Care For Maternal Health Services Research Articles

Adoption of policies to improve respectful maternity care in Timor-Leste.

There are now well-established global standards for supporting improvement in women's experience of maternity services, including frameworks for the prevention of mistreatment during childbirth. To support initiatives to improve the quality of care in maternal health services in Timor-Leste, we examine the adoption of global respectful maternity care standards in the national intrapartum care policy and in three urban birth facilities in Dili. From May to July 2022, we conducted a desk review of the Timor-Leste National Intrapartum Care Standards and Clinical Protocols for Referral Facilities and Community Health Centres. This was followed by a health-facility audit of policies, guidelines and procedures in three main maternity facilities in the capital, Dili to examine the extent to which the WHO (2016) standards for women's experiences of care have been adopted. Despite the availability of global guidelines, key standards to improve women's experience of care have not been included in the National Intrapartum Care guidelines in Timor-Leste. There was no mention of avoiding mistreatment of women, needing informed consent for procedures, or strengthening women's own capability and confidence. In the policy wording, women tended to be distanced from the care 'procedures' and the protocols could be improved by taking a more woman-centred approach. The results of the health facility assessment showed extremely low use of standards that improve women's experiences of care. Health Facility 1 and 2 met two of the 21 quality measures, while Health Facility 3 met none of them. The discourse communicated through policy fundamentally affects how health care issues are framed and how policies are enacted. Given the findings of this study, combined with previously documented issues around quality of care and low satisfaction with maternal health services, there is a need for a fundamental shift in the culture of care for women. This will require an immediate focus on leadership, training and policy-frameworks to increase respectful care for women in health facilities. It will also require longer-term effort to address the power imbalances that drive mistreatment of women within and across social systems, and to support models of care that inherently foster understanding and compassion.

Evaluating equity across the continuum of care for maternal health services: analysis of national health surveys from 25 sub-Saharan African countries

BackgroundEnsuring access to the continuum of care for maternal, neonatal, and child health is an effective strategy for reducing maternal and child mortality. We investigated the extent of dropout, wealth-related inequalities, and drivers of inequality in the continuum of care for maternal health services in sub-Saharan Africa.MethodsWe analysed Demographic and Health Surveys (DHS) conducted between 2013 and 2019 across 25 sub-Saharan African countries. We defined the continuum of care for maternal health services as women who had received at least four ANC contacts (ANC 4 + contacts), skilled care at birth, and immediate postnatal care (PNC). We used concentration index to estimate wealth-related inequalities across the continuum of care. Multilevel logistic regression models were used to identify predictors of inequality in completing the continuum of care.ResultsWe included data on 196,717 women with the most recent live birth. About 87% of women reported having at least one ANC contact, but only 30% of women received the recommended care package that includes ANC 4 + contacts, skilled care at birth, and PNC. The proportion of women who had completed the continuum of care ranged from 6.5% in Chad to 69.5% in Sierra Leone. Nearly 9% of women reported not having contact with the health system during pregnancy or childbirth; this ranged from 0.1% in Burundi to 34% in Chad. Disadvantaged women were more likely to have no contact with health systems and less likely to have the recommended care package than women from wealthier households. Women with higher education levels, higher exposure to mass media (radio and TV), and higher household wealth status had higher odds of completing the continuum of care.ConclusionsPersistent and increasing inequalities were observed along the continuum of care from pregnancy to the postnatal period, with socioeconomically disadvantaged women more likely to drop out of care. Improving access to and integration of services is required to improve maternal health. Initiatives and efforts to improve maternal health should prioritise and address the needs of communities and groups with low coverage of maternal health services.

Effectiveness of a continuum of care in maternal health services on the reduction of maternal and neonatal mortality: Systematic review and meta-analysis

BackgroundSustainable Development Goals −3 (SDG – 3) were to ensure healthy live and promote well-being by reducing global maternal and neonatal deaths. These were to be implemented through the concept of continuum of care in maternal health program framework to improve health outcomes. There is a paucity of published evidences; as such, this review is designed to assess the effectiveness of the concept of continuum of care in maternal and neonatal health services on the reduction of maternal and neonatal mortality. MethodsA search was conducted using the key words; maternal and neonatal, health services, continuum of care, maternal and neonatal mortality. Search focused on PubMed, Cochrane, MEDLINE and Google Scholar. Extractions of articles were done based on predetermine criteria. Data were compiled, and screened, entered and analysis was done using STATA 13 and Rev. Man. software. Effects of the intervention package were determined and the result was interpreted in random effect RR with 95%CI. The publication bias was determined by using funnel plot, Egger and Bagger test, heterogeneity, and sensitivity test. ResultsA total of 4685 articles were retrieved of these 20 articles reviewed. Articles on 631,975 live births (LBs) were analyzed. Results showed the distribution as follows; 23,126 newborns died within 28 days resulting [NMR = 35/1000LBs among the intervention group whereas NMR = 39/1000LBs among the control group]. The pooled effect of the intervention was significantly reduced neonatal mortality (RR = 0.84; 95%CI: 0.77–0.91). Similarly, 1268 women died during the pregnancy period up to 42 days after childbirth that resulted [MMR = 330/100,000LBs among the intervention group whereas MMR = 460/100,000LBs among the control group]. The pooled effect of the intervention was not a statistically significant association with maternal mortality (RR = 0.64; 95%CI: 0.41–1.00). ConclusionAdoption of continuum of care concepts in maternal health services reduced maternal and neonatal mortality. We recommend strengthening and effective implementation of a continuum of care in maternal health services to improve maternal and neonatal health care outcomes.

Adopting international recommendations to design a model for maternal health service to cope with pandemic disruption for Indonesian primary care

BackgroundLimited evidence is available as the reference for the model of care on providing maternity care in low-and-middle-income countries (LMICs) to cope with pandemic disruption. This study aimed to adopt international recommendations to develop the model of care with the context of Indonesian settings.MethodsFour codesign workshops and substitute interviews with stakeholders, covering the (i) exploration of service provision during the pandemic, (ii) adoption of international recommendations, (iii) designing and (iv) finalising model of care for maternal health services in primary care under the COVID-19 pandemic. The study took place in Yogyakarta Province Indonesia from July-November 2021. The participants were general practitioners, midwives, nurses, patients, and obstetricians. The data were analysed thematically.ResultsTwenty-three participants were recruited. As many as 23, 16, 14 and 16 participants participated in the first to fourth codesign workshops or substitute interviews. Key recommendations agreed upon in the workshop were health screening, maintaining antenatal-postnatal breastfeeding care, limiting visitors, using telemedicine, and creating a multidisciplinary team to provide the care. A model of care for improving maternal service was also agreed and received suggestions from the participants. Identified barriers to the recommendation implementation, such as the available clinical resources and negotiating providers’ authority in practice.ConclusionRecommendations and the model of care for improving maternity care in Indonesia are beneficial to be implemented in Indonesian primary care during the COVID-19 pandemic. Further research includes pilot studies to explore the acceptability of the model and recommendation implementation in practice.

Effects of continuity of maternal health services on immediate newborn care practices, Northwestern Ethiopia: multilevel and propensity score matching (PSM) modeling

BackgroundDespite priority being given to maternal and child health programs in Ethiopia, the reduction of neonatal mortality rate is stagnant, which is more than double the national target. Immediate newborn care and continuity of maternal health services are comprehensive, wide-ranging, and core strategies to overcome neonatal mortality and morbidity. However, the evidence of immediate newborn care practices and the effectiveness of continuity of maternal health services on immediate newborn care practices are scarce. Hence, this study aimed to fill this gap. MethodsA prospective follow-up study was conducted from March 2020 to January 2021, among 2198 pregnant women screened from the study areas. The data were collected using pretested semi-structured questionnaires and a registration logbook. Data were coded, entered, cleaned, and analyzed using STATA software 14. Descriptive statistics, multilevel regression, and propensity score matching (PSM) models were computed. Finally, ICC (ρ), AOR, and coefficient (β) along with 95%CI were calculated and statistical significance was considered at a p-value < 0.05. ResultsThe magnitude of immediate newborn care practice was 50.9% (95%CI: 50.5%, 51.3%). Partner attended primary cycle school (AOR = 2.32), women attended ANC visit ≥4 (AOR = 2.69), initiated 1st ANC visit between 4–6 months of GA (AOR = 0.47), IFA supplementation (AOR = 2.99), women who make a decision (AOR = 2.25), women whose husband make a decision (AOR = 1.66) and immunizing the newborn (AOR = 2.46) were determinant factors of immediate newborn care practices. As treatment effect, completion of COC in MHS via time dimension (β = 0.31; 95%CI: 0.27, 0.35); whole key service MHS (β = 0.43; 95%CI: 0.39, 0.48) and COC via space dimension (β = 0.17; 95%CI: 0.12, 0.21) were significantly increased the likelihood of immediate newborn care practices. ConclusionThe magnitude of optimal immediate newborn care practices was low. Different enabling factors were discovered in the study. Therefore, strengthening those enabling factors such as partner education, immunization program, IFA supplementation, early initiation and receiving ANC services, the decision-making power of women and partners, as well as scaling up a continuum of care in maternal health services are strongly recommended.

Completion and determinants of a continuum of care in maternal health services in Benishangul Gumuz region: A prospective follow-up study.

The provision of a continuum of care to women throughout pregnancy, labor, and after delivery has become a fundamental strategy for improving maternal and neonatal health. A better understanding of where the gaps are in seeking care along the pathway and what factors contribute to the gaps is required for successful program implementation. Hence, this study was targeted to determine the status and determinant factors of the completion rate of a continuum of care in maternal health services. A prospective follow-up study was conducted among 2,198 sampled pregnant women and followed for 11 months in Benishangul-Gumuz region. A multistage clustered sampling technique was employed to select the study participants. Data were collected via face-to-face interviews using a pretested, semi-structured questionnaire, and logbook registry. Collected data were edited, cleaned, and analyzed using STATA software. The multilevel regression model was used to examine the effects of individual- and community-level factors and expressed as AOR with 95% CI. The completion rate of a continuum of care via visit-based, content-based, and space dimensions was 33.1, 20, and 37.2%, respectively. The enabling factors were having information on maternal health services (AOR = 2.25; 95% CI: 1.11-4.55), iron and folic acid supplementation (AOR = 2.58; 95% CI: 1.37-4.86), tetanus toxoid vaccination during pregnancy (AOR = 2.21; 95% CI: 1.39-3.52), having pregnant-related problems (AOR = 2.1; 95% CI: 1.15-3.71), dry and stimulate newborn (AOR = 2.61; 95% CI: 1.42-4.77), appropriate cord care (AOR = 2.01; 95% CI: 1.07-3.79), and immunizing newborn (AOR = 6.9; 95% CI: 3.79-12.59), whereas risk factors were ever having a stillbirth (AOR = 0.52; 95% CI: 0.32-0.85) and delay of 1st ANC initiation at 4-6 months of pregnancy (AOR = 0.45; 95% CI: 0.3-0.68). The completion rates via visit-based, content-based, and space dimensions were low. Different determinant factors which have a programmatically important implication were identified. Thus, interventions should focus on increasing women's awareness and improving the availability and accessibility of the whole packages of maternal health services to facilitate the completion rate.

Associations between Indonesia’s national health insurance, effective coverage in maternal health and neonatal mortality: a multilevel interrupted time-series analysis 2000–2017

BackgroundWe assessed the effect of Indonesia’s national health insurance programme (Jaminan Kesehatan Nasional (JKN)) on effective coverage for maternal and child health across geographical regions and population groups.MethodsWe used four...

The effects of completion of continuum of care in maternal health services on adverse birth outcomes in Northwestern Ethiopia: a prospective follow-up study

BackgroundGlobally, around 4 million babies die within the first month of birth annually with more than 3 million stillbirths. Of them, 99% of newborn deaths and 98% of stillbirths occur in developing countries. Despite giving priority to maternal health services, adverse birth outcomes are still major public health problems in the study area. Hence, a continuum of care (CoC) is a core key strategy to overcome those challenges. The study conducted on the effectiveness of continuum of care in maternal health services was scarce in developing countries and not done in the study area. We aimed to assess the effectiveness of continuum of care and determinants of adverse birth outcomes.MethodsCommunity and health facility-linked prospective follow-up study designs were employed from March 2020 to January 2021 in Northwestern Ethiopia. A multistage clustered sampling technique was used to recruit 2198 pregnant women. Data were collected by using a semi-structured and pretested questionnaire. Collected data were coded, entered, cleaned, and analyzed by STATA 14. Multilevel logistic regression model was used to identify community and individual-level factors. Finally, propensity score matching was applied to determine the effectiveness of continuum of care.ResultsThe magnitude of adverse birth outcomes was 12.4% (95% CI 12.2–12.7): stillbirth (2.8%; 95% CI 2.7–3.0), neonatal mortality (3.1%; 95% CI 2.9–3.2), and neonatal morbidity (6.8%; 95% CI 6.6–7.0). Risk factors were poor household wealth (AOR = 3.3; 95% CI 1.07–10.23), pregnant-related maternal complications during pregnancy (AOR = 3.29; 95% CI 1.68–6.46), childbirth (AOR = 6.08; 95% CI 2.36–15.48), after childbirth (AOR = 5.24; 95% CI 2.23–12.33), an offensive odor of amniotic fluid (AOR = 3.04; 95% CI 1.37–6.75) and history of stillbirth (AOR = 4.2; 95% CI 1.78–9.93). Whereas, receiving iron-folic acid (AOR = 0.44; 95% CI 0.14–0.98), initiating breastfeeding within 1 h (AOR = 0.22; 95% CI 0.10–0.50) and immunizing newborn (AOR = 0.33; 95% CI 0.12–0.93) were protective factors. As treatment effect, completion of continuum of care via time dimension (β = − 0.03; 95% CI − 0.05, − 0.01) and space dimension (β = − 0.03; 95% CI − 0.04, − 0.01) were significantly reduce perinatal death.ConclusionsAdverse birth outcomes were high as compared with national targets. Completion of continuum of care is an effective intervention for reducing perinatal death. Efforts should be made to strengthen the continuum of care in maternal health services, iron supplementation, immunizing and early initiation of breastfeeding.

Continuum of maternal healthcare services utilization and its associated factors in Ethiopia: A systematic review and meta-analysis.

The continuum of care throughout pregnancy, childbirth, and postnatal period is one of the vital strategies for improving maternal and neonatal health and preventing maternal and neonatal mortalities and morbidities. The level and determinants of the complete continuum of care for maternal health services reported by different studies were extremely varied in Ethiopia. Therefore, this meta-analysis aimed to estimate the overall prevalence of a complete continuum of maternal health care services utilization and its associated factors in Ethiopia. Databases such as PubMed/MEDLINE, Science Direct, DOJA, African journals online, Cochrane library, Google scholar, web of science, and Ethiopian universities’ institutional repository were used to search for relevant studies. A total of seven studies with 4854 study participants were involved in this study. Data were extracted by two reviewers and exported to STATA Version 11 for analysis. The I2 statistics and Egger’s test were used to assess heterogeneity and publication bias, respectively. The random-effects random effects model was used to estimate the level of complete continuum of care for maternal health services. The pooled prevalence of complete continuum of maternal healthcare services utilization was 25.51%. Employed mothers (OR = 3.16, 95%CI = 1.82, 5.47), first antenatal ante natal care visit before 16 weeks (OR = 7.53, 95% CI = 2.94, 19.29), birth preparedness and complication readiness plan (OR = 1.95, 95% CI = 1.12, 3.41), secondary and above educational status (OR = 2.97, 95% CI = 2.00, 4.41), planned pregnancy (OR = 6.86, 95% CI = 3.47, 13.58) and autonomy (OR = 3.73, 95% CI = 2.24–6.23) were significantly associated with continuum of maternal healthcare services utilization. In conclusion, the national level of complete continuum of maternal healthcare service utilization was low in Ethiopia. Being employed mothers, first ante natal care visit before 16 weeks, birth preparedness and complication readiness plan, secondary and above educational status, autonomy, and planned pregnancy were the major determinants of continuum of maternal healthcare services utilization.

Barriers to Utilization of Postnatal Care Services: Mothers and Health Providers Perspective.

Access to and utilization of post-natal care services is a major challenge as the majority of maternal deaths occur during post-natal period. Although geographical factors and access to health facilities in urban area are feasible as compared to rural area the utilization of all three postnatal visits remains low. Hence, this study aims to explore the barriers in utilization of postnatal care services by mothers from the perspective of mother's and health service providers as well. A qualitative study was done using community- based exploratory design in urban area of Kathmandu district. In-depth interview with mothers with infants above 45 days to 1 year of age and key informant interviews with health care providers were done using interview guidelines. Thematic analysis was done. Seven themes emerged through thematic analysis, which were further classified into category and sub categories. Poor recording and reporting system, poor health communication, postnatal care visits less prioritized among maternal health services, prerequisites to construction, and postnatal care services/information dependent on female community health volunteer, less utilization of mass media, and perception of people were identified as barrier for utilization of postnatal services. The common reason for non-utilization of postnatal care service is identified as poor health communication that resulted in lack of knowledge on the benefit and timing of postnatal care. Lack of awareness among women on postnatal care services shows lack of effort in making postnatal care related information easily available and accessible. Hence, education and awareness on postnatal care services along with proper therapeutic communication is seen essential to complete the continuum of care in maternal health services.

Community's experience and perceptions of maternal health services across the continuum of care in Ethiopia: A qualitative study.

Continuum of care is an effective strategy to ensure that every woman receives a series of maternal health services continuously from early pregnancy to postpartum stages. The community perceptions regarding the use of maternal services across the continuum of care are essential for utilization of care in low-income settings but information in that regard is scanty. This study explored the community perceptions on the continuum of care for maternal health services in Ethiopia. This study employed a phenomenological qualitative research approach. Four focus group discussions involving 26 participants and eight in-depth interviews were conducted with women who recently delivered, community health workers, and community leaders that were purposively selected for the study in West Gojjam zone, Amhara region. All the interviews and discussions were audio-taped; the records were transcribed verbatim. Data were coded and analyzed thematically using ATLAS.ti software. We identified three primary themes: practice of maternal health services; factors influencing the decision to use maternal health services; and reasons for discontinuation across the continuum of maternal health services. The study showed that women faced multiple challenges to continuously uptake maternal health services. Late antenatal care booking was the main reasons for discontinuation of maternal health services across the continuum at the antepartum stage. Women's negative experiences during care including poor quality of care, incompetent and unfriendly health providers, disrespectful care, high opportunity costs, difficulties in getting transportation, and timely referrals at healthcare facilities, particularly at health centers affect utilization of maternal health services across the continuum of care. In addition to the reverberation effect of the intrapartum care factors, the major reasons mentioned for discontinuation at the postpartum stage were lack of awareness about postnatal care and service delivery modality where women are not scheduled for postpartum consultations. This study showed that rural mothers still face multiple challenges to utilize maternal health services as recommended by the national guidelines. Negative experiences women encountered in health facilities, community perceptions about postnatal care services as well as challenges related to service access and opportunity costs remained fundamental to be reasons for discontinuation across the continuum pathways.

The relationship between inequitable gender norms and provider attitudes and quality of care in maternal health services in Rwanda: a mixed methods study

BackgroundRwanda has made great progress in improving reproductive, maternal, and newborn health (RMNH) care; however, barriers to ensuring timely and full RMNH service utilization persist, including women’s limited decision-making power and poor-quality care. This study sought to better understand whether and how gender and power dynamics between providers and clients affect their perceptions and experiences of quality care during antenatal care, labor and childbirth.MethodsThis mixed methods study included a self-administered survey with 151 RMNH providers with questions on attitudes about gender roles, RMNH care, provider-client relations, labor and childbirth, which took place between January to February 2018. Two separate factor analyses were conducted on provider responses to create a Gender Attitudes Scale and an RMNH Quality of Care Scale. Three focus group discussions (FGDs) conducted in February 2019 with RMNH providers, female and male clients, explored attitudes about gender norms, provision and quality of RMNH care, provider-client interactions and power dynamics, and men’s involvement. Data were analyzed thematically.ResultsInequitable gender norms and attitudes – among both RMNH care providers and clients – impact the quality of RMNH care. The qualitative results illustrate how gender norms and attitudes influence the provision of care and provider-client interactions, in addition to the impact of men’s involvement on the quality of care. Complementing this finding, the survey found a relationship between health providers’ gender attitudes and their attitudes towards quality RMNH care: gender equitable attitudes were associated with greater support for respectful, quality RMNH care.ConclusionsOur findings suggest that gender attitudes and power dynamics between providers and their clients, and between female clients and their partners, can negatively impact the utilization and provision of quality RMNH care. There is a need for capacity building efforts to challenge health providers’ inequitable gender attitudes and practices and equip them to be aware of gender and power dynamics between themselves and their clients. These efforts can be made alongside community interventions to transform harmful gender norms, including those that increase women’s agency and autonomy over their bodies and their health care, promote uptake of health services, and improve couple power dynamics.

Reducing Disrespect and Abuse of Women During Antenatal Care and Delivery Services at Injibara General Hospital, Northwest Ethiopia: A Pre-Post Interventional Study.

IntroductionDisrespect and abuse during pregnancy and childbirth continue to be a barrier for the utilization and quality of care in maternal health services. This study was therefore aimed at reducing the disrespect and abuse of mothers during antenatal care and delivery services at Injibara general hospital, northwest Ethiopia.Materials and MethodsA pre–post interventional mixed method design was conducted among a total of 738 randomly selected mothers who attended antenatal care and delivery services from November 1, 2018 to May 20, 2019. To collect the data, exit interview using an interviewer-administered structured questionnaire was used. Provision of training, preparation of standard written guidelines and protocols, waiting room construction, availing screening or curtain, equipment, essential drugs and supplies, supportive supervision and mentoring, and staff motivation were the lists of interventions applied to decrease disrespect and abuse. Descriptive statistics and independent t-test were computed. The independanet t-test is used because the study populations at the baseline and endline were different. A p-value of <0.05 and a mean difference with 95% CI was used to test the significance of the interventions.ResultsThe study revealed that disrespect and abuse during pregnancy and childbirth decreased from 71.8% at baseline to 15.9% at the end-line with a 55.9% change (mean difference: 0.56, 95% CI: 0.55–0.57). Alongside, the magnitude on the subscales of disrespect and abuse (physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination and neglected care) was decreased at post-intervention, compared with the baseline.ConclusionRespectful maternal healthcare after the intervention was significantly improved. The finding suggests that provision of training to healthcare providers, written policies and procedures that describe the responsibilities of healthcare providers in the respectful maternal care process, improving facility infrastructure, availing supplies, regular supportive supervision and mentoring and motivation of high-performance employees have the potential to enhance respectful maternal care. Therefore, incorporating such training into pre-service curricula and in‐service training of healthcare workers may indorse the practice of respectful maternal care.

Influence of China\u2019s 2009 healthcare reform on the utilisation of continuum of care for maternal health services: evidence from two cross-sectional household surveys in Shaanxi Province

BackgroundContinuum of care for maternal health services (CMHS) is a proven approach to improve health and safety for mothers and newborns. This study aims to explore the influence of China’s 2009 healthcare reform on improving the CMHS utilisation.MethodsThis population-based cross-sectional quantitative study included 2332 women drawn from the fourth and fifth National Health Service Surveys of Shaanxi Province, conducted in 2008 and 2013 respectively, before and after China’s 2009 healthcare reform. A generalised linear mixed model (GLMM) was applied to analyse the influence of this healthcare reform on utilisation of CMHS. Concentration curves, concentration indexes and its decomposition method were used to analyse the equity of changes in utilisation.ResultsThis study showed post-reform CMHS utilisation was higher in both rural and urban women than the CMHS utilisation pre-reform (according to China’s policy defining CMHS). The rate of CMHS utilisation increased from 24.66 to 41.55% for urban women and from 18.31 to 50.49% for rural women (urban: χ2 = 20.64, P < 0.001; rural: χ2 = 131.38, P < 0.001). This finding is consistent when the WHO’s definition of CMHS is applied for rural women after reform (12.13% vs 19.26%; χ2 = 10.99, P = 0.001); for urban women, CMHS utilisation increased from 15.70 to 20.56% (χ2 = 2.57, P = 0.109). The GLMM showed that the rate of CMHS utilisation for urban women post-reform was five times higher than pre-reform rates (OR = 5.02, 95%CL: 1.90, 13.31); it was close to 15 times higher for rural women (OR = 14.70, 95%CL: 5.43, 39.76). The concentration index for urban women decreased from 0.130 pre-reform (95%CI: − 0.026, 0.411) to − 0.041 post-reform (95%CI: − 0.096, 0.007); it decreased from 0.104 (95%CI: − 0.012, 0.222) to 0.019 (95%CI: − 0.014, 0.060) for rural women. The horizontal inequity index for both groups of women also decreased (0.136 to − 0.047 urban and 0.111 to 0.019 for rural).ConclusionsChina’s 2009 healthcare reform has positively influenced utilisation rates and equity of CMHS’s utilisation among both urban and rural women in Shaanxi Province. Addressing economic and educational attainment gaps between the rich and the poor may be effective ways to improve the persistent health inequities for rural women.

Frequency and management of non-obstetric fistula in the Democratic Republic of Congo: experience from the Fistula Care Plus project.

ObjectiveTo describe the frequency, causes and post‐repair outcomes of NOF in hospitals supported by the Fistula Care Plus (FC+) project in the Democratic Republic of Congo.MethodsRetrospective cohort study from 1 January 2015 to 31 December 2017 in three FC + supported fistula repair sites.ResultsOf 1984 women treated for female genital fistula between 2015 and 2017 in the three FC + supported hospitals, 384 (19%) were considered to be non‐obstetric fistula (NOF) cases. 49.3% were married/in a relationship at the time of treatment vs. 69% before the fistula, P < 0.001. Type III (n = 247; 64.3%) and type I (n = 121; 31.5%) fistulas according to Kees/Waaldijk classification were the most common. The main causes of NOF were medical procedure (n = 305; 79.4%); of these, caesarean section (n = 234; 76.7%) and hysterectomy (n = 54; 17.7%) were the most common. At hospital discharge, the fistula was closed and dry in 353 women (95.7%).ConclusionNon‐obstetric fistula, particularly due to iatrogenic causes, was relatively common in the DRC, calling for more prevention that includes improved quality of care in maternal health services.

Availability and Continuity of Care for Maternal Health Services in the Primary Health Centres in Nnewi, Nigeria (January - March 2010).

Background:In some primary health care settings, even where the health services are not available, provisions are not made to ensure continuity of care. This study aimed to determine the availability and level of continuity of care for maternal health services in the primary health centers (PHCs) in Nnewi, Nigeria.Methods:This was a cross-sectional survey. Using multistage sampling technique, 280 women utilizing maternal health services from four randomly selected public PHCs in Nnewi, Nigeria were chosen for the study. Data collection employed a mix of quantitative and qualitative methods.Results:The mean ± standard deviation for age of the respondents was 29.2 ± 5.9 years. The facilities studied provided out-patient services, but the only in-patient services provided was for women who delivered or those in labor. None of the facilities is equipped to provide even basic essential obstetric care services. None had standardized a protocol for referring clients, referral forms, a transport system, or a community loan scheme in place. Forty-four (15.7%) women were referred for care outside of the PHCs for the following reasons: Lack of drugs and supplies (9.1%); lack of equipment (90.9%), lack of skilled personnel (45.5%) among others.Conclusions:This study showed that despite the unavailability of some services, appropriate strategies were not in place to ensure the coherent pattern of services within and between the PHCs and other levels of care. Delivery to the clients of comprehensive and integrated maternal health services, and efficient referral systems are thus recommended.

Raising concerns: Quality of care in maternal health services in South Africa

There are increasing concerns regarding the quality of care afforded to women in public maternal health facilities in South Africa. There have been reports of human rights violations committed by midwives in state services, including verbal and physical abuse, lack of informed consent and routine humiliation of patients during labour and childbirth. There is, however, a paucity of qualitative research that has documented women's stories of birth and maternal health care in this context. This article explores 48 childbirth stories gathered by a non-governmental organisation in the Western Cape region of South Africa. A thematic narrative analysis of the women's accounts of their childbirth experiences in public health care facilities is provided. It was found that two thirds of women (n=32) reported a negative childbirth experience with most of these reported as very bad experiences (n=22). One third of the women reported a positive birth experience (n=14) characterised by supportive caregivers. Themes of abuse, dehumanisation, disrespect and neglect, however, dominated most of the women's accounts of giving birth within public maternal health services in the Western Cape, South Africa.