Navigating a polycrisis: barriers to maternal healthcare access in Burkina Faso

Research Priorities to Support Women Veterans' Reproductive Health and Health Care Within a Learning Health Care System.

Rwanda makes health-facility deliveries more feasible

Significant progress has been made in maternal, newborn, and child health (MNCH) in recent decades. Between 1990 and 2015, the global mortality rate for children under age five years dropped by 53 percent, from 90.6 deaths per 1,000 live births in 1990 to 42.5 in 2015 (Liu and others 2016). Maternal mortality is also on the decline globally.Despite progress, maternal, neonatal, and under-five mortality remain high in many low- and middle-income countries (LMICs). In 2015, approximately 303,000 women died as a result of complications from pregnancy and childbirth (WHO 2015). Globally, an estimated 5.9 million children under age five years die each year, including 2.7 million within the first month of life (Liu and others 2016).Health indicators differ across countries, regions, and socioeconomic levels (Lozano and others 2011). Approximately 99 percent of all newborn deaths occur in LMICs (Bayer 2001). Maternal mortality is concentrated in Sub-Saharan Africa (Hogan and others 2010), where mortality rates for the poor are double those for the nonpoor, and they are higher among rural populations and women with low levels of education (PLoS Medicine Editors 2010). Children living in low-income countries are three times more likely to die before age five years than children living in high-income countries (HICs) (Black and others 2013).Pneumonia, diarrhea, malaria, and inadequate nutrition drive early childhood deaths around the world. In 2015, an estimated 526,000 episodes of diarrhea and 922,000 cases of pneumonia in children under age five years led to death (Liu and others 2016). Undernutrition is a primary underlying cause of 3.5 million maternal and child deaths each year (Black and others 2013); stunting, wasting, and micronutrient deficiencies are responsible for approximately 35 percent of the disease burden in children under age five years and 11 percent of the total global disease burden (Lozano and others 2011). Although maternal mortality is caused chiefly by postpartum hemorrhage, preeclampsia and eclampsia, and sepsis, a large proportion of maternal deaths can be attributed to limited access to skilled care during childbirth and the postnatal period (Lozano and others 2011) as well as to limited access to family planning services and safe abortions (UNFPA and Guttmacher Institute 2010).An appropriate mix of interventions can significantly reduce the burden of maternal and child mortality and morbidity. However, these interventions often do not reach those who need them most (Bayer 2001; Sines, Tinker, and Ruben 2006). An integrated approach that includes community-based care as an essential component has the potential to substantially improve maternal, newborn, and child health outcomes.This chapter provides a summary of community-based programs for improving MNCH. The chapter discusses strategies to improve the supply of services, including through community-based interventions and home visitations implemented by community health workers (CHWs), and strategies to increase demand for services, including through community mobilization efforts. The chapter summarizes the evidence about the impact of such interventions, describes contextual factors that affect implementation, and considers issues of cost-effectiveness. It concludes by highlighting research gaps, the challenges of scaling up, and the way forward.

Black women are disproportionately impacted by chronic illness and are significantly more likely to experience severe morbidity and mortality as a consequence of pregnancy and childbirth.1, 2 As seen in a myriad of stories on maternal death and "near misses", Black women often experience maltreatment in clinical settings.3-5 With rising national media and scientific attention to the depth of racial inequities, Black maternal health has emerged as a priority for government and private funders.6-9 Providing financial support for maternal health research and programming is necessary, but insufficient, in eliminating disparate outcomes. There must be intentional, sustainable investments in the people best able to understand: Black women. Absent from the current landscape is a robust, well-supported cadre of Black maternal health scholar-activists who combine scientific and policy knowledge with the socio-cultural expertise that accompanies lived experience. Federal research institutes and private sector funders in the United States have acknowledged preventable inequities and have dedicated resources to identify causes, mechanisms of influence, and solutions for reducing disparate outcomes.7, 8 However, the conceptualization, design, and conduct of these studies (as well as funding decisions to support them) occur primarily among White researchers, which plausibly limits reductions in inequities.10 Specific investments in the educational trajectory of Black women are urgent and necessary to further enhance the quality, diversity, and impact of the maternal child health (MCH) field. The Public Health and MCH workforce needs to be further diversified with Black women scholar-activists because they are also culturally representative of the very populations at the greatest risk to experience maternal and infant health disparities. For example, Black women are 3.2 times more likely to die from pregnancy-related deaths compared to their White counterparts, and these disparities increase with age to 4–5 times more likely.11 Simultaneously, research demonstrates that when Black newborns are cared for by Black physicians, their mortality rate as compared to White infants is cut in half.12 By increasing the MCH workforce to include Black women scholar-activists and health care providers, the likelihood for improvement in health inequities increases. The goal of this commentary is to provide: (1) a brief overview of challenges Black women encounter on the path to and within science careers, (2) examples of successful approaches used to overcome these challenges, and (3) an urgent call to action for the field to commit to the training and development of Black women scholars in public and maternal health with the goal of eliminating maternal health inequities. In a similar manner to how structural racism and sexism produce adverse outcomes in labor and delivery,13-15 these same mechanisms also produce unfavorable outcomes for Black women in academia. At every level of the professional path to a career in scientific research, Black women consistently face bias: unwarranted and seemingly unavoidable experiences that make it more challenging for them to enroll in and graduate from school. For example, Black women describe experiencing isolation, invisibility, exclusion, pressure to continuously prove themselves worthy, a lack of mentorship, and a lack of sponsorship throughout scholarship.16 In addition, after graduation, they are often met with structural, interpersonal, and intrapersonal challenges in obtaining, managing, and remaining in research-focused academic and other scientific positions.17 Obstacles include exclusion from collaborative opportunities, questioning of credentials and expertise by students and colleagues, criticism of their chosen outlets for publication, extra service requests and additional mentoring burden.18 Hindering the progression of Black women into high level leadership positions also presents barriers to the mentorship of burgeoning Black female scholars, thus continuing this pernicious cycle. Many training programs have been used to improve graduation and retention rates among Black students in higher education. These programs are of particular importance due to the evidence that Black students' experiences on college campuses have a significant impact on their academic longevity.19 For Black college students, factors such as the level of faculty support, availability of research-based programming, and feelings of institutional connectedness and belonging have dramatic effects on their personal and academic development and matriculation.19 The Meyerhoff Scholars Program at the University of Maryland, Baltimore County is an example of a training program that has successfully increased the numbers of Black undergraduate college students who succeed in science, mathematics, and engineering.20 Meyerhoff students were more than 10 times as likely than the historical African American sample to attend graduate school in science, technology, engineering and mathematics (STEM) fields, and almost two times as likely to attend medical school.20 Raising Achievement in Mathematics and Science scholar and similar programs at historically Black colleges and universities (HBCUs) are used to improve retention and graduation rates among minority students specifically in the STEM fields.21 A study at Winston-Salem State University found that prior to the implementation of these training programs, graduation rates for full-time students were 17.8% in 2008 and for STEM majors it was 9.3%.21 With the programs in place, graduation rates increased dramatically. The Raising Achievement in Mathematics and Science scholar program participants had a 98.8% graduation rate over 4 years and 100% of the 2009 scholar cohort graduated in STEM and were enrolled in either MS/PhD graduate programs or professional schools.21 Spelman College also employs several programs to orient and support Black women students in STEM careers. Spelman has the Research Initiative for Scientific Enhancement training program, which supports the career pursuits of women and underrepresented minorities interested in biomedical research.22 In addition, between 2015 and 2019, Spelman College was ranked by the National Science Foundation as the number 1 institution of origin for Black PhDs in STEM disciplines.23 These types of programs and the contributions of Historically Black Colleges and Universities (HBCU's) to the Black female scientific workforce emphasizes their importance and necessity in contributing toward the development and advancement of Black women in research and advocacy. The W. Montague Cobb/National Medical Association Health Institute (also known as The Cobb Institute) is an organization that focuses on improving health inequities and addressing structural racism through research, education, and mentorship.24 The Cobb Scholars Program was launched in 2016 for senior residents, fellows, postdoctoral scientists, or early-stage investigators that come from underrepresented groups and are interested in biomedical and behavioral research.24 The scholars receive mentorship in leadership and research from interdisciplinary senior fellows which provides for collaboration and coaching across sectors to enrich their experience. Predominately White institutions can also help advance this goal. For example, the Pathways for Students into Health Professions program, housed within the University of California, Los Angeles campus, focuses on supporting underrepresented minority undergraduate students in MCH professions through the provisions of faculty mentorship, paid internships, and learning opportunities through various seminars.25 Although the program is not specifically built for Black students, it does prioritize students coming from non-dominant racial and ethnic groups, and research has found that students who completed the program were significantly more likely to report an interest in MCH topics and careers when compared to pre-enrollment.25 Many mentorship and training programs are open to those coming from other non-dominant racial and ethnic groups, as well as multiple gender identities.26 However, Black women often face different and distinct challenges as compared to their Black male counterparts or women of other racial backgrounds.27 Thus, there is a critical need to focus on the unique training and mentorship needs of Black women in academia. To bolster impacts within the MCH field, it would be useful to develop and implement programs to support Black women in their matriculation in public health, social sciences, and health care graduate programs with a focus on MCH research. There are a few graduate programs designed to support Black women in health care and health sciences that can be adapted for scholar-activists. For example, the Association of Black Women Physicians offers the Sister-to-Sister Mentoring Program that provides mentorship to Black women physicians, residents, and medical students.28 The program, Black Girl White Coat, is a social media mentorship initiative that hopes to provide further representation for groups that have been historically marginalized and oppressed.29 In addition, the ADVANCE Institutional Transformation Project of Jackson State University is a STEM mentorship program designed to support and empower Black women scholar-activists as well as provide a mentorship pipeline for early career scientists.30 Each of these programs aim to cultivate community and camaraderie among women who frequently, by nature of their racial and gender identity, are isolated in academic and professional settings. By adapting these mentorship programs to accommodate the needs of aspiring Black maternal health scholars, we can expand the support of early career professionals beyond undergraduate trainings. The profound impact of intentional investment in the form of mentorship, academic skill building, and providing opportunities for advocacy in the next generation of leaders cannot be overstated. This common thread among the following programs remain at the crux of the case for increased financial and programming support dedicated to the academic and career development of Black maternal health scholars. HBCU's must be central in the creation of a pipeline of leaders and scholars from historically underrepresented communities trained to work toward health equity in maternal health. For the past few years, Health Resources Services Administration through the Maternal and Child Health Bureau has formed an Alliance with 10 HBCU's to enhance the resources and expertise of faculty and students in HBCU's to address health inequities in MCH populations.31 The Alliance meets monthly to discuss strategies to strengthen research, outreach, advocacy, and services and has recently presented recommendations to the Maternal and Child Health Bureau. The Charles Drew University's Black Maternal Health Center of Excellence is one of the promising new programs underway that has been designed to address the persisting birthing disparities that disproportionately impact Black birthing people in Los Angeles County and the local Charles Drew community.32 The initiative names racism as a root cause to the disproportionately higher rates of infant and maternal death for Black birthing people countywide.33 In response to growing maternal morbidity and mortality rates in the state of Georgia, The Morehouse School of Medicine launched the Center for Maternal Health Equity in 2019.34 Their approach to tackling maternal health inequities is multifaceted; the Center utilizes research, workforce training, community engagement, and policy advocacy to improve reproductive justice.34 There is a paucity of evaluated programs tailored to meet the needs of Black women scholar-activists. However, many of the programs that currently exist offer foundations and frameworks that can be augmented to fit the needs of Black women and students within the MCH fields. The Diversity Scholars Leadership Program at the Boston University School of Public Health Center of Excellence in MCH is designed for students from underrepresented minority communities during their public health graduate studies in MCH.35 The National Birth Equity Collaborative is a Black-led organization that serves as a hands-on training program for promising scholars in the field.36 The Collaborative recruits interns from across multiple public health disciplines with experience in research, policy, training, advocacy, and community-centered work, with a commitment to reproductive justice and advancing birth equity.37 Founded in July 2020 during the dual pandemics of racism and COVID-19, The Maternal Outcomes for Translational Health Equity Research (MOTHER) Lab at Tufts University School of Medicine was created with two main goals: (1) to train, mentor, and engage bright scholars of color and White allies; and (2) to provide a research and training space to ensure scholars are supported as they prepare to go into their respective fields to dismantle systemic racism.38 Through a keen focus on the development of research skills, advocacy, and leadership among its students, the MOTHER Lab provides a framework for the development of maternal health scholars that can serve as model for other research labs housed in schools of public health or medicine. The MOTHER Lab is a unit within the newly formed Center for Black Maternal Health and Reproductive Justice that houses faculty, staff, and students with a dedicated interest in addressing maternal health inequities. This center would contribute to immense progress in filling current gaps for mentorship, research, and sustainable change in this field.39 Research has shown that mentorship for students of color in White spaces are especially beneficial and can become a positive predictor component to their academic and professional futures; this center would provide training, research, and mentorship opportunities for scholars and providers in the field of Black maternal health equity.40, 41 Additionally, the Center for Black Maternal Health and Reproductive Justice and the MOTHER Lab scholarly program for maternal health students are founded and run by Black female scholars with lived experience, thus representing a unique opportunity to engage and train the next generation of leaders. Finally, policy agendas such as the Black Maternal Health Momnibus Act of 2021 (suite of 12 bills proposed in Congress), provide new and exciting ways to support the development of scholar-activists at the local, national, and state level that are dedicated to eliminating maternal mortality and morbidity in Black women.42 These 12 bills address current Black maternal health disparities through numerous distinct methods, but prominently include expanded funding for research on the topic and diversifying the MCH workforce as important methods. One of these bills (Protecting Moms Who Served Act of 2021) has been signed into law, while parts of several others have been partially incorporated in the proposed Build Back Better Act (Data to Save Moms Act, Kira Johnson Act, Maternal Health Pandemic Response Act of 2020, Perinatal Workforce Act, Protecting Moms and Babies Against Climate Change Act, and the Tech to Save Moms Act).43 Unique obstacles encountered from secondary school and throughout graduate education contribute to a lack of adequate representation of Black women in public health. This ultimately leads to a lack of lived experience and scholarship of scholars from communities most affected by the Black maternal health crisis. Modeling the success of other heavily invested pipeline mentorship and training programs, increased support of burgeoning Black maternal health scholar-activists may help mitigate this issue. Furthermore, existing policies and proposed legislation to diversify the public health workforce create the platform needed to build out the investment in Black women scholars who can lead the movement for maternal health equity. The authors have no funding to report.

Reducing Maternal and Perinatal Mortality Through a Community Collaborative Approach: Introduction to a Special Issue on the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP)

Elevating the Needs of Minor Adolescents in a Landscape of Reduced Abortion Access in the United States

Reproductive, maternal, newborn, and child health (RMNCH) has been a priority for both governments and civil society in low- and middle-income countries (LMICs). This priority was affirmed by world leaders in the Millennium Development Goals (MDGs) that called for countries to reduce child mortality by 67 percent and maternal mortality by 75 percent between 1990 and 2015. Although substantial progress on these targets has been made, few countries achieved the needed reductions. The United Nations (UN) Secretary-General’s Global Strategy for Women’s and Children’s Health, launched in 2010 and expanded in 2015 to include adolescents, is an indication of the continued global commitment to the survival and well-being of women and children (Ban 2010). Annual official development assistance for maternal, newborn, and child health has increased from US$2.7 billion in 2003 to US$8.3 billion in 2012, when there was an additional US$4.5 billion for reproductive health (Arregoces and others 2015). A continued focus on RMNCH is needed to address the remaining considerable burden of disease in LMICs from unwanted pregnancies; high maternal, newborn, and child mortality and stillbirths; high rates of undernutrition; frequent communicable and noncommunicable diseases; and loss of human capacity. Cost-effective interventions are available and can be implemented at high coverage in LMICs to greatly reduce these problems at an affordable cost.RMNCH encompasses health problems across the life course from adolescent girls and women before and during pregnancy and delivery, to newborns and children. An important conceptual framework is the continuum-of-care approach in two dimensions. One dimension recognizes the links from mother to child and the need for health services across the stages of the life course. The other is the delivery of integrated preventive and therapeutic health interventions through service platforms ranging from the community to the primary health center and the hospital.This volume presents the levels and trends of RMNCH indicators, proven interventions for prevention of mortality, costs of these interventions and potential health service delivery platforms, and system innovations. Other volumes in the third edition of Disease Control Priorities also cover topics of importance to women and children that are related to the RMNCH health services packages (box 1.1). These topics include the following:

Supplement1 December 2020Looking Outward to Look Within: The Health Resources and Services Administration Maternal Mortality Summit, and What It Means for Women EverywhereFREEDoris Chou, MDDoris Chou, MDUNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland (D.C.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-3259 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In 2015, when world leaders approved and became signatories to the Sustainable Development Goals 2015–2030 (SDG) Framework, a critical nuance was noted (1). Unlike the Millennium Development Goals, which focused on improving the status of lower-resourced countries between 1990 and 2015, this global pact intends for all countries, regardless of resource level, to collectively contribute to the global agenda. High-, middle-, and low-income countries alike are expected to report on and improve their populations' and countries' status across 17 goals as measured by targets with more than 200 indicators (2).In that framework, SDG 3.1/3.2 assesses the state of maternal and child health services and outcomes (2). As a vital barometer of any health system, SDG 3.1/3.2 asks whether a country can sustain itself by ensuring its future: the lives of women and their newborns. Unfortunately, the promise of the future often goes unfulfilled. In the United States, it is estimated that 2 women die every 3 days because of pregnancy (3–5). The absolute numbers may appear to be small, but any maternal death is unacceptable.To address this issue, the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services convened the HRSA Maternal Mortality Summit in June 2018. The purpose of the summit was to "discuss evidence-based approaches and identify innovative solutions to decreasing maternal mortality and morbidity rates in the U.S. and globally" (6). Participants included U.S. domestic experts as well as those from Brazil, Canada, Finland, India, Rwanda, and the United Kingdom.Although at first glance the experiences of Canada, Finland, and the United Kingdom are natural comparisons, U.S.-based practitioners readily found commonalities among all the shared experiences in the root causes of ill maternal health. Before the summit, it is unlikely that the general U.S. public would spontaneously identify with maternal health experiences from Brazil, India, and Rwanda. However, many of the participants found resonance in the discourse around the effects of nutrition, education, and social and cultural forces that shape care-seeking and implementation of medical advice (issues of access, accessibility, and acceptance). Above all, constructs of ethnicity, race, social status, and "women's agency and autonomy" amplified throughout the country-led discussions. The same themes could be found both between countries and across U.S. states.During the summit, countries shared openly on the challenges of measuring and documenting maternal deaths. All countries discussed the limitations of any one measurement system to accurately capture all the maternal deaths as it directly affects the ability of programs and efforts made by countries to address the causes of maternal death (and morbidity). The discussants shared how shifting demographics, social determinants, and risk factors could result in inequities, which often contributed to maternal morbidity and deaths.Nevertheless, maternal ill health is preventable. A positive pregnancy brings benefits not only to the individual, but also to her community, society, and country. Sweeping and long-standing changes do not come easily; there is no single "magic bullet." Concerted and transparent efforts are needed to change the rhetoric from "It's not my/our problem" to asking the difficult questions of "Why does maternal ill health occur?" and "How can we move forward?" by focusing on what can be done rather than focusing on what cannot.The World Health Organization (WHO) works worldwide to promote health, keep the world safe, and serve vulnerable persons. With partners, the WHO developed the Ending Preventable Maternal Mortality (EPMM) initiative to support countries as they determine the processes to assure appropriate resource allocation to strengthen health systems and enable them to move toward universal health coverage for all who are in need, with the aim of improving maternal and newborn health (7). Integrating EPMM principles and strategies enables countries to realize improved maternal health by prioritizing country leadership and supportive legal, regulatory, and financial mechanisms and integrating maternal and newborn health care to preserve the mother–baby dyad (7). The EPMM initiative calls for a human rights framework to ensure that high-quality sexual, reproductive, maternal, and newborn health care is accessible and available to all who need it and for the empowerment of women, girls, families, and communities (7).Focusing the EPMM lens on the United States, the HRSA summit highlighted essential areas to address. These include general health among women and the effects of inequities and disparities. Additional concerns are the availability of a robust health workforce and the relevant policies and financial implications that drive the overall U.S. health agenda. Readers of this supplement will find thoughtful consideration of these themes and articulation of some of the efforts undertaken to address American maternal mortality and morbidity.The first article provides a narrative landscape review of U.S. maternal health epidemiology (8). The robust series of papers that follow distill the U.S context of racial/ethnic, socioeconomic, and geographic disparities in the care and health outcomes of reproductive-aged women (9–11) and consider the availability of timely access to skilled health personnel and high-quality care, which provide opportunities for prevention and intervention (10–12). Finally, changes in care for mothers of the sickest newborns (13) and maternal comorbid conditions (14, 15) provide concrete strategies to improve health outcomes.Within HRSA sits the Maternal and Child Health Bureau, whose mission is to "improve the health of America's mothers, children, and families" (16). With the summit and this supplement, the HRSA and the United States have taken a step toward ensuring that maternal health is a priority both domestically and internationally. The global community welcomes the continuation and development of this initiative from the landmark meeting.Maternal mortality remains a scourge for every country. Although it can strike any woman, anywhere, fundamentally some predictable patterns can be addressed, with the result that fewer women will die during pregnancy and childbirth. Multilateral sharing and learning from mutual experiences provide potential paths forward in order to reach the collective SDG maternal mortality goal of a global maternal mortality ratio of less than 70 deaths per 100 000 live births (2, 7).

ObjectivesThis paper assesses inequalities in access to reproductive and maternal health services among females affected by forced displacement and sexual and gender-based violence in conflict settings in Colombia. This was accomplished through the following approaches: first, we assessed the gaps and gradients in three selected reproductive and maternal health care services. Second, we analyzed the patterns of inequalities in reproductive and maternal health care services and changes over time. And finally, we identified challenges and strategies for reaching girls and women who are the hardest to reach in conflict settings, in order to accelerate progress towards universal health coverage and to contribute to meeting the Sustainable Development Goals of good health and well-being and gender equality by 2030.MethodsThree types of data were required: data about health outcomes (relating to rates of females affected by conflict), information about reproductive and maternal health care services to provide a social dimension to unmask inequalities (unmet needs in family planning, antenatal care and skilled births attendance); and data on the female population. Data sources used include the National Information System for Social Protection, the National Registry of Victims, the National Administrative Department of Statistics, and Demographic Health Survey at three specific time points: 2005, 2010 and 2015. We estimated the slope index of inequality to express absolute inequality (gaps) and the concentration index to expresses relative inequality (gradients), and to understand whether inequality was eliminated over time.ResultsOur findings show that even though absolute health care service-related inequalities dropped over time, relative inequalities worsened or remain unchanged. All summary measures still indicated the existence of inequalities as well as common patterns. Our findings suggest that there is a pattern of marginal exclusion and incremental patterns of inequality in the reproductive and maternal health care service provided to female affected by armed conflict.ConclusionsOverall, the effects of conflict continue to threaten reproductive and maternal health in Colombia, impeding progress towards the realization of universal health care (UHC) and reinforcing already-existing inequities. Key messages and steps forward include the need to understand the two distinct patterns of inequalities identified in this study in order to prompt improved general policy responses. Addressing unmet needs in reproductive and maternal health requires supporting gender equality and prioritizing the girls and women in regions with the highest rates of victims of armed conflict, with the objective of leaving no girl or woman behind. This analysis represents the first attempt to analyze coverage-related inequality in reproductive and maternal health care services for female affected by armed conflict in Colombia. As the World Health Organization and global health systems leaders call for more inclusive engagement, this approach may serve as the key to shaping people-centred health systems. In this particular case, health care facilities must be located in close proximity to girls and women in conflict and post-conflict settings in order to deliver essential reproductive and maternal health care services. Finally, reducing inequalities in opportunities would not only promote equity, but also drive sustainable development.

<h3>Context:</h3> Evidence-based reproductive and sexual health care are essential women’s health services but disparities in access, use, and outcomes persist. Community health centers (CHCs) provide care to 20% of reproductive age (15-44 years) women in the US and are considered a key source of care for women of reproductive age. As the largest primary care system for low-income, uninsured, and publicly insured individuals, CHCs have particular interest in the impact of policies including the Affordable Care Act, and Medicaid expansion on women’s reproductive care. <h3>Objective:</h3> Understand patient, provider, and CHC leader perceptions of how ACA and state level policies have impacted women’s reproductive health care in the past five years <h3>Study design:</h3> Semi-structured interviews with patients, providers, and health system leaders. Findings will be integrated with a larger mixed-methods study to evaluate the impact of federal and state policies on women’s reproductive health care utilization and outcomes. <h3>Setting:</h3> CHCs and public health departments from the OCHIN practice-based research network of 123 health care organizations in 19 states. <h3>Participants:</h3> Up to 40 patients, 30 providers or clinic staff, and 12 health system leaders (executive leaders, medical directors) from CHCs or CHC lookalikes across a mix of: Medicaid expansion/non-expansion states; rural/urban sites; and primary care/family planning/prenatal care sites. <h3>Outcomes:</h3> Patient, provider, and health system perspectives on contraceptive, preventive, prenatal and postpartum care provision, access, and utilization in CHC settings in the post-ACA environment. <h3>Results:</h3> We found federal (e.g. ACA, Title X) and state (e.g. Medicaid expansion, 1115 waivers, reproductive health programs) policies as well as provider, clinic, and community factors contribute to perceptions of availability, accessibility, and acceptability of women’s reproductive health care. Participants recommended priority areas to focus development of strategies and approaches to improve, expand, or otherwise modify care in relation to community and policy contexts in an evolving landscape of reproductive care in CHC settings. <h3>Conclusions:</h3> Understanding individual, CHC, and policy factors affecting the provision and utilization of women’s reproductive care will contribute to ongoing policy, community, and practice interventions to improve equitable, evidence-based care and reproductive health among people served in CHC settings.

COVID-19 and its associated lockdowns and restrictions on movement may be impacting women and men’s access to and use of health care services including contraceptive, prenatal, and postnatal care. Yet we know little of its impact to date, especially in low- and middle-income countries, including India. Understanding how COVID-19 impacts the use of these services now, and as it persists, is essential for improving access and use today. Additionally, these data are necessary to understand fertility and other health-related outcomes we may see in the future. The objectives of this study are to understand a Facebook sample of respondent’s perceived barriers to contraceptive, prenatal, and postnatal care in India and how these changed over 4 months of the COVID-19 pandemic. To meet this need, we conducted four rounds of monthly online surveys with men and women (N = 9,140) recruited using Facebook ads in India between April and July 2020, a period when the national lockdown was tapered from the strictest to restricted. While about 75% of respondents reported no barriers to contraception due to COVID-19, about half of those pregnant or postpartum reported barriers to pre- and postnatal care. Barriers to care for contraception, prenatal, and postnatal care increased significantly over time. Most respondents reported some change on fertility preferences, with more respondents reporting desire to delay, rather than to have a child sooner, due to COVID-19. Overall, as the early COVID-19 pandemic persisted, barriers to reproductive and maternal health care increased in India, suggesting that as the pandemic continued there have likely been additional challenges for people seeking these services. It is essential that health care providers begin to address these barriers to ensure access to care throughout these important time periods.

HIV/AIDS continues to pose a significant public health challenge in Africa, with Sub-Saharan Africa accounting for the majority of global cases. While international donor funding has historically underpinned HIV/AIDS programs across the continent, the declining availability of external resources has emphasized the need for sustainable domestic financing. Local governments, situated at the intersection of national policies and community-level implementation, play a pivotal role in bridging this funding gap. This review examines the contributions of local governments to HIV/AIDS program funding in Africa through a comparative lens, focusing on successes, challenges, and opportunities for strengthening their role. Case studies from South Africa, Uganda, Nigeria, and Kenya highlight diverse approaches to resource mobilization, policy implementation, and community engagement. Persistent barriers, including limited fiscal capacity, donor dependency, weak governance structures, political instability, and competing priorities, are analyzed to inform strategic recommendations. The findings underscore the need for enhanced fiscal decentralization, capacity building, and innovative financing mechanisms to empower local governments in sustaining HIV/AIDS responses. By fostering greater local government participation, Africa can achieve more resilient and effective health systems, ensuring progress toward ending AIDS as a public health threat by 2030. Keywords: HIV/AIDS funding, Local government, Sustainable financing, Sub-Saharan Africa, Public health policy.

Despite its reduction over the last decade, the maternal mortality rate in Uganda remains high, due to in part a lack of access to maternal health care. In an effort to increase access to care, a quasi-experimental trial using vouchers was implemented in Eastern Uganda between 2009 and 2011. Findings from the trial reported a dramatic increase in pregnant women’s access to institutional delivery. Sustainability of such interventions, however, is an important challenge. While such interventions are able to successfully address immediate access barriers, such as lack of financial resources and transportation, they are reliant on external resources to sustain them and are not designed to address the underlying causes contributing to women’s lack of access, including those related to gender. In an effort to examine ways to sustain the intervention beyond external financial resources, project implementers conducted a follow-up qualitative study to explore the root causes of women’s lack of maternal health care access and utilization. Based on emergent findings, a gender analysis of the data was conducted to identify key gender dynamics affecting maternal health and maternal health care. This paper reports the key gender dynamics identified during the analysis, by detailing how gender power relations affect maternal health care access and utilization in relation to: access to resources; division of labour, including women’s workload during and after pregnancy and lack of male involvement at health facilities; social norms, including perceptions of women’s attitudes and behaviour during pregnancy, men’s attitudes towards fatherhood, attitudes towards domestic violence, and health worker attitudes and behaviour; and decision-making. It concludes by discussing the need for integrating gender into maternal health care interventions if they are to address the root causes of barriers to maternal health access and utilization and improve access to and use of maternal health care in the long term.

Petra ten Hoope-Bender: a “midwife's midwife”

IntroductionQuality care delivery is an essential lifesaving interventions for maternal healthcare and reduction in mortality from preventable reproductive conditions. In African countries like Nigeria, numerous perceptions and militating factors present unique challenges in optimizing the utilization of maternal and reproductive healthcare services. As women continuously evolve away from the utilization of healthcare services, achieving universal health coverage for all emerges as a matter of concern.MethodA phenomenological and descriptive research design was used. The study participants comprised a total of 38 women selected from primary and tertiary healthcare institutions. They were purposively selected from four healthcare institutions in Nsukka, Enugu State, Nigeria.ResultFindings revealed that most rural women at the prenatal stage, utilize maternal healthcare services, but at the postnatal stage, they reject reproductive healthcare services owing to certain perceptions. Concerns about sub-optimal utilization of maternal and reproductive healthcare services were found under enabling, predisposing and need factors. Evidence-based interventions included instituting health insurance policies, improving the healthcare sector, personnel, collaboration among stakeholders, and grass-roots community education. Participants showed little knowledge of social workers’ engagement in healthcare institutions.ConclusionFunctional network of care between private and public healthcare system is the key to optimizing maternal and reproductive healthcare utilization. The study recommends stakeholder and community engagement in achieving functional networks of care, strengthening relational linkages between frontline health workers and equip rural women with better knowledge. All these are geared toward achieving optimal utilization of maternal and reproductive healthcare services among women in low-resourced Nigerian settings.