Advancing maternal and perinatal health in low- and middle-income countries: A multi-country review of policies and programmes.

The Sustainable Development Goals prioritize maternal mortality reduction, with a global average target of < 70 per 100,000 live births by 2030. Current pace of reduction is far short of what is needed to achieve the global target. It is estimated that globally there are 300,000 maternal deaths, 2.4 million newborn deaths and 2 million stillbirths annually. Majority of these deaths occur in low-and-middle-income countries. Global initiatives like, Ending Preventable Maternal Mortality (EPMM) and Every Newborn Action Plan (ENAP), have outlined the broad strategies for maternal and newborn health programmes. A set of coverage targets and ten milestones were launched to support low-and-middle-income countries in accelerating progress in improving maternal, perinatal and newborn health and wellbeing. WHO, UNICEF and UNFPA, undertook a scoping review to understand how country strategies evolved in different contexts over the past two decades to improve maternal survival and wellbeing, and how countries in similar settings could accelerate progress considering the changing epidemiology and demography. Case studies were conducted to inform countries in similar settings and various global initiatives. Six countries were selected based on standard criteria-Cambodia, Democratic Republic of the Congo, Georgia, Guatemala, Pakistan and Sierra Leone representing different stages of the obstetric transition. A conceptual framework, encapsulating the interrelated factors impacting maternal health outcomes, was used to organize data collection and analysis. While all six countries made remarkable progress in improving maternal and perinatal health, the pace of progress and the factors influencing the successes and challenges varied across the countries. The context, opportunities and challenges varied from country to country. Two strategic directions were identified for next steps including the need to implement and evaluate innovative service delivery models using an updated obstetric transition as an organizing framework and expanding our vision to address equity and well-being.

Midwifery curricula inclusion of sexual and reproductive health in crisis settings in the Democratic Republic of Congo.

AIM: This discussion paper aims to argue for the inclusion of the Minimum Initial Service Package (MISP) for sexual and reproductive health in crisis settings in all midwifery curricula. BACKGROUND: The Democratic Republic of Congo continues to experience long-standing humanitarian crises that have affected the population's health, especially in relation to sexual violence and other sexual and reproductive health issues. The MISP was established in 1996 to meet the most vital sexual and reproductive health needs of crisis-affected populations and has become an international minimum standard in humanitarian response. DESIGN: Case study. METHODS: This paper is a case presentation describing the process and lessons learned related to the introduction of the MISP into the first- and third-year pre-service midwifery curricula at multiple midwifery education facilities in the Democratic Republic of Congo. RESULTS: Six main lessons were identified during the initial implementation phases of the revised midwifery curricula: seizing the opportunity to influence long-term change, engaging teamwork, addressing instructors' concerns, mobilizing resources for curriculum implementation, assessing school infrastructure readiness during field visits, and meeting immediate humanitarian needs with in-service training. The lessons learned may assist other nations experiencing humanitarian crises with the implementation of the MISP. CONCLUSIONS: This pre-service training strategy holds promise for both a sustainable and prompt solution to bridge the gap in competent human resources to deliver quality sexual and reproductive health services in humanitarian settings.

Situation analysis for delivering integrated comprehensive sexual and reproductive health services for displaced population of Kasaï, Democratic Republic of Congo: Protocol for a mixed method study.

INTRODUCTION: Delivering integrated sexual and reproductive health services (SRHS) in emergencies is important in order to save lives of the most vulnerable as well as to combat poverty, reduce inequities and social injustice. More than 60% of preventable maternal deaths occur in conflict areas and especially among the internally displaced persons (IDP). Between 2016 and 2018, unprecedented violence erupted in the Kasaï's region, in the Democratic Republic of Congo (DRC), called the Kamuina Nsapu Insurgency. During that period, an estimated three million of adolescent girls and women were forced to flee; and have faced growing threat to their health, safety, security, and well-being including significant sexual and reproductive health challenges. Between August 2016 and May 2017, the "Sous-Cluster sur les violences basées sur le genre (SC-VBG)" in DRC (2017) reported 1,429 Gender Based Violence (GBV) incidents in the 49 service delivery points in the provinces of Kasaï, Kasaï Central and Kasaï Oriental. Rape cases represented 79% of reported incidents whereas sexual assault and forced marriage accounted for respectively 11% and 4% of Gender Based Violence (GBV) among women and adolescent girls. This study aims to assess the availability of SRHS in the displaced camps in Kasaï; to evaluate the SRHS needs of young girls and women in the reproductive age (12-49). Studies of sexual and reproductive health (SRH) in the Democratic Republic of Congo (DRC) have often included adolescent girls under the age of 15 because of high prevalence of child marriage and early onset of childbearing, especially in the humanitarian context. According to the 2013 Demographic and Health Survey (DHS), about 16% of surveyed women got married by age 14 while the prevalence of early child marriage (marriage by 15) was estimated at 30%; to assess the use of SRHS services and identify barriers as well as challenges for SRH service delivery and use. Findings from this study will help provide evidence to inform towards more needs-based and responsive SRH service delivery. This is hoped for ultimately improve the quality and effectiveness of services, when considering service delivery and response in humanitarian settings. DATA AND METHODS: We will conduct a mixed-methods study design, which will combine quantitative and qualitative approaches. Based on the estimation of the sample size, quantitative data will be drawn from the community-based survey (500 women of reproductive age per site) and health facility assessments will include assessments of 45 health facilities and 135 health providers' interviews. Qualitative data will comprise materials from 30 Key Informant Interviews (KII) and 24 Focus Group Discussions (FGDs), which are believed to achieve the needed saturation levels. Data analysis will include thematic and content analysis for the KIIs and FGDs using ATLAS.ti software for the qualitative arm. For the quantitative arm, data analysis will combine frequency and bivariate chi-square analysis, coupled with multi-level regression models, using Stata 15 software. Statistic differences will be established at the significance level of 0.05. We submitted this protocol to the national ethical committee of the ministry of health in September 2019 and it was approved in January 2020. It needs further approval from the Scientific Oversee Committee (SOC) and the Provincial Ministry of Health. Prior to data collection, informed consents will be obtained from all respondents.

Integrating sexual and reproductive health into health system strengthening in humanitarian settings: a planning workshop toolkit to transition from minimum to comprehensive services in the Democratic Republic of Congo, Bangladesh, and Yemen.

BACKGROUND: Planning to transition from the Minimum Initial Service Package for Sexual and Reproductive Health (SRH) toward comprehensive SRH services has been a challenge in humanitarian settings. To bridge this gap, a workshop toolkit for SRH coordinators was designed to support effective planning. This article aims to describe the toolkit design, piloting, and final product. METHODS: Anchored in the Health System Building Blocks Framework of the World Health Organization, the design entailed two complementary and participatory strategies. First, a collaborative design phase with iterative feedback loops involved global partners with extensive operational experience in the initial toolkit conception. The second phase engaged stakeholders from three major humanitarian crises to participate in pilot workshops to contextualize, evaluate, validate, and improve the toolkit using qualitative interviews and end-of-workshop evaluations. The aim of this two-phase design process was to finalize a planning toolkit that can be utilized in and adapted to diverse humanitarian contexts, and efficiently and effectively meet its objectives. Pilots occurred in the Democratic Republic of Congo for the Kasai region crisis, Bangladesh for the Rohingya humanitarian response in Cox's Bazar, and Yemen for selected Governorates. RESULTS: Results suggest that the toolkit enabled facilitators to foster a systematic, participatory, interactive, and inclusive planning process among participants over a two-day workshop. The approach was reportedly effective and time-efficient in producing a joint work plan. The main planning priorities cutting across settings included improving comprehensive SRH services in general, healthcare workforce strengthening, such as midwifery capacity development, increasing community mobilization and engagement, focusing on adolescent SRH, and enhancing maternal and newborn health services in terms of quality, coverage, and referral pathways. Recommendations for improvement included a dedicated and adequately anticipated pre-workshop preparation to gather relevant data, encouraging participants to undertake preliminary study to equalize knowledge to partake fully in the workshop, and enlisting participants from marginalized and underserved populations. CONCLUSION: Collaborative design and piloting efforts resulted in a workshop toolkit that could support a systematic and efficient identification of priority activities and services related to comprehensive SRH. Such priorities could help meet the SRH needs of communities emerging from acute humanitarian situations while strengthening the overall health system.

Effectiveness of post-partum family planning interventions on contraceptive use and method mix at 1 year after childbirth in Kinshasa, DR Congo (Yam Daabo): a single-blind, cluster-randomised controlled trial.

BACKGROUND: In rural Burkina Faso, a package of six low-technology, post-partum contraceptive interventions (ie, refresher training for providers, a counselling tool, supportive supervision, daily availability of contraceptive services, client appointment cards, and invitation letters to attend appointments for partners), aimed at strengthening existing primary health-care services and enhancing demand for them, doubled the use of modern contraceptives at 12 months post partum (ie, 55% uptake in intervention recipients vs 29% in routine-care users). This study assessed the effect of a similar package but in urban settings of Kinshasa province, Democratic Republic of the Congo, in an effort to reduce the unmet need for post-partum family planning. METHODS: Yam Daabo was a multi-intervention, single-blinded, cluster-randomised controlled trial done in six primary health-care centres (clusters) in Kinshasa. Centres were randomly allocated to receive the six-component intervention or standard antenatal and postnatal care in matched pairs (1:1) on the basis of number of monthly births, the ratio of health workers per population in the health zone, and the urban and suburban settings. Only data analysts could be masked to cluster allocation. Health-care facilities were eligible if they provided a continuum of antenatal, delivery, and postnatal care, were well stocked with contraceptives, and were situated close to the main study centre. All pregnant women presenting to the six centres were eligible if they were in their third pregnancy trimester and had no counterindications to deliver in the facility. The main outcome was prevalence of use of modern contraceptives at 12 months after delivery. Analysis was by modified intention-to-treat using generalised linear mixed models or Fisher's exact test for small groups. Prevalence ratios were adjusted for cluster effects and baseline characteristics. This study was registered with the Pan-African Clinical Trials Registry (PACTR201609001784334). FINDINGS: From July 1, 2016, to Feb 2, 2017, eight of 52 clinics assessed for eligibility met the criteria and were randomised. Of 690 women approached, 576 (83%) women were enrolled: 286 in the four intervention clusters and 290 in the four control clusters. Of them, 519 (90%) completed the 12-month study exit interview (252 in the intervention group and 267 in the control group) and were included in the intention-to-treat analysis. At 12 months, 115 (46%) of 252 women in the intervention group and 94 (35%) of 267 in the control group were using modern contraceptives (adjusted prevalence ratio [PR] 1·58, 95% CI 0·74-3·38), with significant differences in the use of contraceptive implants (22% vs 6%; adjusted PR 4·36, 95% CI 1·96-9·70), but without difference in the use of short-acting contraceptives (23% vs 28%; 0·92, 0·29-2·98) and non-modern or inappropriate methods (7% vs 18%; 0·45, 0·13-1·54). There were no serious adverse events or maternal deaths related to the study. INTERPRETATION: The Yam Daabo intervention package did not have a significant effect on the overall use of effective modern contraceptives but significantly increased implant use in women post partum who live in urban settings in Kinshasa up to a year after childbirth. However, interferences from external family planning initiatives in the control group might have diminished differences between the services received. Such an intervention could be potentially relevant in similar contexts in DR Congo and other countries. FUNDING: Government of France; UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Participatory action research to identify a package of interventions to promote postpartum family planning in Burkina Faso and the Democratic Republic of Congo.

BACKGROUND: The YAM DAABO study ("your choice" in Mooré) takes place in Burkina Faso and the Democratic Republic of Congo. It has the objective to identify a package of postpartum family planning (PPFP) interventions to strengthen primary healthcare services and determine its effectiveness on contraceptive uptake during the first year postpartum. This article presents the process of identifying the PPFP interventions and its detailed contents. METHODS: Based on participatory action research principles, we adopted an inclusive process with two complementary approaches: a bottom-up formative approach and a circular reflective approach, both of which involved a wide range of stakeholders. For the bottom-up component, we worked in each country in three formative sites and used qualitative methods to identify barriers and catalysts to PPFP uptake. The results informed the package design which occurred during the circular reflective approach - a research workshop gathering service providers, members of both country research teams, and the WHO coordination team. RESULTS: As barriers and catalysts were found to be similar in both countries and with the view to scaling up our strategy to other comparable settings, we identified a common package of six low-cost, low-technology, and easily-scalable interventions that addressed the main service delivery obstacles related to PPFP: (1) refresher training of service providers, (2) regularly scheduled and strengthened supportive supervision of service providers, (3) enhanced availability of services 7 days a week, (4) a counseling tool, (5) appointment cards for women, and (6) invitation letters for partners. CONCLUSIONS: Our research strategy assumes that postpartum contraceptive uptake can be increased by supporting providers, enhancing the availability of services, and engaging women and their partners. The package does not promote any modern contraceptive method over another but prioritizes the importance of women's right to information and choice regarding postpartum fertility options. The effectiveness of the package will be studied in the experimental phase. If found to be effective, this intervention package may be relevant to and scalable in other parts of Burkina Faso and the DRC, and possibly other Sub-Saharan countries. TRIAL REGISTRATION: Retrospectively registered in the Pan African Clinical Trials Registry ( PACTR201609001784334 , 27 September 2016).

Birth spacing and informed family planning choices after childbirth in Burkina Faso and the Democratic Republic of Congo: Participatory action research to design and evaluate a decision-making tool for providers and their clients.

OBJECTIVES: Postpartum family planning (PPFP) is essential for maternal and newborn health but is often not systematically addressed before or after childbirth. This article describes the development and field-testing of a PPFP counseling tool to support providers and women. METHODS: Participatory action research involving women, men, providers, policymakers, researchers, and contraceptive experts from Burkina Faso and the Democratic Republic of Congo. RESULTS: The tool consists of an A4-size flipchart with illustrations on the client side and clinical information and counseling tips on the provider side, and can be used during visits of the antenatal-delivery-postnatal care continuum. Qualitative results suggest that the tool is easily understandable, user-friendly, relevant, and useful with regard to providing PPFP information to clients, and respectful of clients' rights and choices. It may have a positive influence on clients' attitudes towards PPFP and their decision to use contraception. CONCLUSIONS: The tool holds promise in guiding a systematic discussion on birth spacing options among providers and clients. Its impact on contraceptive uptake requires further research. PRACTICE IMPLICATIONS: If proven effective, the tool could be disseminated to Ministries of Health and local, regional, and global partners to strengthen national family planning and maternal and child health strategies in low-resource countries.