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance.

In humanitarian contexts, abortion complications are a leading cause of maternal mortality. Providing quality post-abortion care (PAC) is therefore an important part of needed services. We assessed the quality of PAC in two hospitals supported by an international organization in Jigawa State (Nigeria) and Bangui (Central African Republic). We measured quality indicators in four components: 1) an assessment of the equipment and human resources available in hospitals, 2) a survey of the knowledge, attitudes, practices, and behavior of clinicians providing PAC, 3) an assessment of the medical care provided by clinicians to women presenting with abortion complications and, 4) a survey of a subgroup of these women who were hospitalized. Both hospitals had almost all the equipment and human resources necessary to provide post-abortion care. Less than 2.5% of women received a non-recommended method to evacuate their uterus in both hospitals. More than 80% of women received a blood transfusion or antibiotics when they needed them. However, 30% of women received antibiotics without written justification and only 15% of women reported being able to ask questions about their treatment. Overall, only 65% of Nigerian women and 34% of Central African women said that the staff provided them with the best care all the time. The fact that less than 2% of women experienced a very severe complication 24 hours or more after their arrival at the two hospitals suggests that the care provided was lifesaving. But they urgently need to adopt a better patient-centered approach as well as to improve the rational management of antibiotics.

Promoting mental wellbeing in pregnant women living in Pakistan with the Safe Motherhood-Accessible Resilience Training (SM-ART) intervention: a randomized controlled trial.

BACKGROUND: The negative impact of adverse perinatal mental health extends beyond the mother and child; therefore, it is essential to make an early intervention for the management of mental illness during pregnancy. Resilience-building interventions are demonstrated to reduce depression and anxiety among expectant mothers, yet research in this field is limited. This study aims to examine the effect of the 'Safe Motherhood-Accessible Resilience Training (SM-ART)' on resilience, marital adjustment, depression, and pregnancy-related anxiety in a sample of pregnant women in Karachi, Pakistan. METHOD: In this single-blinded block randomized controlled study, 200 pregnant women were recruited and randomly assigned to either an intervention or a control group using computer-generated randomization and opaque sealed envelopes. The intervention group received the SM-ART intervention consisting of six, weekly sessions ranging from 60 to 90 min. Outcomes (Resilience, depression, pregnancy-related anxiety and marital harmony) were assessed through validated instruments at baseline and after six weeks of both intervention and control groups. RESULTS: The results revealed a significant increase in mean resilience scores (Difference:6.91, Effect size: 0.48, p-value < 0.05) and a decrease in depressive symptoms (Difference: -2.12, Effect size: 0.21, p-value < 0.05) in the intervention group compared to the control group. However, no significant change was observed in anxiety and marital adjustment scores. CONCLUSION: The SM-ART intervention has the potential to boost resilience scores and decrease depressive symptoms in pregnant women and offers a promising intervention to improve maternal psychological health. TRIAL REGISTRATION: NCT04694261, Date of first trial registration: 05/01/2021.

Comparison between the Roche Cobas 4800 Human Papillomavirus (HPV), Abbott RealTime High-Risk HPV, Seegene Anyplex II HPV28, and Novel Seegene Allplex HPV28 Assays for High-Risk HPV Detection and Genotyping in Mocked Self-Samples.

Infection with high-risk human papillomavirus (hrHPV) is well recognized as the main cause of cervical cancer. The recently developed Seegene Allplex HPV28 assay is a novel quantitative PCR (qPCR) assay designed to separately detect and quantify 28 distinct HPV genotypes in a fully automated and user-friendly manner. This study evaluated and compared the performance of this new assay with the performance of the Roche Cobas 4800, the Abbott RealTime high-risk HPV, and the Seegene Anyplex II HPV28 assays. A total of 114 mocked self-samples, i.e., semicervical samples collected by gynecologists using the Viba-Brush, were analyzed with all four HPV assays. Agreement in terms of detecting and genotyping HPV was assessed by the mean of the Cohen's kappa (κ) coefficient. Results of all four HPV assays agreed in 85.9% of the cases when using the Abbott RealTime manufacturer's recommended quantification cycle (Cq) cutoff for positivity (<32.00) and 91.2% when using an adapted range (32.00 to 36.00). An intercomparison of the included assays demonstrated an overall agreement ranging from 85.9 to 100.0% (κ = 0.42 to 1.00) when using the manufacturer's guidelines and 92.9 to 100.0% (κ = 0.60 to 1.00) with the adapted range. For all assays, highly significant, strongly positive Pearson correlations were shown between the Cq values of positive test results. This study thereby shows high concordance between results of the included HPV assays on mocked self-samples. Based on these findings, we imply that the novel Allplex HPV28 assay demonstrates a comparable performance to those of available qPCR HPV assays, potentially providing opportunities for the simplification and standardization of future large-scale testing. IMPORTANCE This study proves that the novel Allplex HPV28 assay has a good diagnostic performance in comparison with the well-known, validated, and frequently used Roche Cobas 4800, Abbott RealTime, and Anyplex II HPV28 assays. According to our experience, the novel Allplex HPV28 assay had a user-friendly and automated workflow with short hands-on time, had an open platform which facilitates the use of add-on assays, and provided quick and easy-to-interpret results. Together with its ability to detect and quantify 28 HPV genotypes, the Allplex HPV28 assay could therefore potentially provide opportunities for the simplification and standardization of future diagnostic testing programs.

Development and Validation of Safe Motherhood-Accessible Resilience Training (SM-ART) Intervention to Improve Perinatal Mental Health.

Perinatal mental health issues in women can lead to a variety of health complications for both mother and child. Building resilience can strengthen coping mechanisms for pregnant women to improve their mental health and protect themselves and their children. The study aims to develop and validate the contextual and cultural appropriateness of the Safe Motherhood-Accessible Resilience Training (SM-ART) intervention for pregnant women in Pakistan. A three-phase approach was used to develop and validate an intervention that promotes resilience in pregnant women. Phase I comprised a needs assessment with stakeholders (pregnant women and key informants) to elicit opinions regarding module content. In Phase II, an intervention to build resilience was developed with the help of a literature review and formative assessment findings, and Phase III involved the validation of the intervention by eight mental health experts. The experts assessed the Content Validity Index (CVI) of the SM-ART intervention on a self-developed checklist. The resultant SM-ART intervention consists of six modules with strong to perfect CVI scores for each of the modules. Qualitative responses endorsed the strengths of the intervention as having innovative and engaging activities, contextual and cultural relevance, and a detailed, comprehensive facilitator guide. SM-ART was successfully developed and validated and is now ready for testing to promote the resilience of pregnant women at risk of perinatal mental illness.

Resilience and prenatal mental health in Pakistan: a qualitative inquiry.

BACKGROUND: Women in Pakistan suffer from a high rate of depression. The stress of low-income, illiteracy, exposure to violence and living in a patriarchal society are predisposing vulnerabilities for depression, particularly during and following pregnancy. The resilience of an individual plays a significant role in promoting prenatal mental health, but this has yet to be thoroughly researched. In this article, our objective is to identify the core characteristics of resilience among pregnant women, which will then help us in developing an intervention. METHODS: The exploratory-descriptive study was conducted over 6 months in five different antenatal hospitals in Sindh, Pakistan. A total of 17 semi-structured interviews were conducted with pregnant women, purposefully selected with heterogeneous characteristics to explore diverse perspectives, while symptoms of depression were quantified by the Edinburgh Postnatal Depression Scale before the interview. Verbatim transcriptions were coded openly and merged into categories and themes. RESULT: A total of six themes emerged from in-depth thematic analysis: 1) purpose of life, 2) dealing with emotions, 3) believing in yourself, 4) optimistic approach, 5) strengthening support and relationship and 6) spirituality and humanity. Women agreed that these characteristics could help them improve their mental health. CONCLUSION: In conclusion, these themes were the core components of pregnant women's resilience which ultimately could help to promote prenatal mental health. These pave a pathway towards developing culturally and contextually resilience interventions aimed at enhancing mental health of pregnant women which then may improve neonatal and family mental wellbeing.

Barriers and facilitators to cervical cancer screening among under-screened women in Cuenca, Ecuador: the perspectives of women and health professionals.

BACKGROUND: Cervical cancer screening is a cost-effective method responsible for reducing cervical cancer-related mortality by 70% in countries that have achieved high coverage through nationwide screening strategies. However, there are disparities in access to screening. In Ecuador, although cervical cancer is the second most common cancer in women, only 58.4% of women of reproductive age have ever been screened for cervical cancer. METHODOLOGY: A qualitative study was performed to understand the current barriers to screening and to identify strategies that could increase uptake in Azuay province, Ecuador. Seven focus group discussions (FGDs) were conducted with under-screened women and health professionals (HPs). The FGDs were recorded and transcribed. Content analysis was done using the socio-ecological framework to categorize and analyse the data. RESULTS: Overall, 28 women and 27 HPs participated in the study. The two groups perceived different barriers to cervical cancer screening. The HPs considered barriers to be mainly at the policy level (lack of a structured screening plan; lack of health promotion) and the individual level (lack of risk perception; personal beliefs). The women identified barriers mainly at organizational level, such as long waiting times, lack of access to health centres, and inadequate patient-physician communication. Both groups mentioned facilitators at policy level, such as national campaigns promoting cervical cancer screening, and at community and individual level, including health literacy and women's empowerment. CONCLUSIONS: The women considered access to health services the main barrier to screening, while the HPs identified a lack of investment in screening programmes and cultural patterns at the community level as major obstacles. To take an integrated approach to cervical cancer prevention, the perspectives of both groups should be taken into account. Additionally, new strategies and technologies, such as self-administered human papillomavirus (HPV) testing and community participation, should be implemented to increase access to cervical cancer screening.

Improving access to maternal health services among rural hard-to-reach fishing communities in Uganda, the role of community health workers.

OBJECTIVES: To explore whether community health worker household-based maternal health visits improve antenatal care and skilled birth attendance among hard-to-reach fishing villages on Lake Victoria, Uganda. METHODS: This quasi-experimental 18-month prospective study involved 486 consenting women aged 15-49 years, who were pregnant or had a pregnancy outcome in the past 6 months, from 6 island fishing communities. The community health worker household-based intervention (community health workers' household visits to provide counseling, blood pressure measurement, anemia, and HIV testing) involved 243 women from three fishing communities. Random effects logistic regression was used to determine the association between the community health worker intervention and antenatal care and skilled birth attendance among women who had at least 5 months of pregnancy or childbirth at follow-up. RESULTS: Almost all women accepted the community health worker intervention (90.9% (221/243)). Hypertension was at 12.5% (27/216) among those who accepted blood pressure measurements, a third (33.3% (9/27)) were pregnant. HIV prevalence was 23.5% (52/221). Over a third (34.2% (69/202)) of women tested had anemia (hemoglobin levels less than 11 g/dL). The community health worker intervention was associated with attendance of first antenatal care visit within 20 weeks of pregnancy (adjusted odd ratio = 2.1 (95% confidence interval 0.6-7.6)), attendance of at least four antenatal care visits (adjusted odd ratio = 0.9 (95% confidence interval 0.4-2.0)), and skilled birth attendance (adjusted odd ratio = 0.5 (95% confidence interval 0.1-1.5)), though not statistically significant. CONCLUSION: Community health workers have a crucial role in improving early antenatal care attendance, early community-based diagnosis of anemia, hypertensive disorders, and HIV among women in these hard-to-reach fishing communities.

Nevirapine hair and plasma concentrations and HIV-1 viral suppression among HIV infected ante-partum and post-partum women attended in a mother and child prevention program in Maputo city, Mozambique.

INTRODUCTION: Prevention of mother to child transmission of HIV (PMTCT) is frequently challenged by irregular access to more effective anti-retroviral therapy. Nevirapine single dose (sdNVP), sdNVP+AZT+3TC for MTCT prophylaxis and NVP+ AZT+3TC for treatment and PMTCT were withdrawn due to low genetic resistance barrier and low efficacy. However current PMTCT lines in Mozambique include DTG+3TC+TDF, TDF+3TC+EFV, DTG +ABC+3TC, and AZT + NVP syrup prophylaxis for exposed babies. We assessed NVP hair and plasma concentrations and association with HIV-1RNA suppression among HIV+ ante-partum and post-partum women under PMTCT in Maputo, Mozambique. METHODS: From December 2013 to November 2014, prospectively were enrolled 200 HIV+ ante-partum women on 200mg nevirapine and zidovudine 300 plus lamivudine 150mg twice daily at least with 3 months treatment and seen again at 24 weeks post-partum. Self-reported pill-taking adherence, NVP concentrations in hair, plasma, hemoglobin, CD4 cell count, HIV-1 RNA load was evaluated. NVP concentration in hair and plasma was analyzed as categorical quartile variable based on better data fit. NVP concentration was set between ≤3.77 ng/ml in plasma and ≤17,20 ng/mg in hair in quartile one to ≥5.36 ng/ml in plasma and ≥53.21 ng/mg in hair in quartile four. Logistic regression models for repeated measures were calculated. Following the World Health Organization (WHO) guidelines we set viral suppression at HIV-1RNA < 1000 c/mL. Outcome was HIV-1 RNA<1000 copies/ml. Predictor was NVP concentration in hair categorized in quartiles. RESULTS: In total 369 person-visits (median of 1.85) were recorded. Self-reported adherence was 98% (IQR 97-100%) at ante-partum. In 25% person visits, NVP concentrations were within therapeutic levels (3.77 ng/ml to 5.35 ng/ml) in plasma and (17.20 ng/mg to 53.20 ng/mg) in hair. In 50% person visits NVP concentrations were above 5.36 ng/ml in plasm and 53.21 ng/mg in hair. HIV-1 RNA suppression was found in 34.7% of women with two viral loads, one at enrollment and another in post-partum. Odds of HIV-1 RNA suppression in quartile 4, was about 6 times higher than in quartile 1 (p-value = 0.006) for NVP hair concentration and 7 times for NVP plasma concentration (p-value = 0.012). CONCLUSIONS: The study results alert for potential low efficacy of current PMTCT drug regimens in use in Mozambique. Affordable means for individual monitoring adherence, ART plasma and hair levels, drug resistant and HIV-1 RNA levels monitoring are recommended for prompt identification of inadequate drug regimens exposure patterns and adjust accordingly.

Towards a global framework for assessing male involvement in maternal health: results of an international Delphi study.

PURPOSE: Currently, no standard instrument exists for assessing the concept of male involvement in maternal health, hampering comparison of results and interpretation of the literature. The aim of this study was to construct the key elements of a global multidimensional male involvement framework, based on the latest evidence and input of experts in the field. METHODS: For this purpose, a Delphi study, including an international panel of 26 experts, was carried out. The study consisted of three rounds, with 92% of respondents completing all three surveys. Experts were asked to rate indicators within six categories in terms of validity, feasibility, sensitivity, specificity and context robustness. Furthermore, they were encouraged to clarify their rating with open text responses. Indicators were excluded or adapted according to experts' feedback before inclusion. A 85% agreement was used as threshold for consensus. RESULTS: A general consensus was reached for a global framework for assessing male involvement in maternal health, consisting of five categories: involvement in communication, involvement in decision-making, practical involvement, physical involvement and emotional involvement. CONCLUSIONS: Using the male involvement framework as a tool to assess the concept of male involvement in maternal health at local, national, and international levels could allow improved assessment and comparison of study findings. Further research is needed for refining the indicators according to context and exploring how shared decision-making, gender equality and women's empowerment can be assessed and facilitated within male involvement programmes.

Mobility for maternal health among women in hard-to-reach fishing communities on Lake Victoria, Uganda; a community-based cross-sectional survey.

BACKGROUND: Maternal mortality is still a challenge in Uganda, at 336 deaths per 100,000 live births, especially in rural hard to reach communities. Distance to a health facility influences maternal deaths. We explored women's mobility for maternal health, distances travelled for antenatal care (ANC) and childbirth among hard-to-reach Lake Victoria islands fishing communities (FCs) of Kalangala district, Uganda. METHODS: A cross sectional survey among 450 consenting women aged 15-49 years, with a prior childbirth was conducted in 6 islands FCs, during January-May 2018. Data was collected on socio-demographics, ANC, birth attendance, and distances travelled from residence to ANC or childbirth during the most recent childbirth. Regression modeling was used to determine factors associated with over 5 km travel distance and mobility for childbirth. RESULTS: The majority of women were residing in communities with a government (public) health facility [84.2 %, (379/450)]. Most ANC was at facilities within 5 km distance [72 %, (157/218)], while most women had travelled outside their communities for childbirth [58.9 %, (265/450)]. The longest distance travelled was 257.5 km for ANC and 426 km for childbirth attendance. Travel of over 5 km for childbirth was associated with adolescent girls and young women (AGYW) [AOR = 1.9, 95 % CI (1.1-3.6)], up to five years residency duration [AOR = 1.8, 95 % CI (1.0-3.3)], and absence of a public health facility in the community [AOR = 6.1, 95 % CI (1.4-27.1)]. Women who had stayed in the communities for up to 5 years [AOR = 3.0, 95 % CI (1.3-6.7)], those whose partners had completed at least eight years of formal education [AOR = 2.2, 95 % CI (1.0-4.7)], and those with up to one lifetime birth [AOR = 6.0, 95 % CI (2.0-18.1)] were likely to have moved to away from their communities for childbirth. CONCLUSIONS: Despite most women who attended ANC doing so within their communities, we observed that majority chose to give birth outside their communities. Longer travel distances were more likely among AGYW, among shorter term community residents and where public health facilities were absent. TRIAL REGISTRATION: PACTR201903906459874 (Retrospectively registered). https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5977 .

Systematic review of the concept 'male involvement in maternal health' by natural language processing and descriptive analysis.

INTRODUCTION: Experts agree that male involvement in maternal health is a multifaceted concept, but a robust assessment is lacking, hampering interpretation of the literature. This systematic review aims to examine the conceptualisation of male involvement in maternal health globally and review commonly used indicators. METHODS: PubMed, Embase, Scopus, Web of Science and CINAHL databases were searched for quantitative literature (between the years 2000 and 2020) containing indicators representing male involvement in maternal health, which was defined as the involvement, participation, engagement or support of men in all activities related to maternal health. RESULTS: After full-text review, 282 studies were included in the review. Most studies were conducted in Africa (43%), followed by North America (23%), Asia (15%) and Europe (12%). Descriptive and text mining analysis showed male involvement has been conceptualised by focusing on two main aspects: psychosocial support and instrumental support for maternal health care utilisation. Differences in measurement and topics were noted according to continent with Africa focusing on HIV prevention, North America and Europe on psychosocial health and stress, and Asia on nutrition. One-third of studies used one single indicator and no common pattern of indicators could be identified. Antenatal care attendance was the most used indicator (40%), followed by financial support (17%), presence during childbirth (17%) and HIV testing (14%). Majority of studies did not collect data from men directly. DISCUSSION: Researchers often focus on a single aspect of male involvement, resulting in a narrow set of indicators. Aspects such as communication, shared decision making and the subjective feeling of support have received little attention. We believe a broader holistic scope can broaden the potential of male involvement programmes and stimulate a gender-transformative approach. Further research is recommended to develop a robust and comprehensive set of indicators for assessing male involvement in maternal health.

The potential role of network-oriented interventions for survivors of sexual and gender-based violence among asylum seekers in Belgium.

BACKGROUND: Social support and social network members have been identified as an important factor in mitigating the effects of sexual and gender-based violence (SGBV) and improving the coping process for many survivors. Network oriented strategies have been advocated for among domestic violence survivors, as they help build on improving social support and addressing factors that alleviate repeat victimization. There are opportunities to implement such strategies among asylum seekers who are survivors of SGBV in asylum centres, however, this has not been fully explored. This study sought to identify key strategies and opportunities for developing peer-led and network-oriented strategies for mitigating the effects of SGBV among asylum seekers at these centres. METHODS: Twenty-seven interviews, were conducted with service providers (n = 14) / asylum seekers (n = 13) at three asylum centres in Belgium. A theoretical model developed by the research team from a literature review and discussions with experts and stakeholders, was used as a theoretical framework to analyse the data. An abduction approach with qualitative content analysis was used by the two researchers to analyse the data. Data triangulation was done with findings from observations at these centres over a period of a year. RESULTS: Many of the asylum seekers presented with PTSD or psychosomatic symptoms, because of different forms of SGBV, including intimate partner violence, or other trauma experienced during migration. Peer and family support were very influential in mitigating the effects and social costs of violence among the asylum seekers by providing emotional and material support. Social assistants were viewed as an information resource that was essential for most of the asylum seekers. Peer-peer support was identified as a potential tool for mitigating the effects of SGBV. CONCLUSION: Interventions involving asylum seekers and members of their network (especially peers), have the potential for improving physical and mental health outcomes of asylum seekers who are SGBV survivors.

Preparedness and Responses Faced during the COVID-19 Pandemic in Belgium: An Observational Study and Using the National Open Data.

This study aimed to descript the Belgian COVID-19 responses process according to the WHO's (World Health Organization) Health Emergency and Disaster Risk Management Framework (Health EDRM Framework) and to present the measures taken and epidemic impact in the different phases of COVID-19 in Belgium. The WHO's EDRM Framework was used for reviewing the Belgian Public health emergency preparedness and responses in the context of COVID-19. Information on the measures taken was collected through the literature review including all government's communication, reports, and scientific papers. All epidemic data were extracted from a national open database managed and published by the Sciensano. Additionally, two authors closely followed the Belgian situation since the beginning of the pandemic and updated the data every day. During the COVID-19 pandemic, the anti-epidemic strategy was mainly to avoid medical resources exceeding the upper limit. Belgium issued a series of emergency decrees to limit the spread of the virus. An existing structure of "federal-region-municipal" as the framework of public health emergency preparedness and response was adapted. The emergency response process in Belgium was divided into four phases: information-evaluation-coordination-decision-making at the region level and the final decision-making at the federal level. Belgium also implemented a phased plan in the process of setting up and lifting the lockdown. However, it was vulnerable in early response, due to the shortage of medical equipment supplies in general, and more particularly for the long term care facilities (LTCFs). Belgium has achieved an intensive cooperation between stakeholders based on an existing multisectoral emergency organization framework. Legislation, medical insurance, and good communication also played a role in limiting the spread of viruses. However, the authorities underestimated the risk of an epidemic and did not take quarantine measures among people suspected affected by SARS-COV-2 in the early stages, resulting in insufficient medical equipment supply and a large number of deaths in the LTCF. The implementation of the lockdown measure in Belgium also encountered obstacles. The lockdown and its exit strategy were both closely related to the pandemic situation and social and economic life. The authorities should strengthen information management, improve the public awareness of the measures, and find out the balance points between the social and economic life and infection control measures.

A qualitative study on midwives' identity and perspectives on the occurrence of disrespect and abuse in Maputo city.

BACKGROUND: Midwifery care plays a vital role in the reduction of preventable maternal and newborn mortality and morbidity. There is a growing concern about the quality of care during facility based childbirth and the occurrence of disrespect and abuse (D&A) worldwide. While several studies have reported a high prevalence of D&A, evidence about the drivers of D&A is scarce. This study aims to explore midwives' professional identity and perspectives on the occurrence of D&A in urban Mozambique. METHODS: A qualitative study took place in the central hospital of Maputo, Mozambique. Nine focus group discussions with midwives were conducted, interviewing 54 midwives. RQDA software was used for analysing the data by open coding and thematic analysis from a grounded theory perspective. RESULTS: Midwives felt proud of their profession but felt they were disrespected by the institution and wider society because of their inferior status compared to doctors. Furthermore, they felt blamed for poor health outcomes. The occurrence of D&A seemed more likely in emergency situations but midwives tended to blame this on women being "uncooperative". The involvement of birth companions was a protective factor against D&A together with supervision. CONCLUSION: In order to improve quality of care and reduce the occurrence of D&A midwives will need to be treated with more respect within the health system. Furthermore, they should be trained in handling obstetric emergency situations with respect and dignity for the patient. Systematic and constructive supervision might be another promising strategy for preventing D&A.

A cross-sectional study of the role of men and the knowledge of danger signs during pregnancy in southern Mozambique.

BACKGROUND: The role of the male partner and wider family in maternal health, especially in case of emergencies, has been receiving increasing attention over the last decade. Qualitative research has highlighted that women depend on others to access high quality maternity care. Currently little is known about these factors in relation to maternal health in Mozambique. METHODS: A cross sectional household survey was conducted with men and women in southern Mozambique about decision making, financial support and knowledge of danger signs. A multivariable logistic model was used to identify factors associated with knowledge of danger signs and Cohen's kappa for agreement among couples. RESULTS: A total of 775 men and women from Marracuene and Manhica districts were interviewed. Maternal health care decisions were frequently made jointly by the couple (32-49%) and financial support was mainly provided by the man (46-80%). Parental and parent-in-law involvement in decision making and financial support was minimal (0-3%). The average number of danger signs respondents knew was 2.05 and no significant difference (p = 0.294) was found between men and women. Communication with the partner was a significant predictor for higher knowledge of danger signs for both men (p = 0.01) and women (p = 0.03). There was very low agreement within couples regarding decision making (p = 0.04), financial support (p = 0.01) and presence at antenatal care consultations (p = 0.001). Results suggest women and men have a high willingness for more male participation in antenatal care, although their understanding of what constitutes this participation is not clear. CONCLUSION: The study findings highlight the important role men play in decision making and financial support for maternal health care issues. Strengthening male involvement in antenatal care services, by investing in counselling and receiving couples, could help accelerate gains in maternal health in Mozambique. Maternal health care studies should collect more data from men directly as men and women often report different views and behavior regarding maternal health care issues and male involvement.

Components of antenatal care received by women in fishing communities on Lake Victoria, Uganda; a cross sectional survey.

BACKGROUND: Uganda has one of the highest maternal deaths at a ratio of 336 per 100,000 live births. As Uganda strives to achieve sustainable development goals, appropriate antenatal care is key to reduction of maternal mortality. We explored women's reported receipt of seven of the Uganda guidelines components of antenatal care, and associated factors in hard to reach Lake Victoria island fishing communities of Kalangala district. METHODS: A cross sectional survey among 486 consenting women aged 15-49 years, who were pregnant at any time in the past 6 months was conducted in 6 island fishing communities of Kalangala district, Uganda, during January-May 2018. Interviewer administered questionnaires, were used to collect data on socio-demographics and receipt of seven of the Uganda guidelines components of antenatal care. Regression modeling was used to determine factors associated with receipt of all seven components. RESULTS: Over three fifths (65.0%) had at least one ANC visit during current or most recent pregnancy. Fewer than a quarter of women who reported attending care at least four times received all seven ANC components [(23.6%), P < 0.05]. Women who reported receipt of ANC from the mainland were twice as likely to have received all seven components as those who received care from islands (aOR = 1.8; 95% CI:0.9-3.7). Receipt of care from a doctor was associated with thrice likelihood of receiving all components relative to ANC by a midwife or nurse (aOR = 3.2; 95% CI:1.1-9.1). CONCLUSIONS: We observed that the delivery of antenatal care components per Ugandan guidelines is poor in these communities. Cost effective endeavors to improve components of antenatal care received by women are urgently needed. Task shifting some components of ANC to community health workers may improve care in these island communities. TRIAL REGISTRATION: PACTR201903906459874 (Retrospectively registered).

Universal cervical cancer control through a right to health lens: refocusing national policy and programmes on underserved women.

BACKGROUND: Cervical cancer claims 311,000 lives annually, and 90% of these deaths occur in low- and middle-income countries. Cervical cancer is a highly preventable and treatable disease, if detected through screening at an early stage. Governments have a responsibility to screen women for precancerous cervical lesions. Yet, national screening programmes overlook many poor women and those marginalised in society. Under-screened women (called hard-to-reach) experience a higher incidence of cervical cancer and elevated mortality rates compared to regularly-screened women. Such inequalities deprive hard-to-reach women of the full enjoyment of their right to sexual and reproductive health, as laid out in Article 12 of the International Covenant on Economic, Social and Cultural Rights and General Comment No. 22. DISCUSSION: This article argues first for tailored and innovative national cervical cancer screening programmes (NCSP) grounded in human rights law, to close the disparity between women who are afforded screening and those who are not. Second, acknowledging socioeconomic disparities requires governments to adopt and refine universal cancer control through NCSPs aligned with human rights duties, including to reach all eligible women. Commonly reported- and chronically under-addressed- screening disparities relate to the availability of sufficient health facilities and human resources (example from Kenya), the physical accessibility of health services for rural and remote populations (example from Brazil), and the accessibility of information sensitive to cultural, ethnic, and linguistic barriers (example from Ecuador). Third, governments can adopt new technologies to overcome individual and structural barriers to cervical cancer screening. National cervical cancer screening programmes should tailor screening methods to under-screened women, bearing in mind that eliminating systemic discrimination may require committing greater resources to traditionally neglected groups. CONCLUSION: Governments have human rights obligations to refocus screening policies and programmes on women who are disproportionately affected by discrimination that impairs their full enjoyment of the right to sexual and reproductive health. National cervical cancer screening programmes that keep the right to health principles (above) central will be able to expand screening among low-income, isolated and other marginalised populations, but also women in general, who, for a variety of reasons, do not visit healthcare providers for regular screenings.

A systematic review of intimate partner violence interventions focused on improving social support and/ mental health outcomes of survivors.

BACKGROUND: Intimate partner violence (IPV) is a key public health issue, with a myriad of physical, sexual and emotional consequences for the survivors of violence. Social support has been found to be an important factor in mitigating and moderating the consequences of IPV and improving health outcomes. This study's objective was to identify and assess network oriented and support mediated IPV interventions, focused on improving mental health outcomes among IPV survivors. METHODS: A systematic scoping review of the literature was done adhering to PRISMA guidelines. The search covered a period of 1980 to 2017 with no language restrictions across the following databases, Medline, Embase, Web of Science, PROQUEST, and Cochrane. Studies were included if they were primary studies of IPV interventions targeted at survivors focused on improving access to social support, mental health outcomes and access to resources for survivors. RESULTS: 337 articles were subjected to full text screening, of which 27 articles met screening criteria. The review included both quantitative and qualitative articles. As the focus of the review was on social support, we identified interventions that were i) focused on individual IPV survivors and improving their access to resources and coping strategies, and ii) interventions focused on both individual IPV survivors as well as their communities and networks. We categorized social support interventions identified by the review as Survivor focused, advocate/case management interventions (15 studies), survivor focused, advocate/case management interventions with a psychotherapy component (3 studies), community-focused, social support interventions (6 studies), community-focused, social support interventions with a psychotherapy component (3 studies). Most of the studies, resulted in improvements in social support and/or mental health outcomes of survivors, with little evidence of their effect on IPV reduction or increase in healthcare utilization. CONCLUSION: There is good evidence of the effect of IPV interventions focused on improving access to social support through the use of advocates with strong linkages with community based structures and networks, on better mental health outcomes of survivors, there is a need for more robust/ high quality research to assess in what contexts and for whom, these interventions work better compared to other forms of IPV interventions.

Induced abortion: a cross-sectional study on knowledge of and attitudes toward the new abortion law in Maputo and Quelimane cities, Mozambique.

BACKGROUND: Maternal mortality, of which 6.7% is attributable to abortion complications, remains high in Mozambique. The objective of this paper is to assess the level of induced abortion at the community, as well as to assess awareness of and attitudes towards the new abortion law among women of reproductive age in suburban areas of Maputo and Quelimane cities. METHODS: A cross-sectional household survey among women aged 15-49 years in Maputo and Quelimane cities was conducted using a multi-stage clustered sampling design. Data on sociodemographic characteristics, maternal outcomes, contraceptive use, knowledge and attitudes towards the new abortion law were collected. Bivariate and multiple logistic regression analysis using the complex samples procedure in SPSS were applied. RESULTS: A total of 1657 women (827 Maputo and 830 Quelimane) were interviewed between August 2016 and February 2017. The mean age was 27 years; 45.7% were married and 75.5% had ever been pregnant. 9.2% of the women reported having had an induced abortion, of which 20.0% (17) had unsafe abortion. Of the respondents, 28.8% knew the new legal status of abortion. 17% thought that the legalization of abortion was beneficial to women's health. Having ever been pregnant, being unmarried, student, Muslim, as well as residing in Maputo were associated with higher odds of having knowledge of the new abortion law. CONCLUSION: Reports of abortion appear to be low compared to other studies from Sub-Saharan African countries. Furthermore, respondents demonstrated limited knowledge of the abortion law. Social factors such as education status, religion, residence in a large city as well as pregnancy history were associated with having knowledge of the abortion law. Only a small percentage of women perceived abortion as beneficial to women's health. There is a need for widespread sensitization about the new law and its benefits.