Factors that influence the uptake of postnatal care from the perspective of fathers, partners and other family members: a qualitative evidence synthesis.

BACKGROUND: Postnatal care (PNC) is a key component of maternity provision and presents opportunities for healthcare providers to optimise the health and well-being of women and newborns. However, PNC is often undervalued by parents, family members and healthcare providers. As part of a larger qualitative review exploring the factors that influence PNC uptake by relevant stakeholders, we examined a subset of studies highlighting the views of fathers, partners and family members of postpartum women. METHODS: We undertook a qualitative evidence synthesis using a framework synthesis approach. We searched multiple databases and included studies with extractable qualitative data focusing on PNC utilisation. We identified and labelled a subset of articles reflecting the views of fathers, partners and other family members. Data abstraction and quality assessment were carried out using a bespoke data extraction form and established quality assessment tools. The framework was developed a priori based on previous research on the topic and adapted accordingly. Findings were assessed for confidence using the GRADE-CERQual approach and are presented by country income group. RESULTS: Of 12 678 papers identified from the original search, 109 were tagged as 'family members views' and, of these, 30 were eligible for this review. Twenty-nine incorporated fathers' views, 7 included the views of grandmothers or mothers-in-law, 4 incorporated other family member views and 1 included comothers. Four themes emerged: access and availability; adapting to fatherhood; sociocultural influences and experiences of care. These findings highlight the significant role played by fathers and family members on the uptake of PNC by women as well as the distinct concerns and needs of fathers during the early postnatal period. CONCLUSION: To optimise access to postnatal care, health providers should adopt a more inclusive approach incorporating flexible contact opportunities, the availability of more 'family-friendly' information and access to psychosocial support services for both parents.

Engaging women and men in the gender-synchronised, community-based Mbereko+Men intervention to improve maternal mental health and perinatal care-seeking in Manicaland, Zimbabwe: A cluster-randomised controlled pragmatic trial.

Background: Maternal mental morbidity and low perinatal health service utilisation in resource-constrained settings contribute substantially to the global burden of poor maternal, newborn, and child health. The community-based Mbereko+Men program in rural Zimbabwe engaged women and men in complementary activities to improve men's support for women and babies, coparents' equitable, informed health decision-making, and ultimately, maternal mental health and care-seeking for maternal and newborn health services. The study aimed to test the effectiveness of the Mbereko+Men program on maternal mental health at 0-6 months after childbirth. Methods: We conducted a cluster-randomised controlled pragmatic trial using a two-arm parallel design with four clusters per arm. Data was data collected through cross-sectional surveys before and after the implementation of the intervention or standard care. Rural health facility catchments in Mutasa District, Zimbabwe, were randomised using a true random number sequence. Survey participants were women who had given birth within 0-6 months and their male coparents. The primary outcome was women's mean Edinburgh Postnatal Depression Scale (EPDS) score. Secondary outcomes captured care-seeking, men's supportive behaviours, and gender dynamics in coparent relationships. Masking was not used. All clusters were included in the analysis. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620001014943) in October 2020. Results: Between April 13 and May 20, 2016, 457 women and 242 men participated in the pre-intervention survey; between October 19 and November 30, 2017, 433 women and 273 men participated in the post-intervention survey. Women's mean EPDS scores declined in both arms. The decline was 34% greater in the intervention arm (adjusted risk ratio = 0.66; 95% confidence interval = 0.48, 0.90, P = 0.008). Improvements in care-seeking, men's support, and coparents' relationships were detected. Conclusions: A low-intensity gender-synchronised intervention engaged women and men to improve maternal mental health and care-seeking in a setting characterised by gender inequality and demand-side barriers to care.

How do women, men, and health providers perceive interventions to influence men's engagement in maternal and newborn health? A qualitative evidence synthesis.

Globally, there is growing awareness of the important contributions men can make as key stakeholders in maternal and newborn health (MNH), and increased investment in interventions designed to influence men's engagement to improve MNH outcomes. Interventions typically target men, women, couples or health providers, yet how these stakeholders perceive and experience interventions is not well understood and the fact that women may experience these interventions as disempowering has been identified as a major concern. This review aims to synthesise how women, men, and providers perceive and experience interventions designed to influence men's engagement in MNH, in order to identify perceived benefits and risks of participating in interventions, and other key factors affecting uptake of and adherence to interventions. We conducted a qualitative evidence synthesis based on a systematic search of the literature, analysing a purposive sample of 66 out of 144 included studies to enable rich synthesis. Women, men and providers report that interventions enable more and better care for women, newborns and men, and strengthen family relationships between the newborn, father and mother. At the same time, stakeholders report that poorly designed or implemented interventions carry risks of harm, including constraining some women's access to MNH services and compounding negative impacts of existing gender inequalities. Limited health system capacity to deliver men-friendly MNH services, and pervasive gender inequality, can limit the accessibility and acceptability of interventions. Sociodemographic factors, household needs, and peer networks can influence how men choose to support MNH, and may affect demand for and adherence to interventions. Overall, perceived benefits of interventions designed to influence men's engagement in MNH are compelling, reported risks of harm are likely manageable through careful implementation, and there is clear evidence of demand from women and men, and some providers, for increased opportunities and support for men to engage in MNH.

Defining Preterm Birth and Stillbirth in the Western Pacific: A Systematic Review.

Preterm birth and stillbirth are important global perinatal health indicators. Definitions of these indicators can differ between countries, affecting comparability of preterm birth and stillbirth rates across countries. This study aimed to document national-level adherence to World Health Organization (WHO) definitions of preterm birth and stillbirth in the WHO Western Pacific region. A systematic search of government health websites and 4 electronic databases was conducted. Any official report or published study describing the national definition of preterm birth or stillbirth published between 2000 and 2020 was eligible for inclusion. A total of 58 data sources from 21 countries were identified. There was considerable variation in how preterm birth and stillbirth was defined across the region. The most frequently used lower gestational age threshold for viability of preterm birth was 28 weeks gestation (range 20-28 weeks), and stillbirth was most frequently classified from 20 weeks gestation (range 12-28 weeks). High-income countries more frequently used earlier gestational ages for preterm birth and stillbirth compared with low- to middle-income countries. The findings highlight the importance of clear, standardized, internationally comparable definitions for perinatal indicators. Further research is needed to determine the impact on regional preterm birth and stillbirth rates.

The prevalence of uterine fundal pressure during the second stage of labour for women giving birth in health facilities: a systematic review and meta-analysis.

BACKGROUND: Uterine fundal pressure involves a birth attendant pushing on the woman's uterine fundus to assist vaginal birth. It is used in some clinical settings, though guidelines recommend against it. This systematic review aimed to determine the prevalence of uterine fundal pressure during the second stage of labour for women giving birth vaginally at health facilities. METHODS: The population of interest were women who experienced labour in a health facility and in whom vaginal birth was anticipated. The primary outcome was the use of fundal pressure during second stage of labour. MEDLINE, EMBASE, CINAHL and Global Index Medicus databases were searched for eligible studies published from 1 January 2000 onwards. Meta-analysis was conducted to determine a pooled prevalence, with subgroup analyses to explore heterogeneity. RESULTS: Eighty data sets from 76 studies (n = 898,544 women) were included, reporting data from 22 countries. The prevalence of fundal pressure ranged from 0.6% to 69.2% between studies, with a pooled prevalence of 23.2% (95% CI 19.4-27.0, I2 = 99.97%). There were significant differences in prevalence between country income level (p < 0.001, prevalence highest in lower-middle income countries) and method of measuring use of fundal pressure (p = 0.001, prevalence highest in studies that measured fundal pressure based on women's self-report). CONCLUSIONS: The use of uterine fundal pressure on women during vaginal birth in health facilities is widespread. Efforts to prevent this potentially unnecessary and harmful practice are needed.

Uterine fundal pressure involves a health worker pushing on the uppermost part of a woman's abdomen during the pushing phase of labour, with the aim of assisting or accelerating vaginal birth. The World Health Organization and other bodies specifically recommend against the use of fundal pressure, as it is not beneficial and is potentially harmful to women. This study undertook a review to determine how often fundal pressure is used on women giving birth in hospitals around the world. We searched five databases and found 76 studies from 22 countries. We determined that 23.2% of women experience some form of fundal pressure during the pushing phase of labour. Results between studies varied widely, ranging from 0.6% to 69.2% of women experiencing some form of fundal pressure. This may be due to different study populations, or different methods of assessing or documenting fundal pressure use. It may also reflect differences in clinical practice or guidelines. Despite these differences, our findings indicate uterine fundal pressure is still widespread and efforts to prevent this potentially unnecessary and harmful practice are needed.

Men's and women's knowledge of danger signs relevant to postnatal and neonatal care-seeking: A cross sectional study from Bungoma County, Kenya.

BACKGROUND: Neonatal and maternal mortality rates remain high in Kenya. Knowledge of neonatal danger signs may reduce delay in deciding to seek care. Evidence is emerging on the influential role of male partners in improving maternal and newborn health. This study analysed the factors that determine men's and women's knowledge and practices in postnatal and neonatal care-seeking, in order to inform design of future interventions. METHODS: A quantitative, cross-sectional study was undertaken in Bungoma County, Kenya. Women who had recently given birth (n = 348) and men whose wives had recently given birth (n = 82) completed questionnaires on knowledge and care-seeking practices relating to the postnatal period. Univariate and multivariate logistic regression analyses were performed to investigate associations with key maternal and newborn health outcomes. RESULTS: 51.2% of women and 50.0% of men knew at least one neonatal danger sign, however women knew more individual danger signs than men. In the univariate model, women's knowledge of a least one neonatal danger sign was associated with attending antenatal care ≥4 times (OR 4.46, 95%CI 2.73-7.29, p<0.001), facility birth (OR 3.26, 95%CI 1.89-5.72, p<0.001), and having a male partner accompany them to antenatal care (OR 3.34, 95%CI 1.35-8.27, p = 0.009). Higher monthly household income (≥10,000KSh, approximately US$100) was associated with facility delivery (AOR 11.99, 95%CI 1.59-90.40, p = 0.009). CONCLUSION: Knowledge of neonatal danger signs was low, however there was an association between knowledge of danger signs and increased healthcare service use, including male partner involvement in antenatal care. Future interventions should consider the extra costs of facility delivery and the barriers to men participating in antenatal and postnatal care.

Women's sleep position during pregnancy in low- and middle-income countries: a systematic review.

BACKGROUND: Approximately 2.6 million babies are stillborn each year globally, of which 98% occur in low- and middle-income countries (LMICs). A 2019 individual participant data meta-analysis of 6 studies from high-income countries found that maternal supine going-to-sleep position increased the risk of stillbirth. It is not clear whether this impact would be the same in LMICs, and the normal sleep behaviour of pregnant women in LMICs is not well understood. OBJECTIVE: Determine the prevalence of different sleeping positions among pregnant women in LMICs, and what (if any) positions were associated with stillbirth using a systematic review. SEARCH STRATEGY: We systematically searched the databases Medline, Embase, Emcare, CINAHL and Global Index Medicus for relevant studies, with no date or language restrictions on 4 April 2020. Reference lists of included studies were also screened. SELECTION CRITERIA: Observational studies of maternal sleep position during pregnancy in LMICs DATA COLLECTION AND ANALYSIS: Recovered citations were screened and eligible studies were included for extraction. These steps were performed by two independent reviewers. Risk of bias was assessed using the Newcastle-Ottawa Scale. MAIN RESULTS: A total of 3480 citations were screened but only two studies met the inclusion criteria. The studies were conducted in Ghana and India and reported on different maternal sleep positions: supine and left lateral. In Ghana, a prevalence of 9.7% for supine sleeping position amongst 220 women was found. The primary outcome could not be extracted from the Indian study as sleep position information was only reported for women who had a stillbirth (100 of the 300 participants). CONCLUSION: There is limited information on maternal sleeping position in LMICs. Since sleep position may be a modifiable risk factor for stillbirth, there is a need for further research to understand the sleep practices and behaviours of pregnant women in LMICs. PROSPERO registration: CRD42020173314.

The cost-effectiveness of tranexamic acid for treatment of postpartum hemorrhage: A systematic review.

BACKGROUND: Postpartum hemorrhage (PPH) is responsible for nearly one quarter of maternal deaths. A 2017 multicountry trial found that incorporating tranexamic acid (TXA) into the PPH management package was effective in reducing maternal death due to bleeding. OBJECTIVE: To systematically review studies assessing the cost-effectiveness of tranexamic acid for PPH treatment. SEARCH STRATEGY: Nine databases were searched using variations of keywords 'tranexamic acid', 'postpartum hemorrhage' and 'cost effectiveness'. SELECTION CRITERIA: Eligible studies were any type of economic or effectiveness evaluation studies on tranexamic acid for treating women with PPH. DATA COLLECTION AND ANALYSIS: Two reviewers independently screened citations and extracted data on cost effectiveness measures. Quality was assessed using the Consensus on Health Economic Criteria list. MAIN RESULTS: Four studies were included, of which two were abstracts. Three studies concluded that early administration of TXA was cost-saving or cost-effective. One abstract reported TXA was not cost-effective in the USA unless the probability of death due to hemorrhage is higher. CONCLUSION: Available evidence (four studies in three countries) suggests that this life-saving intervention may be below willingness to pay thresholds (cost-effective) or cost saving. Further studies conducted in different populations and settings are needed to inform health policy decision-making to reduce PPH-associated morbidity and mortality.

Usability, acceptability, and feasibility of the World Health Organization Labour Care Guide: A mixed-methods, multicountry evaluation.

INTRODUCTION: The World Health Organization's (WHO) Labour Care Guide (LCG) is a "next-generation" partograph based on WHO's latest intrapartum care recommendations. It aims to optimize clinical care provided to women and their experience of care. We evaluated the LCG's usability, feasibility, and acceptability among maternity care practitioners in clinical settings. METHODS: Mixed-methods evaluation with doctors, midwives, and nurses in 12 health facilities across Argentina, India, Kenya, Malawi, Nigeria, and Tanzania. Purposively sampled and trained practitioners applied the LCG in low-risk women during labor and rated experiences, satisfaction, and usability. Practitioners were invited to focus group discussions (FGDs) to share experiences and perceptions of the LCG, which were subjected to framework analysis. RESULTS: One hundred and thirty-six practitioners applied the LCG in managing labor and birth of 1,226 low-risk women. The majority of women had a spontaneous vaginal birth (91.6%); two cases of intrapartum stillbirths (1.63 per 1000 births) occurred. Practitioner satisfaction with the LCG was high, and median usability score was 67.5%. Practitioners described the LCG as supporting precise and meticulous monitoring during labor, encouraging critical thinking in labor management, and improving the provision of woman-centered care. CONCLUSIONS: The LCG is feasible and acceptable to use across different clinical settings and can promote woman-centered care, though some design improvements would benefit usability. Implementing the LCG needs to be accompanied by training and supportive supervision, and strategies to promote an enabling environment (including updated policies on supportive care interventions, and ensuring essential equipment is available).

Gender inequalities in health and wellbeing across the first two decades of life: an analysis of 40 low-income and middle-income countries in the Asia-Pacific region.

BACKGROUND: By adulthood, gender inequalities in health and wellbeing are apparent. Yet, the timing and nature of gender inequalities during childhood and adolescence are less clear. We describe the emergence of gender inequalities in health and wellbeing across the first two decades of life. METHODS: We focused on the 40 low-income and middle-income countries in Asia and the Pacific. A measurement framework was developed around four key domains of wellbeing across the first two decades: health, education and transition to employment, protection, and a safe environment. Specific measurement constructs were then defined by considering gender indicator frameworks, the Sustainable Development Goals, indicator frameworks for child and adolescent health and wellbeing, and key stakeholder input. Available data were then mapped to define 87 indicators, subsequently populated using databases (UN agencies and the Global Burden of Diseases, Injuries, and Risk Factors Study) and nationally representative surveys. Where possible, estimates in girls were compared with boys to report relative risks. FINDINGS: Although son preference is evident in some settings-as shown by higher than expected male-to-female sex ratios at birth in India, Vietnam, and China (all >1·10 compared with an expected ratio of 1·05) and excess mortality of girl children in some South Asian and Pacific nations-it is during early adolescence where marked gender inequalities consistently emerged. Adolescent girls face considerable disadvantage in relation to sexual and reproductive health (notably in South Asia and the Pacific), with high rates of child marriage (≥30% of women aged 20-24 years married before 18 years in Bangladesh, Nepal, and Afghanistan), fertility (≥65 livebirths per 1000 girls in Nauru, Laos, Afghanistan, Nepal, Marshall Islands, Bangladesh, Vanuatu, and Papua New Guinea), and intimate partner violence (>20% in Timor Leste, Afghanistan, Pakistan, and Myanmar). Despite educational parity in many countries, females aged 15-24 years were less likely than males to be in education, employment, or training in 17 of 19 countries for which data were available. Compared with girls, adolescent boys experienced excess all-cause mortality and substantially higher mortality due to unintentional injury, interpersonal violence, alcohol and other drugs, and suicide, and higher prevalence of harmful drinking and tobacco smoking. INTERPRETATION: These findings call for a focus on gender policy and programming in later childhood and early adolescence before gender inequalities become embedded. FUNDING: UNICEF.

Male involvement interventions and improved couples' emotional relationships in Tanzania and Zimbabwe: 'When we are walking together, I feel happy'.

Male involvement in maternal and child health is recognised as a valuable strategy to improve care-seeking and uptake of optimal home care practices for women and children in low- and middle-income settings. However, the specific mechanisms by which involving men can lead to observed behaviour change are not well substantiated. A qualitative study conducted to explore men's and women's experiences of male involvement interventions in Tanzania and Zimbabwe found that, for some women and men, the interventions had fostered more loving partner relationships. Both male and female participants identified these changes as profoundly meaningful and highly valued. Our findings illustrate key pathways by which male involvement interventions were able to improve couples' emotional relationships. Findings also indicate that these positive impacts on couple relationships can motivate and support men's behaviour change, to improve care-seeking and home care practices. Men's and women's subjective experiences of partner relationships following male involvement interventions have not been well documented to date. Findings highlight the importance of increased love, happiness and emotional intimacy in couple relationships - both as a wellbeing outcome valued by men and women, and as a contributor to the effectiveness of male involvement interventions.

Expectant fathers' participation in antenatal care services in Papua New Guinea: a qualitative inquiry.

BACKGROUND: The importance of engaging men in maternal and child health programs is well recognised internationally. In Papua New Guinea (PNG), men's involvement in maternal and child health services remains limited and barriers and enablers to involving fathers in antenatal care have not been well studied. The purpose of this paper is to explore attitudes to expectant fathers participating in antenatal care, and to identify barriers and enablers to men's participation in antenatal care with their pregnant partner in PNG. METHODS: Twenty-eight focus group discussions were conducted with purposively selected pregnant women, expectant fathers, older men and older women across four provinces of PNG. Fourteen key informant interviews were also conducted with health workers. Qualitative data generated were analysed thematically. RESULTS: While some men accompany their pregnant partners to the antenatal clinic and wait outside, very few men participate in antenatal consultations. Factors supporting fathers' participation in antenatal consultations included feelings of shared responsibility for the unborn child, concern for the mother's or baby's health, the child being a first child, friendly health workers, and male health workers. Sociocultural norms and taboos were the most significant barrier to fathers' participation in antenatal care, contributing to men feeling ashamed or embarrassed to attend clinic with their partner. Other barriers to men's participation included fear of HIV or sexually transmitted infection testing, lack of separate waiting spaces for men, rude treatment by health workers, and being in a polygamous relationship. Building community awareness of the benefits of fathers participating in maternal and child health service, inviting fathers to attend antenatal care if their pregnant partner would like them to, and ensuring clinic spaces and staff are welcoming to men were strategies suggested for increasing fathers' participation in antenatal care. CONCLUSION: This study identified significant sociocultural and health service barriers to expectant fathers' participation in antenatal care in PNG. Our findings highlight the need to address these barriers - through health staff training and support, changes to health facility layout and community awareness raising - so that couples in PNG can access the benefits of men's participation in antenatal care.

Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions.

BACKGROUND: Emerging evidence and program experience indicate that engaging men in maternal and newborn health can have considerable health benefits for women and children in low- and middle-income countries. Previous reviews have identified male involvement as a promising intervention, but with a complex evidence base and limited direct evidence of effectiveness for mortality and morbidity outcomes. OBJECTIVE: To determine the effect of interventions to engage men during pregnancy, childbirth and infancy on mortality and morbidity, as well as effects on mechanisms by which male involvement is hypothesised to influence mortality and morbidity outcomes: home care practices, care-seeking, and couple relationships. METHODS: Using a comprehensive, highly sensitive mapping of maternal health intervention studies conducted in low- and middle-income countries between 2000 and 2012, we identified interventions that have engaged men to improve maternal and newborn health. Primary outcomes were care-seeking for essential services, mortality and morbidity, and home care practices. Secondary outcomes relating to couple relationships were extracted from included studies. RESULTS: Thirteen studies from nine countries were included. Interventions to engage men were associated with improved antenatal care attendance, skilled birth attendance, facility birth, postpartum care, birth and complications preparedness and maternal nutrition. The impact of interventions on mortality, morbidity and breastfeeding was less clear. Included interventions improved male partner support for women and increased couple communication and joint decision-making, with ambiguous effects on women's autonomy. CONCLUSION: Interventions to engage men in maternal and newborn health can increase care-seeking, improve home care practices, and support more equitable couple communication and decision-making for maternal and newborn health. These findings support engaging men as a health promotion strategy, although evidence gaps remain around effects on mortality and morbidity. Findings also indicate that interventions to increase male involvement should be carefully designed and implemented to mitigate potential harmful effects on couple relationship dynamics.

WHISPER or SHOUT study: protocol of a cluster-randomised controlled trial assessing mHealth sexual reproductive health and nutrition interventions among female sex workers in Mombasa, Kenya.

INTRODUCTION: New interventions are required to reduce unintended pregnancies among female sex workers (FSWs) in low- and middle-income countries and to improve their nutritional health. Given sex workers' high mobile phone usage, repeated exposure to short messaging service (SMS) messages could address individual and interpersonal barriers to contraceptive uptake and better nutrition. METHODS: In this two-arm cluster randomised trial, each arm constitutes an equal-attention control group for the other. SMS messages were developed systematically, participatory and theory-driven and cover either sexual and reproductive health (WHISPER) or nutrition (SHOUT). Messages are sent to participants 2-3 times/week for 12 months and include fact-based and motivational content as well as role model stories. Participants can send reply texts to obtain additional information. Sex work venues (clusters) in Mombasa, Kenya, were randomly sampled with a probability proportionate to venue size. Up to 10 women were recruited from each venue to enrol 860 women. FSWs aged 16-35 years, who owned a mobile phone and were not pregnant at enrolment were eligible. Structured questionnaires, pregnancy tests, HIV and syphilis rapid tests and full blood counts were performed at enrolment, with subsequent visits at 6 and 12 months. ANALYSIS: The primary outcomes of WHISPER and SHOUT are unintended pregnancy incidence and prevalence of anaemia at 12 months, respectively. Each will be compared between study groups using discrete-time survival analysis. POTENTIAL LIMITATIONS: Contamination may occur if participants discuss their intervention with those in the other trial arm. This is mitigated by cluster recruitment and only sampling a small proportion of sex work venues from the sampling frame. CONCLUSIONS: The design allows for the simultaneous testing of two independent mHealth interventions for which messaging frequency and study procedures are identical. This trial may guide future mHealth initiatives and provide methodological insights into use of reciprocal control groups. TRIAL REGISTRATION NUMBER: ACTRN12616000852459; Pre-results.

Challenging gender inequity through male involvement in maternal and newborn health: critical assessment of an emerging evidence base.

Men's involvement in the health of women and children is considered an important avenue for addressing gender influences on maternal and newborn health. The impact of male involvement around the time of childbirth on maternal and newborn health outcomes was examined as one part of a systematic review of maternal health intervention studies published between 2000 and 2012. Of 33,888 articles screened, 13 eligible studies relating to male involvement were identified. The interventions documented in these studies comprise an emerging evidence base for male involvement in maternal and newborn health. We conducted a secondary qualitative analysis of the 13 studies, reviewing content that had been systematically extracted. A critical assessment of this extracted content finds important gaps in the evidence base, which are likely to limit how 'male involvement' is understood and implemented in maternal and newborn health policy, programmes and research. Collectively, the studies point to the need for an evidence base that includes studies that clearly articulate and document the gender-transformative potential of involving men. This broader evidence base could support the use of male involvement as a strategy to improve both health and gender equity outcomes.