Ghanaian women's experience of intimate partner violence (IPV) during group antenatal care: a brief report from a cluster randomised controlled trial.

Intimate partner violence (IPV) impacts women of reproductive age globally and can lead to significant negative consequences during pregnancy. This study describes an exploratory aim of a cluster randomised controlled trial designed to assess the outcomes of Group Antenatal Care (ANC) in Ghana. The purpose was to understand the effect of a healthy relationship Group ANC module on experiences of IPV and safety planning as well as to explore the relationship between self-efficacy on the experiences of IPV and safety planning. Data were collected at baseline and at 11-14 months postpartum (post). Survey measures captured reported experiences of violence, self-efficacy, and safety. The chi-square test was used to compare baseline and post scores, and a logistic regression was performed to ascertain the effects of self-efficacy on the experiences of IPV in both groups. The sample included 1,751 participants, of whom 27.9% reported IPV at baseline. Between baseline and postpartum, there was a small increase in reported emotional (6.2% vs. 4.6%) and sexual (5.4% vs. 3.2%) violence in the intervention group compared to the control group. Logistic regression demonstrated that an increasing self-efficacy score was associated with an increased likelihood of experiencing IPV. There were no changes in safety knowledge. This study found higher rates of reported sexual and emotional violence post-intervention among the intervention group. Group ANC may be just one part of a portfolio of interventions needed to address IPV at all socio-ecological levels.Paper ContextMain findings: There was no reduction in experiences of intimate partner violence or increases in safety planning among Ghanaian pregnant women participating in a Group Antenatal Care session focused on healthy relationships and safety planning.Added knowledge: Group Antenatal Care has been identified as an effective modality for providing antenatal care and facilitating conversations about sensitive topics such as intimate partner violence and safety. However, this study highlights the importance of developing multifaceted approaches to decrease the risk of intimate partner violence among women, especially during the critical times of pregnancy and postpartum.Global health impact for policy and action: Effective global health action and policy must extend beyond educational efforts, incorporating multifaceted strategies that include healthcare provider training, robust community engagement, and legislation aimed at preventing intimate partner violence, with a special focus on safeguarding the well-being of women during pregnancy and the postpartum period.

Facilitators and barriers to home blood pressure monitoring among pregnant women in Ghana: a mixed-methods analysis of patient perspectives.

BACKGROUND: The benefit of home blood pressure monitoring during pregnancy and in low-resource settings is incompletely understood. The objective of this study was to explore the experiences, barriers, and facilitators of home blood pressure monitoring among pregnant women in Ghana. METHODS: This concurrent triangulation mixed-methods study was conducted at an urban tertiary hospital in Ghana. Participants were recruited from adult pregnant women presenting for routine antenatal care. Upon enrollment, participants' demographics and history were collected. At the next study visit, participants received audiovisual and hands-on training on using an automatic blood pressure monitor; they then monitored and logged their blood pressure daily at home for 2-4 weeks. At the final study visit, verbally administered surveys and semi-structured interviews assessed participant's experiences. Quantitative data were analyzed using R version 4.2.2, and frequencies and descriptive statistics were calculated. Qualitative data were imported into DeDoose 9.0.78 for thematic analysis. RESULTS: Of 235 enrolled participants, 194 completed surveys; of those, 33 completed in-depth interviews. Participants' mean age was 31.6 (SD 5.3) years, 32.1% had not previously given birth, and 31.1% had less than a senior high school education. On a 4-point Likert scale, the majority reported they "definitely" were able to remember (n = 134, 69.1%), could find the time (n = 124, 63.9%), had the energy (n = 157, 80.9%), could use the blood pressure monitor without problems (n = 155, 79.9%), and had family approval (n = 182, 96.3%) while engaging in home blood pressure monitoring. 95.88% (n = 186) believed that pregnant women in Ghana should monitor their blood pressure at home. Qualitative thematic analysis demonstrated that most participants liked home blood pressure monitoring because of increased knowledge of their health during pregnancy. While most participants found measuring their blood pressure at home doable, many faced challenges. Participants' experiences with five key factors influenced how easy or difficult their experience was: 1) Time, stress, and daily responsibilities; 2) Perceived importance of BP in pregnancy; 3) Role of family; 4) Capability of performing monitoring; 5) Convenience of monitoring. CONCLUSIONS: Among pregnant women in urban Ghana, home blood pressure monitoring was perceived as positive, important, and doable; however, challenges must be addressed.

Improving health literacy through group antenatal care: results from a cluster randomized controlled trial in Ghana.

BACKGROUND: Although the majority of Ghanaian women receive antenatal care (ANC), many exhibit low health literacy by misinterpreting and incorrectly operationalizing ANC messages, leading to poor maternal and newborn health outcomes. Prior research in low-resource settings has found group antenatal care (G-ANC) feasible for women and providers. This study aims to determine the effect of G-ANC on increasing maternal health literacy. We hypothesized that pregnant women randomized into G-ANC would exhibit a greater increase in maternal health literacy than women in routine, individual ANC. METHODS: A 5-year cluster randomized controlled trial was conducted in 14 rural and peri-urban health facilities in the Eastern Region of Ghana. Facilities were paired based on patient volume and average gestational age at ANC enrollment and then randomized into intervention (G-ANC) vs. control (routine, individual ANC); 1761 pregnant women were recruited. Data collection occurred at baseline (T0) and post-birth (T2) using the Maternal Health Literacy scale, a 12-item composite scale to assess maternal health literacy. Logistic regression compared changes in health literacy from T0 to T2. RESULTS: Overall, women in both the intervention and control groups improved their health literacy scores over time (p < 0.0001). Women in the intervention group scored significantly higher on 3 individual items and on overall composite scores (p < 0.0001) and were more likely to attend 8 or more ANC visits. CONCLUSION: While health literacy scores improved for all women attending ANC, women randomized into G-ANC exhibited greater improvement in overall health literacy post-birth compared to those receiving routine individual care. Life-saving information provided during ANC must be presented in an understandable format to prevent women and newborns from dying of preventable causes. TRIAL REGISTRY: Ethical approval for the study was obtained from the Institutional Review Boards of the University of Michigan (HUM#00161464) and the Ghana Health Service (GHS-ERC: 016/04/19).

The use of a mobile obstetric emergency system to improve obstetric referrals in Bong County, Liberia: A pre-post study.

OBJECTIVE: Liberia experiences an unmet need for cesarean section with about 5% population coverage, lower than 9%-19% coverage associated with improved maternal and newborn outcomes. Delays in the referral process for comprehensive emergency obstetric and newborn care (CEmONC) services due to ineffective communication between a rural health facility (RHF) and a district hospital contribute to the low CS rate. This study examined the association between mobile obstetric emergency system (MORES) implementation and referral time for obstetric emergencies as well as maternal/newborn outcomes. METHODS: A pre-post descriptive analysis was conducted on data collected from 20 rural health facilities (RHFs) and two hospitals in Bong County. Women with referral data from both RHFs and hospitals were matched and information including transfer time, reasons for referral, and maternal and newborn outcomes were extracted. Descriptive analysis and logistic regression models examined the relationship between the intervention's implementation and mode of delivery, maternal outcome, newborn outcome, and transfer time from RHF to district hospital. Ethics approval was obtained from two study centers. RESULTS: Women had higher odds of undergoing a CS at endline (OR: 1.86 95% CI: 0.99-3.46) compared to baseline. Additionally, newborns had lower odds of showing non-vigorous symptoms (OR: 0.31; 95% CI: 0.14-0.68), defined as a newborn with poor respiratory effort, muscle tone, or heart rate. There was no significant association between the intervention's implementation and transfer time. CONCLUSION: The MORES intervention is a promising means to increase timely care seeking along the referral pathway which may enhance access to cesarean section as well as improved newborn outcome in low- and middle-income countries.

Ability and accuracy of patient-performed blood pressure monitoring among pregnant women in urban Ghana.

BACKGROUND: Patient-performed blood pressure monitoring in pregnancy is rarely performed in low- and middle-income country settings, including Ghana. The clinical efficacy of home blood pressure monitoring relies on a pregnant patient being able to independently execute the correct steps to position and use a blood pressure monitor and to achieve accurate blood pressure measurements. OBJECTIVE: This study aimed to (1) assess whether pregnant women can correctly use an automatic blood pressure monitor to check their blood pressure before and after a brief training and (2) determine whether blood pressure values measured by pregnant women using an automatic monitor are similar to values measured by a healthcare provider using a standard clinic monitor. STUDY DESIGN: This was a cross-sectional study conducted at the Korle Bu Teaching Hospital, a tertiary hospital in Accra, Ghana. Participants were adult pregnant women presenting for their first prenatal care visit. Data collection was performed by 2 Ghanaian physicians. Information on demographics, obstetrical history, and past medical history was collected. A brief training was provided on the correct use of the blood pressure monitor, including a verbal script, annotated photographs, and a hands-on demonstration. Pre- and posttraining assessments using a 9-item checklist of correct preparation, position, and use of an automatic blood pressure monitor were performed. Following a modified British Hypertension Society protocol, a series of 4 blood pressure measurements were taken, alternating between provider performed using a clinic monitor and patient performed using an automatic monitor intended for individual use and validated in pregnancy. RESULTS: Among 176 participants, the mean age was 31.5 years (±5.6), and 130 (73.9%) were multiparous. Regarding socioeconomic characteristics, 128 (72.7%) were married, 171 (97.2%) had public insurance, and 87 (49.7%) had completed ≤9 years of formal education. Regarding clinical blood pressure issues, 19 (10.9%) had a history of a hypertensive disorder in a previous pregnancy, and 6 (3.4%) had chronic hypertension. Before receiving any training, 21 participants (12.1%) performed all 9 steps correctly to prepare, position, and use the automatic blood pressure monitor. Comparing pretraining vs posttraining ability, statistically significant increases were seen in the correct performance of each step and the mean number of steps performed correctly (6.1±1.8 vs 9.0±0.2, respectively; P<.001) and proportion performing all 9 steps correctly (12.1% vs 96.6%, respectively; P<.001). The mean difference between doctor-performed and patient-performed blood pressure measurements was 5.6±4.8 mm Hg for systolic blood pressure values and 3.4±3.08 mm Hg for diastolic blood pressure values, with most differences within 5 mm Hg for both systolic blood pressure values (102/176 [58.0%]) and diastolic blood pressure values (141/176 [80.1%]). CONCLUSION: After a brief training, pregnant women in Ghana demonstrated that they are able to use an automatic blood pressure monitor to check their blood pressure correctly and accurately.

Acceptability of a Whatsapp Triage, Referral, and Transfer System for Obstetric Patients in Rural Liberia.

Background: Maternal mortality continues to disproportionately affect low- and middle-income countries, including Liberia. Though the relationship between obstetric triage systems and improved maternal outcomes is well documented, standardized triage protocols are lacking in rural Liberia. Mobile health interventions are a promising method to triage obstetric patients. Objectives: This study explores the acceptability of a WhatsApp Triage, Referral, and Transfer (WAT-RT) system among Liberian midwives and community health assistants. Methods: Individual interviews and focus group discussions were conducted among midwives (n = 18) and community health assistants (n = 112). Interviews were designed to understand the current referral system in rural Liberia, how a WAT-RT System can address referral limitations, and the acceptability of the WAT-RT System. Data were audio recorded, transcribed, and translated into English. Data analysis was conducted via NVivo12 with independent and cooperative techniques among multiple researchers. Findings: The current referral system is not standardized with limitations including a lack of triage protocols, transportation difficulties, and inconsistent communication of patient information, which could be addressed by a WAT-RT System. The acceptability for the WAT-RT System was high. Facilitators to implementation included utilizing a pre-existing communication and referral infrastructure, access and competency surrounding mobile phones, and increased opportunities for training and inter-provider collaboration. Barriers included disproportionate phone access between midwives and community health assistants, network reliability, and a lack of data standards. Recommendations for successful implementation included centralizing phone financing and standardizing triage protocols. Conclusions: The WAT-RT System demonstrated high acceptability among frontline health care providers in rural Liberia. Barriers to program success could be reasonably addressed with simple interventions and planning. Multiple benefits included addressing care delays for obstetric patients, promoting bidirectional provider communication, and increasing the quality of obstetric triage. Future studies should focus on piloting the WAT-RT System among this population and recruiting other key stakeholders to determine intervention feasibility.

Charge midwives' awareness of and their role in promoting respectful maternity care at a tertiary health facility in Ghana: A qualitative study.

BACKGROUND: Evidence suggests that the implementation of respectful maternity care (RMC) interventions is one of the surest and most effective means of minimising mistreatment during intrapartum care services. However, to ensure the successful implementation of RMC interventions, maternity care providers would have to be aware of RMC, its relevance, and their role in promoting RMC. We explored the awareness and role of charge midwives in promoting RMC at a tertiary health facility in Ghana. METHODS: The study adopted an exploratory descriptive qualitative study design. We conducted nine interviews with charge midwives. All audio data were transcribed verbatim and exported to NVivo-12 for data management and analyses. RESULTS: The study revealed that charge midwives are aware of RMC. Specifically, ward-in-charges perceived RMC as consisting of showing dignity, respect, and privacy, as well as providing women-centred care. Our findings showed that the roles of ward-in-charges included training midwives on RMC and leading by example, showing empathy and establishing friendly relationships with clients, receiving and addressing clients' concerns, and monitoring and supervising midwives. CONCLUSION: We conclude that charge midwives have an important role to play in promoting RMC, which transcends simply providing maternity care. Policymakers and healthcare managers should ensure that charge midwives receive adequate and regular training on RMC. This training should be comprehensive, covering aspects such as effective communication, privacy and confidentiality, informed consent, and women-centred care. The study also underscores a need for policymakers and health facility managers to prioritise the provision of resources and support for the implementation of RMC policies and guidelines in all healthcare facilities. This will ensure that healthcare providers have the necessary tools and resources to provide RMC to clients.

Verbal autopsy analysis of maternal mortality in Bong County, Liberia: a retrospective mixed methods study.

BACKGROUND: While the medical contributors to maternal mortality are well known, the contextual contributors are less known and understudied. Liberia has one of the highest maternal mortality rates in sub-Saharan Africa, with recent increases in maternal deaths in rural Bong County. The purpose of this study was to better classify the contextual factors leading up to maternal deaths and to develop a list of recommendations to prevent future similar deaths. METHODS: A retrospective mixed method study was conducted examining 35 maternal deaths in Bong County, Liberia using verbal autopsy reports from 2019. An interdisciplinary death audit team reviewed and analysed the maternal deaths to determine the contextual causes of the maternal death. FINDINGS: This study identified three contextual causes: limited resources (materials, transportation, facility, staff), inadequate skills and knowledge (staff, community, family, patient), and ineffective communication (between providers, between health facilities and hospitals, and between provider and patient/family). Of these, inadequate patient education (54.28%), inadequate staff education and training (51.42%), ineffective communication between health facilities and hospitals (31.42%), and inadequate materials (28.57%) were most frequently mentioned. CONCLUSION: Maternal mortality remains an issue in Bong County, Liberia, due to addressable contextual causes. Interventions to ameliorate these preventable deaths include ensuring availability of resources and transportation through improved supply chain and health system accountability. Recurring training should be provided to healthcare workers which involves husbands, families and communities. Innovative means for providers and facilities to communicate clearly and consistently should also be prioritised to prevent future maternal deaths in Bong County, Liberia.

Perspectives of healthcare workers on the challenges with obstetric referrals in rural communities in Ghana: a descriptive phenomenology study.

OBJECTIVE: We explored and document healthcare workers' (HCWs') perspectives on the challenges encountered during obstetric referrals. DESIGN: The study adopted a qualitative research approach and a descriptive phenomenology design. HCWs permanently working in 16 rural healthcare facilities in the Sene East and West Districts composed of the target population for this study. Using a purposive sampling technique, participants were recruited and enrolled in in-depth individual interviews (n=25) and focused group discussions (n=12). Data were analysed thematically using QSR NVivo V.12. SETTING: Sixteen rural healthcare facilities in the Sene East and West Districts, Ghana. PARTICIPANTS: Healthcare workers. RESULTS: Areas related to patient as well as institutional level issues challenged the referral processes. At the patients' level, financial constraints, fears associated with referral and patients' non-compliance with referrals were identified as challenges that delayed the referral process. With regard to institutional challenges, the following emerged: referral transportation challenges, poor attitudes of service providers, low staff strength and healthcare bureaucracies. CONCLUSION: We conclude that in order for obstetric referrals in rural Ghana to be effective and timely, there is the need to raise more awareness about the need for patients to comply with referral directives, through health education messages and campaigns. Given our findings on the delays associated with long deliberations, the study recommends the training of more cadre of healthcare providers to facilitate obstetric referral processes. Such an intervention would help to improve the current low staff strength. Also, there is a need to improve ambulatory services in rural communities to counteract the challenges that poor transportation system poses on obstetric referrals.

Improving respectful maternity care through group antenatal care: findings from a cluster randomized controlled trial.

Background: Disrespect and patient mistreatment are identified as barriers to care-seeking and low uptake of facility-based deliveries. These mitigating factors have led to slow progress in the achievement of maternal and child health targets, especially in Ghana. Group antenatal care, as an alternative to individual antenatal was implemented to explore the impact on outcomes, including mothers' perception of respectful care. Methods: A cluster randomized controlled trial was conducted in 14 health facilities across four districts in the Easter Region of Ghana. These facilities were randomized to intervention or control using a matched pair. Data was collected at several timepoints: enrollment (Time 0), 34 weeks gestation to 3 weeks post-delivery (Time 1), 6 to 12 weeks post-delivery (Time 2), 5 to 8 months post-delivery (Time 3), and 11 to 14 months post-delivery (Time 4). Questions related to respectful care were asked at Time 2, while a focus group discussion (FGDs) was conducted as part of a process evaluation to examine participants' experiences about respectful maternity care. Results: The findings from the intervention group indicate that participants perceived higher levels of respect in comparison to the control group. Privacy and con dentiality were maintained. They believed they had been provided with adequate information, education, and counseling, empowering them to make informed decisions. Participants perceived a shortened waiting time and reduced discrimination in care provision. Generally, there were higher levels of satisfaction with antenatal care. Conclusion: The provision of respectful maternity care, which is essential to increasing healthcare utilization, has been demonstrated to correlate positively with group antenatal care.

Group Antenatal Care in Ghana: Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: While group antenatal care (ANC) has been delivered and studied in high-income countries for over a decade, it has only recently been introduced as an alternative to individual care in sub-Saharan Africa. Although the experimental design of the studies from high-resource countries have been scientifically rigorous, findings cannot be generalized to low-resource countries with low literacy rates and high rates of maternal and newborn morbidity and mortality. The Group Antenatal Care Delivery Project (GRAND) is a collaboration between the University of Michigan in the United States and the Dodowa Health Research Centre in Ghana. GRAND is a 5-year, cluster randomized controlled trial (RCT). Our intervention-group ANC-consists of grouping women by similar gestational ages of pregnancy into small groups at the first ANC visit. They then meet with the same group and the same midwife at the recommended intervals for care. OBJECTIVE: This study aims to improve health literacy, increase birth preparedness and complication readiness, and optimize maternal and newborn outcomes among women attending ANC at seven rural health facilities in the Eastern Region of Ghana. METHODS: Quantitative data will be collected at four time points using a secure web application for data collection and a database management tool. Data will be analyzed on an intention-to-treat basis to test the differences between the two arms: women randomized to group-based ANC and women randomized to routine individual ANC. We will conduct a process evaluation concurrently to identify and document patient, provider, and system barriers and facilitators to program implementation. RESULTS: The study was funded in September 2018. Recruitment and enrollment of participants and data collection started in July 2019. In November 2021, we completed participant enrollment in the study (n=1761), and we completed data collection at the third trimester in May 2022 (n=1284). Data collection at the additional three time points is ongoing: 6 weeks postpartum, 6 months postpartum, and 1 year postpartum. CONCLUSIONS: This study is significant and timely because it is among the first RCTs to be conducted to examine the effects of group ANC among low-literacy and nonliterate participants. Our findings have the potential to impact how clinical care is delivered to low-literacy populations, both globally and domestically, to improve maternal and newborn outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT04033003; https://clinicaltrials.gov/ct2/show/NCT04033003. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40828.

The role of Savings and Internal Lending Communities (SILCs) in improving community-level household wealth, financial preparedness for birth, and utilization of reproductive health services in rural Zambia: a secondary analysis.

BACKGROUND: Savings and Internal Lending Communities (SILCs) are a type of informal microfinance mechanism widely adapted in Zambia. The benefits of SILCs paired with other interventions have been studied in many countries. However, limited studies have examined SILCs in the context of maternal health. This study examined the association between having access to SILCs and: 1) household wealth, 2) financial preparedness for birth, and 3) utilization of various reproductive health services (RHSs). METHODS: Secondary analysis was conducted on baseline and endline household survey data collected as part of a Maternity Waiting Home (MWH) intervention trial in 20 rural communities across seven districts of Zambia. Data from 4711 women who gave birth in the previous year (baseline: 2381 endline: 2330) were analyzed. The data were stratified into three community groups (CGs): CG1) communities with neither MWH nor SILC, CG2) communities with only MWH, and CG3) communities with both MWH and SILC. To capture the community level changes with the exposure to SILCs, different women were randomly selected from each of the communities for baseline and endline data, rather than same women being surveyed two times. Interaction effect of CG and timepoint on the outcome variables - household wealth, saving for birth, antenatal care visits, postnatal care visits, MWH utilization, health facility based delivery, and skilled provider assisted delivery - were examined. RESULTS: Interaction effect of CGs and timepoint were significantly associated only with MWH utilization, health facility delivery, and skilled provider delivery. Compared to women from CG3, women from CG1 had lower odds of utilizing MWHs and delivering at health facility at endline. Additionally, women from CG1 and women from CG2 had lower odds of delivering with a skilled provider compared to women from CG3. CONCLUSION: Access to SILCs was associated with increased MWH use and health facility delivery when MWHs were available. Furthermore, access to SILCs was associated with increased skilled provider delivery regardless of the availability of MWH. Future studies should explore the roles of SILCs in improving the continuity of reproductive health services. TRIAL REGISTRATION: NCT02620436.

Barriers and facilitators to facility-based delivery in rural Zambia: a qualitative study of women's perceptions after implementation of an improved maternity waiting homes intervention.

OBJECTIVES: Women in sub-Saharan Africa face well-documented barriers to facility-based deliveries. An improved maternity waiting homes (MWH) model was implemented in rural Zambia to bring pregnant women closer to facilities for delivery. We qualitatively assessed whether MWHs changed perceived barriers to facility delivery among remote-living women. DESIGN: We administered in-depth interviews (IDIs) to a randomly selected subsample of women in intervention (n=78) and control (n=80) groups who participated in the primary quasi-experimental evaluation of an improved MWH model. The IDIs explored perceptions and preferences of delivery location. We conducted content analysis to understand perceived barriers and facilitators to facility delivery. SETTING AND PARTICIPANTS: Participants lived in villages 10+ km from the health facility and had delivered a baby in the previous 12 months. INTERVENTION: The improved MWH model was implemented at 20 rural health facilities. RESULTS: Over 96% of participants in the intervention arm and 90% in the control arm delivered their last baby at a health facility. Key barriers to facility delivery were distance and transportation, and costs associated with delivery. Facilitators included no user fees, penalties for home delivery, desire for safe delivery and availability of MWHs. Most themes were similar between study arms. Both discussed the role MWHs have in improving access to facility-based delivery. Intervention arm participants expressed that the improved MWH model encourages use and helps overcome the distance barrier. Control arm participants either expressed a desire for an improved MWH model or did not consider it in their decision making. CONCLUSIONS: Even in areas with high facility-based delivery rates in rural Zambia, barriers to access persist. MWHs may be useful to address the distance challenge, but no single intervention is likely to address all barriers experienced by rural, low-resourced populations. MWHs should be considered in a broader systems approach to improving access in remote areas. TRIAL REGISTRATION NUMBER: NCT02620436.

Sustainable palm weevil farming as nutrition supplementation at maternity waiting homes in Liberia.

BACKGROUND: Food insecurity is a global health challenge exacerbated by COVID-19. In Liberia, two-thirds of pregnant women are anemic, one-third of children are stunted, and 70% of households experienced food insecurity due to COVID-19. Edible insects are a nutritious, environmentally responsible, and cost-effective dietary supplement used throughout sub-Saharan Africa. Rearing palm weevil insects at maternity waiting homes (MWHs)-residential dwellings near hospitals where pregnant women await childbirth and receive postpartum services-could serve as a nutritious supplement for expectant mothers in Liberia and provide an income generating activity for MWHs. METHODS: Following a one-day training, sixteen participants established palm weevil rearing sites at four MWHs in Liberia. Pre- and post-knowledge scores were assessed immediately prior to and following training. Pre-and post-knowledge scores were analyzed using paired t-test. Participants tracked two palm weevil rearing cycles (four months), using harvest amounts, turnover, barriers to implementation, and income generated as metrics. The number of women attending MWHs was recorded throughout the study period (July-December 2020). RESULTS: Sixteen participants from four MWHs completed the training and two rearing cycles (four months) successfully. All participants showed statistically significant increases in knowledge scores following the one-day workshop with a pre-test score of 2.31 and post-test score of 7.75 out of 10 (p < 0.001). Over the 6-month study, 217 women stayed in four MWHs. Larval production from the various rearing centers ranged from 120 to 721 larvae, with all four sites producing enough palm weevil to sustain MWH residents who desired to consume the insects. One site successfully commercialized its harvest to sell approximately 50% for a total of 2,000 LD (13 USD) in income. Three of the four sites continued edible insect production beyond the four-month study period. CONCLUSIONS: An edible insect project using palm weevil larva is one promising intervention as a nutrition supplement for expectant mothers at pre-established MWHs in rural Liberia. Edible insect rearing also has potential as an income generating activity for MWHs. Future studies should focus on addressing common barriers of remote implementation and metric tracking during the COVID-19 pandemic and reinforcing infrastructure to protect larvae rearing supplies.

Promoting respectful maternity care: challenges and prospects from the perspectives of midwives at a tertiary health facility in Ghana.

BACKGROUND: Evidence shows that women in Ghana experience disrespectful care (slapping, pinching, being shouted at, etc.) from midwives during childbirth. Hence, evidence-based research is needed to advance the adoption of respectful maternity care (RMC) by midwives. We therefore sought to explore and document midwives' perspectives concerning challenges faced and prospects available for promoting RMC in a tertiary health facility. METHODS: We employed an exploratory descriptive qualitative study design. In total, we conducted 12 interviews with midwives educated on RMC. All audio data were transcribed verbatim and exported to NVivo-12 for data management and analyses. We relied on the Consolidated Criteria for Reporting Qualitative Research guideline in reporting this study. RESULTS: The findings were broadly categorised into three themes: emotional support, dignified care and respectful communication which is consistent with the WHO's quality of care framework. For each theme, the current actions that were undertaken to promote RMC, the challenges and recommendations to improve RMC promotion were captured. Overall, the current actions that promoted RMC included provision of sacral massages and reassurance, ensuring confidentiality and consented care, and referring clients who cannot pay to the social welfare unit. The challenges to providing RMC were logistical constraints for ensuring privacy, free movement of clients, and alternative birthing positions. Poor attitudes from some midwives, workload and language barrier were other challenges that emerged. The midwives recommended the appointment of more midwives, as well as the provision of logistics to support alternative birthing positions and privacy. Also, they recommended the implementation of continuous training and capacity building. CONCLUSION: We conclude that in order for midwives to deliver RMC services that include emotional support, dignified care, and respectful communication, the government and hospital administration must make the required adjustments to resolve existing challenges while improving the current supporting activities.

Comparison of quality, birth outcomes, and service utilization between health facilities with and without maternity waiting homes in Liberia.

OBJECTIVE: 1) To assess the quality of health facilities associated with functional Maternity Waiting Homes and health facilities without functional maternity waiting homes in Liberia. 2) To examine birth outcomes and care utilization amongst health facilities with and without functional maternity waiting homes in Liberia. DESIGN: Secondary analysis design using data from a facility capacity checklist and Liberia's Health Management Information System. SETTING: 71 health facilities associated with functional maternity waiting homes and 14 health facilities without functional maternity waiting homes across 14 counties of Liberia. PARTICIPANTS: No human participants were used in this study. METHODS: Independent t-test, Pearson chi-square test, and logistic regression were performed to assess quality, birth outcomes, and service utilization between health facilities with and without functional maternity waiting homes. FINDINGS: The overall health facility quality was not significantly different between health facilities associated with functional maternity waiting homes and those without. However, health facilities with functional maternity waiting homes had better infection control with the presence of soap and sharps boxes. Health facilities with functional maternity waiting homes were also more likely to have parenteral oxytocic drugs and were better able to perform assisted vaginal deliveries. The presence of functional maternity waiting homes were not significantly associated with health facility quality, birth outcomes, or care utilization. CONCLUSION AND IMPLICATIONS: Health facilities with functional MWHs were better prepared to prevent infection and manage complicated deliveries. This study further highlights specific areas for quality improvement amongst these health facilities, including labor complications management.

Direct and opportunity costs related to utilizing maternity waiting homes in rural Zambia.

AIM: To assess the direct and opportunity costs involved in utilising maternity waiting homes. METHOD: A cross-sectional admission survey administered to women who used ten maternity waiting homes across two rural districts in Zambia. A total of 3,796 women participated in the survey. Descriptive analysis was conducted on three domains of the data: demographic characteristics of women, direct costs, and opportunity costs. FINDINGS: Waiting to deliver (86.3%), safe birth (70.8%), and distance (56.0%) were the most frequent reasons women reported for using a maternity waiting home. In terms of direct costs, roughly 65% of the women brought seven days or fewer days' worth of food to the maternity waiting homes, with salt, mealie meals, and vegetables being the most frequently brought items. Only 5.8% of the women spent money on transport. More than half of the women reported paying user fees that ranged from 1 to 5 or more kwacha (US$0.10- 0.52). In terms of opportunity costs, 52% of the women participated in some form of income generating activities (IGAs) when at home. Approximately 35% of the women reported they lost earned income (1 to 50 or more kwacha) by staying at a maternity waiting home. CONCLUSION: A large proportion of women paid for food and user fees to access a maternity waiting home, while a low number of women paid for transport. Even though it is difficult to assign monetary value to women's household chores, being away from these responsibilities and the potential loss of earned income appear to remain a cost to accessing maternity waiting homes. More research is needed to understand how to overcome these financial constraints and assist women in utilising a maternity waiting home.

Out-of-Pocket Expenditures for Delivery for Maternity Waiting Home Users and Non-users in Rural Zambia.

BACKGROUND: Utilizing maternity waiting homes (MWHs) is a strategy to improve access to skilled obstetric care in rural Zambia. However, out-of-pocket (OOP) expenses remain a barrier for many women. We assessed delivery-related expenditure for women who used MWHs and those who did not who delivered at a rural health facility. METHODS: During the endline of an impact evaluation for an MWH intervention, household surveys (n = 826) were conducted with women who delivered a baby in the previous 13 months at a rural health facility and lived >10 km from a health facility in seven districts of rural Zambia. We captured the amount women reported spending on delivery. We compared OOP spending between women who used MWHs and those who did not. Amounts were converted from Zambian kwacha (ZMW) to US dollar (USD). RESULTS: After controlling for confounders, there was no significant difference in delivery-related expenditure between women who used MWHs (US$40.01) and those who did not (US$36.66) (P=.06). Both groups reported baby clothes as the largest expenditure. MWH users reported spending slightly more on accommodation compared to those did not use MWHs, but this difference represents only a fraction of total costs associated with delivery. CONCLUSION: Findings suggest that for women coming from far away, utilizing MWHs while awaiting delivery is not costlier overall than for women who deliver at a health facility but do not utilize a MWH.

If we build it, will they come? Results of a quasi-experimental study assessing the impact of maternity waiting homes on facility-based childbirth and maternity care in Zambia.

INTRODUCTION: Maternity waiting homes (MWHs) aim to increase access to maternity and emergency obstetric care by allowing women to stay near a health centre before delivery. An improved MWH model was developed with community input and included infrastructure, policies and linkages to health centres. We hypothesised this MWH model would increase health facility delivery among remote-living women in Zambia. METHODS: We conducted a quasi-experimental study at 40 rural health centres (RHC) that offer basic emergency obstetric care and had no recent stockouts of oxytocin or magnesium sulfate, located within 2 hours of a referral hospital. Intervention clusters (n=20) received an improved MWH model. Control clusters (n=20) implemented standard of care. Clusters were assigned to study arm using a matched-pair randomisation procedure (n=20) or non-randomly with matching criteria (n=20). We interviewed repeated cross-sectional random samples of women in villages 10+ kilometres from their RHC. The primary outcome was facility delivery; secondary outcomes included postnatal care utilisation, counselling, services received and expenditures. Intention-to-treat analysis was conducted. Generalised estimating equations were used to estimate ORs. RESULTS: We interviewed 2381 women at baseline (March 2016) and 2330 at endline (October 2018). The improved MWH model was associated with increased odds of facility delivery (OR 1.60 (95% CI: 1.13 to 2.27); p<0.001) and MWH utilisation (OR 2.44 (1.62 to 3.67); p<0.001). The intervention was also associated with increased odds of postnatal attendance (OR 1.55 (1.10 to 2.19); p<0.001); counselling for family planning (OR 1.48 (1.15 to 1.91); p=0.002), breast feeding (OR 1.51 (1.20 to 1.90); p<0.001), and kangaroo care (OR 1.44 (1.15, 1.79); p=0.001); and caesarean section (OR 1.71 (1.16 to 2.54); p=0.007). No differences were observed in household expenditures for delivery. CONCLUSION: MWHs near well-equipped RHCs increased access to facility delivery, encouraged use of facilities with emergency care capacity, and improved exposure to counselling. MWHs can be useful in the effort to increase delivery at advanced facilities in areas where substantial numbers of women live remotely. TRIAL REGISTRATION NUMBER: NCT02620436.

High Prevalence of Low Birth Weight Babies Born to Pregnant Women Referred to a District Hospital in Rural Zambia.

OBJECTIVES: Low birthweight (LBW) is a significant public health problem in sub-Saharan Africa and LBW in rural Zambia is high. Our study explored the prevalence of LBW for newborns whose mothers were referred from a rural health center to a district referral hospital in Lundazi, Zambia. METHODS: A five-month retrospective record review of Ministry of Health data was performed to examine birthweight characteristics of a convenience sample of newborns from ten facilities referring to one district hospital (n = 234). RESULTS: Among all cases, 21% (n = 49) of newborns were LBW. For LBW newborns, 73% (n = 36) were preterm with mothers having a pregnancy duration of less than 37 weeks. Newborns whose mothers experienced twin pregnancies (p = .021) and prolonged labor (p = .033) were more often LBW. However, regression models demonstrated no difference among newborns with and without LBW for prolonged labor (p = .344) and twin pregnancies (p = .324) when controlling for variables that could interact with the maternal-newborn delivery outcomes. CONCLUSIONS: for Practice Healthcare providers and policy makers need to address the short and long-term effects of LBW throughout the lifecycle in rural Zambia. More maternal-newborn health research is needed to understand the underlying socioeconomic, social, and cultural determinants influencing LBW in rural Zambia.