Maternal Health Service Delivery Research Articles

Women’s autonomy and maternal health decision making in Kenya: implications for service delivery reform - a qualitative study

BackgroundMaternal and neonatal outcomes in, Kakamega County is characterized by a maternal mortality rate of 316 per 100,000 live births and a neonatal mortality rate of 19 per 1,000 live births. In 2018, approximately 70,000 births occurred in the county, with 35% at home, 28% in primary care facilities, and 37% in hospitals. A maternal and child health service delivery redesign (SDR) that aims to reorganize maternal and newborn health services is being implemented in Kakamega County in Kenya to improve the progress of these indicators. Research has shown that women’s ability to make decisions (voice, agency, and autonomy) is critical for gender equality, empowerment and an important determinant of access and utilization. As part of the Kakamega SDR process evaluation, this study sought to understand women’s processes of decision-making in seeking maternal health care and how these affect women’s ability to access and use antenatal, delivery, and post-natal services.MethodsWe adapted the International Centre for Research on Women (ICRW) conceptual framework for reproductive empowerment to focus on the interrelated concepts of “female autonomy”, and “women’s agency” with the latter incorporating ‘voice’, ‘choice’ and ‘power’. Our adaptation did not consider the influence of sexual relationships and leadership on SRH decision-making. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men in Kakamega County. A thematic analysis approach was used to analyze the data in NVivo 12.ResultsThe results revealed notable findings across three dimensions of agency. Women with previous birthing experiences, high self-esteem, and support from their social networks exhibited greater agency. Additionally, positive previous birthing experiences were associated with increased confidence in making reproductive health choices. Women who had control over financial resources and experienced respectful communication with their partners exhibited higher levels of agency within their households. Distance relational agency demonstrated the impact of health system factors and socio-cultural norms on women’s agency and autonomy. Finally, women who faced barriers such as long waiting times or limited staff availability experienced reduced agency in seeking healthcare.ConclusionsIndividual agency, immediate relational agency, and distance relational agency all play crucial roles in shaping women’s decision-making power and control over their utilization of maternal health services. This study offers valuable insights that can guide the ongoing implementation of an innovative service delivery redesign model, emphasizing the critical need for developing context-specific strategies to promote women’s voices for sustained use.

Association between obtaining injury prevention information and maternal and child health services during COVID-19

BackgroundCoronavirus disease 2019 disrupted the delivery of public maternal and child health services to caregivers of preschool children, leading to decreased opportunities for injury prevention education. We aim to 1) explore the timing, content, and methods of providing injury prevention information desired by pregnant women and mothers and 2) identify mothers who experienced difficulty in obtaining injury prevention information owing to reduced maternal and child health services.MethodsFrom March 24 to 29, 2022, we conducted a population-based cross-sectional study and web-based survey. Of the registered monitors of the internet research company Rakuten Insight, 675 mothers raising their first child aged 0–2 during the COVID-19 period (February 2020 to March 2022) were included in the analysis.ResultsOver half of the mothers wanted injury prevention information throughout their pregnancy. They preferred receiving information through traditional face-to-face services provided by local governments, such as antenatal classes or checkups. However, 34.1% of mothers said they did not obtain the information they needed; this was particularly true of unemployed mothers, had children aged 0–1, and had children with illnesses requiring hospital visits.ConclusionsMothers who could not obtain injury prevention information were originally disadvantaged mothers concerning access to information. The decrease in maternal and child health services may have widened this information gap. These findings can inform recommendations for caregivers, particularly those susceptible to information gaps during emergencies, and offer insights into future injury prevention education strategies.

How interventions to maintain services during the COVID-19 pandemic strengthened systems for delivery of maternal and child health services: a case-study of Wakiso District, Uganda

ABSTRACT Background Health systems are resilient if they absorb, adapt, and transform in response to shocks. Although absorptive and adaptive capacities have been demonstrated during the COVID-19 response, little has been documented about their transformability and strengthened service delivery systems. We aimed to describe improvements in maternal and child health service delivery as a result of investments during the COVID-19 response. Methods This was a descriptive case study conducted in Wakiso District in central Uganda. It included 21 nurses and midwives as key informants and 32 mothers in three focus group discussions. Data were collected using an interview guide following the Systems Engineering Initiative for Patient Safety theoretical framework for service delivery. Results Maternal and child health service delivery during the pandemic involved service provision without changes, service delivery with temporary changes and outcomes, and service delivery that resulted into sustained changes and outcomes. Temporary changes included patient schedule adjustments, community service delivery and negative outcomes such as increased workload and stigma against health workers. Sustained changes that strengthened service delivery included new infrastructure and supplies such as ambulances and equipment, new roles involving infection prevention and control, increased role of community health workers and outcomes such as improved workplace safety and teamwork. Conclusions In spite of the negative impact the COVID-19 pandemic had on health systems, it created the impetus to invest in system improvements. Investments such as new facility infrastructure and emergency medical services were leveraged to improve maternal and child health services delivery. The inter-departmental collaboration during the response to the COVID-19 pandemic resulted into an improved intra-hospital environment for other service delivery. However, there is a need to evaluate lessons beyond health facilities and whether these learnings are deliberately integrated into service delivery. Future responses should also address the psychological and physical impacts suffered by health workers to maintain service delivery.

Sustaining essential health services inLao PDR inthe context ofdonor transition andCOVID-19.

Lao People's Democratic Republic (Lao PDR) aims at graduating from least developed country status by 2026 and must increase the level of domestic financing for health. This paper examines how the government has prepared for the decline of external assistance and how donors have applied their transition approaches. Adapting a World Health Organization (WHO) framework, reflections and lessons were generated based on literature review, informal and formal consultations and focus group discussions with the Lao PDR government and development partners including budget impact discussion. The government has taken three approaches to transition from external to domestic funding: mobilizing domestic resources, increasing efficiency across programs and prioritization with a focus on strengthening primary health care (PHC). The government has increased gradually domestic government health expenditures as a share of the government expenditure from 2.6% in 2013 to 4.9% in 2019. The Ministry of Health has made efforts to design and roll out integrated service delivery of maternal, newborn, child, and adolescent health services, immunization and nutrition; integrated 13 information systems of key health programs into one single District Health Information Software 2; and prioritized PHC, which has led to shifting donors towards supporting PHC. Donors have revisited their aid policies designed to improve sustainability and ownership of the government. However, the government faces challenges in improving cross-programmatic efficiency at the operational level and in further increasing the health budget due to the economic crisis aggravated during Coronavirus disease 2019 (COVID-19). Working to implement donor transition strategies under the current economic situation and country challenges, calls into question the criteria used to evaluate transition. This criterion needs to include more appropriate indicators other than gross national income per capita, which does not reflect a country's readiness and capacity of the health system. There should be a more country-tailored strategy and support for considering the context and system-wide readiness during donor transition.

"Getting pregnant during COVID-19 was a big risk because getting help from the clinic was not easy": COVID-19 experiences of women and healthcare providers in Harare, Zimbabwe.

The COVID-19 pandemic and associated measures may have disrupted delivery of maternal and neonatal health services and reversed the progress made towards dual elimination of mother-to-child transmission of HIV and syphilis in Zimbabwe. This qualitative study explores the impact of the pandemic on the provision and uptake of prevention of mother-to-child transmission (PMTCT) services from the perspectives of women and maternal healthcare providers. Longitudinal in-depth interviews were conducted with 20 pregnant and breastfeeding women aged 20-39 years living with HIV and 20 healthcare workers in two maternity polyclinics in low-income suburbs of Harare, Zimbabwe. Semi-structured interviews were held after the second and third waves of COVID-19 in March and November 2021, respectively. Data were analysed using a modified grounded theory approach. While eight antenatal care contacts are recommended by Zimbabwe's Ministry of Health and Child Care, women reported only being able to access two contacts. Although HIV testing, antiretroviral therapy (ART) refills and syphilis screening services were accessible at first contact, other services such as HIV-viral load monitoring and enhanced adherence counselling were not available for those on ART. Closure of clinics and shortened operating hours during the second COVID-19 wave resulted in more antenatal bookings occurring later during pregnancy and more home deliveries. Six of the 20 (33%) interviewed women reported giving birth at home, assisted by untrained traditional midwives as clinics were closed. Babies delivered at home missed ART prophylaxis and HIV testing at birth despite being HIV-exposed. Although women faced multiple challenges, they continued to attempt to access services after delivery. These findings underline the importance of investing in robust health systems that can respond to emergency situations to ensure continuity of essential HIV prevention, treatment, and care services.

Utilisation of mobile phone interventions to improve the delivery of maternal health services in sub-Saharan Africa: A scoping review protocol.

There has been significant progress in maternal health outcomes in the sub-Saharan African region since the early 1990s, in part due to digital and mobile health interventions. However, critical gaps and disparities remain. Mobile phones in particular have potential to reach underserved, hard-to-reach populations with underdeveloped infrastructure. In spite of the opportunities for mobile phones to address maternal mortality in the region, there is no extensive mapping of the available literature on mobile phone interventions that aim to improve access of maternal care in sub-Saharan Africa. The proposed scoping review aims to map literature on the nature and extent of mobile phones interventions designed to improve maternal care health services in the region. Conduct of this scoping review will be guided by the Joanna Briggs Institute approach. Literature searches will be conducted in multiple electronic databases, including MEDLINE, Embase, CINAHL, APA PsycInfo, Cochrane Central Register of Controlled Trials, Global Health, African Index Medicus, Web of Science, and Applied Social Sciences Index & Abstracts. Grey literature will also be identified. Keyword searches will be used to identify articles. Two reviewers will independently screen eligible titles, abstracts and full articles with a third reviewer to help resolve any disputes. We will extract data on general study characteristics, population characteristics, concept, context, intervention details, study results, gaps and recommendations. Understanding use of mobile phones among underserved, hard-to-reach populations with underdeveloped infrastructure to address maternal mortality in developing countries is very critical to informing health systems on potential effective strategies. This review will complement the evidence base on utilisation of mobile phone interventions to improve the delivery of maternal health services in sub-Saharan Africa.

Policies, Leadership, and Funding - Oh, My! How we are working together to improve perinatal care access & integration in Arizona, U.S.

The United States has the highest maternal mortality rate of any high resource country, and it is the only country outside of Afghanistan and Sudan where the rate is rising. The rate of pregnancy-related mortality in the US increased from 7.2 pregnancy-related deaths per 100,000 live births per year in 1987 to 17.2 in 2017. In Arizona, almost half of all pregnancy-associated deaths in 2016-2018 or three out of five deaths were related to mental health conditions or substance use disorder, and 98% of those deaths were deemed preventable with 48.5% of deaths having a good chance to prevent the death. Over 40% of these deaths were accidents or unintentional overdoses. Social determinants of health, system, and community factors have increasingly been acknowledged as contributing factors to the increasing rate of poor maternal health outcomes nationally, yet few states have been able to comprehensively address these issues due to fragmented health and public health systems of care, as well as severe workforce shortages. 
 The State of Arizona launched a series of initiatives beginning or enhanced in 2019 to improve maternal health outcomes for persons of reproductive age in the State, including a grant-funded initiative to strengthen Arizona’s Maternal Mortality Review Committee and to fund prevention efforts. In 2020, maternal mental health was spotlighted by stakeholders as a crisis related to the COVID-19 pandemic. A maternal mental health task force was appointed by the state legislature and funded through a federal grant to bring statewide stakeholders together to identify gaps in care for the perinatal population, improve statewide data on maternal mortality, and to form a statewide action plan to promote and execute innovation in maternal health service delivery including recommendations to the state government for providers and facilities, regulatory and state policy, payers, law enforcement, other systems, public health, and communities.
 While the effort to improve perinatal care statewide has legislative and grant-funded support, the input from individuals with lived experience, healthcare professionals specializing in serving this population, and our community health workers such as peer support professionals, patient advocates, and BIPOC advocacy organizations have been the key to our momentum and successes. Ultimately, a legion of volunteers (primarily mothers) across the state have co-designed improvements that truly meet the needs in close partnership with the state department of health and state medicaid agency. 
 
 Through community and provider participation, workforce development initiatives, compassionate and informed leadership, change management, and policy making, we have developed a comprehensive strategy to expand access to better care across the continuum of providers and facilities involved in perinatal care outcomes in our state. 
 What we’ve learned and achieved through our evolving statewide efforts will contribute to the efforts of others in communities globally who are working to reduce adverse maternal health outcomes. Lessons learned and best practices in capacity building and sustainability will be shared. 

Impact of Violence against Healthcare Providers on Maternal and Child Health Service Delivery in Karachi

Background There is an increasing global issue with workplace violence against healthcare practitioners. The healthcare system as a whole and individual employee are both hit hard by this. The purpose of this research was to identify the prevalence, nature, and consequences of workplace violence encountered by healthcare workers in maternity and child health service delivery settings in the violent metropolis of Karachi, Pakistan. Methods A quantitative cross-sectional study was conducted among 414 healthcare providers from 14 randomly selected hospitals in Karachi. Participants completed a self-administered questionnaire assessing their experiences of workplace violence, including the type of violence, perpetrators, frequency, and impacts on their health and work performance. Results A shocking 87.9% of healthcare professionals have encountered workplace violence, with verbal/psychological abuse (37.4%) and physical assault (31.6%) being the most prevalent. Violence was most commonly committed by patients' relatives (42.8%) and happened daily (43.2%) or weekly (31.2%). Violence had serious effects, with 87.9% of providers absent 51.9% wanting to resign, and 69.6% feeling PTSD. Violence also lowered paediatric and gynaecology treatment quality. Conclusions Workplace violence is a serious and pervasive problem for healthcare providers in Karachi, with severe consequences for their well-being and the quality of care they provide. Urgent action is needed to address this issue, including stronger enforcement of existing laws, improved hospital security measures, and training for healthcare providers in violence prevention and management strategies. Keywords: workplace violence, healthcare providers, maternal health, child health, healthcare quality

Utilization of Maternal, Nutritional and Child Health Care Services Amidst COVID-19 Pandemic in Uttar Pradesh, India

Background: All maternal health services are essential to be continued for pregnant mothers during lockdown and avoid COVID infection with awareness of people by following all precautions from COVID-19. We aimed to examine changes in service provision and utilization of MNCH services during the pandemic in Uttar Pradesh, India and identify the factors affecting the utilization and service delivery. Objective: To assess the effects of the COVID-19 pandemic on utilization and delivery of maternal health services at health facilities in Uttar Pradesh, India. Method: COVID -19 pandemic data has been collected form website https://prsindia.org/covid-19/cases which provides the day wise data for four major components such as confirmed cases, active cases, cured/discharged and death and pandemic effects on the maternal services including ANC registration, pregnant women registered for ANC within 1st trimester and home and institutional deliveries during April 2019, April 2020 and April 2021. At the same time, through informal discussion with key healthcare professionals and focused desk reviews of published scientific, grey and media-based information and country-specific healthcare policies. Results and summary: Huge difference in the percent change of the beneficiaries received maternal health services among April 2019, April 2020 and April 2021. It is found that there is 88 percent change in the ANC registration for pregnant women in April 2020 against April 2019. It simple means that 371065 pregnant women registered for ANC in April 2019 whereas only 44987 pregnant women registered in April 2019 which is very less number of pregnant women went for ANC visit in public health facilities in Uttar Pradesh. While, during the 2nd wave of COVID-19 pandemic regarding the ANC service, it reflects only 3 percent change based on government HMIS data set, as 361201 pregnant women registered for ANC in April 2021 and its close to April 2019 i.e. 371065. Similarly, 12 percent change for institutional deliveries was found in April 2020 and no change for the institutional deliveries during April 2021. Moreover, more institutional deliveries are occurred during April 2021 against April 2020 and April 2019. The main reason for delayed health seeking was lockdown in April 2020 due to COVID-19 pandemic. The health situation was very worst in all the public health facilities during April 2021 due to COVID-19. Conclusions: COVID-19 severely affected the provision and use of MNCH services in Uttar Pradesh, India, despite efforts at service restoration and adaptations. Strengthening logistics support, capacity enhancement, performance management, and demand creation are needed to improve service provision and utilization during and post-COVID-19.

Impact of quality improvement interventions on facility readiness, quality and uptake of maternal and child health services in developing regions of Ethiopia: a secondary analysis of programme data

BackgroundQuality improvement intervention (QI) was implemented from 2018 to 2021 in health facilities of developing regional states of Ethiopia. The main objective of this study was to examine the impact...

Multilevel analysis of place of delivery among reproductive age women in Ethiopia

AbstractIntroductionThe place where the mother gives birth majorly affects the birth outcome and the mother's well‐being; this is because most maternal mortality, morbidity, and neonatal death occur during the time of labor and delivery and immediately after birth. This study was aimed to identify factors associated with the place of delivery among reproductive age women.MethodSecondary analysis was done using the 2019 Mini Ethiopian Demographic and Health Survey data. A multi‐stage sampling technique was used to select a total of 5527 weighted representative samples of women to include in the analysis. To identify factors associated with the place of delivery, a multilevel mixed effect binary logistic regression model was fitted to consider the hierarchical nature of the data. Statistical significance was declared at p‐value < 0.05.ResultThis study found that women aged 35 to 49 years, mothers with primary and secondary and above, educational status, and women from households with higher wealth index, and participants who had at least one antenatal care visit had higher odds of giving birth in a health facility. Women with two and three and more birth order, who live in rural areas, and women living in communities with higher poverty levels have lower odds of institutional delivery.ConclusionIncreased maternal age, increased maternal educational status, having at least one antenatal care visit, women's household wealth index, increased birth order, rural residence, and higher community poverty level were found to be factors that significantly associated with the place of delivery. Hence, Ethiopia's Federal Minister of Health and another stakeholders should amplify their efforts to increase the accessibility and availability of healthcare facilities and quality maternal health service delivery.

Facilitators for and Barriers to the Implementation of Performance Accountability Mechanisms for Quality Improvement in the Delivery of Maternal Health Services in a District Hospital in Pwani Region, Tanzania.

Tanzania experiences a burden of maternal mortality and morbidity. Despite the efforts to institute accountability mechanisms, little is known about quality improvement in the delivery of maternal health services. This study aimed at exploring barriers and facilitators to enforcing performance accountability mechanisms for quality improvement in maternal health services. A case study design was used to conduct semi-structured interviews with thirteen key informants. Data were analyzed using thematic analyses. The findings were linked to two main performance accountability mechanisms: maternal and perinatal death reviews (MPDRs) and monitoring and evaluation (M&E). Prioritization of the maternal health agenda by the government and the presence of maternal death review committees were the main facilitators for MPDRs, while negligence, inadequate follow-up, poor record-keeping, and delays were the main barriers facing MPDRs. M&E was facilitated by the availability of health management information systems, day-to-day ward rounds, online ordering of medicines, and the use of biometrics. Non-use of data for decision-making, supervision being performed on an ad hoc basis, and inadequate health workforce were the main barriers to M&E. The findings underscore that barriers to the performance accountability mechanisms are systemic and account for limited effectiveness in the improvement of quality of care.

The impact of donor transition on continuity of maternal and newborn health service delivery in Rwenzori sub-region of Uganda: a qualitative country case study analysis

BackgroundThe transition of donor-supported health programmes to country ownership is gaining increasing attention due to reduced development assistance for health globally. It is further accelerated by the ineligibility of previously Low-Income Countries’ elevation into Middle-income status. Despite the increased attention, little is known about the long-term impact of this transition on the continuity of maternal and child health service provision. Hence, we conducted this study to explore the impact of donor transition on the continuity of maternal and newborn health service provision at the sub-national level in Uganda between 2012 and 2021.MethodsWe conducted a qualitative case study of the Rwenzori sub-region in mid-western Uganda which benefited from a USAID project to reduce maternal and newborn deaths between 2012 and 2016. We purposively sampled three districts. Data were collected between January and May 2022 among subnational key informants (n = 26), national level key informants at the Ministry of Health [3], national level donor representatives [3] and subnational level donor representatives [4] giving a total of 36 respondents. Thematic analysis was deductively conducted with findings structured along the WHO’s health systems building blocks (Governance, Human resources for health, Health financing, Health information systems, medical products, Vaccines and Technologies and service delivery) framework.ResultsOverall, continuity of maternal and newborn health service provision was to a greater extent maintained post-donor support. The process was characterised by a phased implementation approach. The embedded learning offered the opportunity to plough back lessons into intervention modification which reflected contextual adaptation. The availability of successor grants from other donors (such as Belgian ENABEL), counterpart funding from the government to bridge the gaps left behind, absorption of USAID-project salaried workforce (such as midwives) onto the public sector payroll, harmonisation of salary structures, the continued use of infrastructure (such as newborn intensive care units), and support for MCH services under PEPFAR support post-transition contributed to the maintenance of coverage. The demand creation for MCH services pre-transition ensured patient demand post-transition. Challenges to the maintenance of coverage were drug stockouts and sustainability of the private sector component among others.ConclusionA general perception of the continuity of maternal and newborn health service provision post-donor transition was observed with internal (government counterpart funding) and external enablers (successor donor funding) contributing to this performance. Opportunities for the continuity of maternal and newborn service delivery performance post-transition exist when harnessed well within the prevailing context. The ability to learn and adapt, the presence of government counterpart funding and commitment to carry on with implementation were major ingredients signalling a crucial role of government in the continuity of service provision post-transition.

Women Leadership and Maternal health Service delivery in Adjumani District

Women Leadership and Maternal health Service delivery in Adjumani District

Assessment of antenatal care services and nutritional status of pregnant women-a cross sectional study in tribal blocks of Nanded district

Background: Maternal and child healthcare is one of the eight basic components of primary healthcare (PHC) in the declaration of Alma-Ata. There is an excellent system of primary health care services for the delivery of maternal and child health services through a network of sub-centres and PHC centres in rural India. Aim and objectives of the study to assess antenatal care (ANC) care services and MCH schemes given to tribal women in Nanded district. Objectives- To study status of ANC care services among tribal ANC mothers. To assess various schemes associated with mother and child health in tribal area. Methods: Study design was a cross-sectional study. Study conducted at tribal blocks in Nanded district. Sampling and sample size: Convenient purposive sampling was used. Study population was 100 ANC mothers of tribal blocks in Nanded district. Results: Total number of families belonging to BPL category were 67% and families belonging to APL were 33%. Maximum of 60% were housewives, 39% of ANC mothers were working in the farm, while only 1 ANC mother was Govt. servant. Conclusions: Addressing the physical and financial barriers of tribal women to access maternal health services, catering the services to their socio-cultural needs, building in trust between beneficiaries in the community and health care delivery system should be the priority.

Personal data governance and privacy in digital reproductive, maternal, newborn, and child health initiatives in Palestine and Jordan: a mapping exercise.

There is a rapid increase in using digital technology for strengthening delivery of reproductive, maternal, newborn, and child health (RMNCH) services. Although digital health has potentially many benefits, utilizing it without taking into consideration the possible risks related to the security and privacy of patients' data, and consequently their rights, would yield negative consequences for potential beneficiaries. Mitigating these risks requires effective governance, especially in humanitarian and low-resourced settings. The issue of governing digital personal data in RMNCH services has to date been inadequately considered in the context of low-and-middle-income countries (LMICs). This paper aimed to understand the ecosystem of digital technology for RMNCH services in Palestine and Jordan, the levels of maturity of them, and the implementation challenges experienced, particularly concerning data governance and human rights. A mapping exercise was conducted to identify digital RMNCH initiatives in Palestine and Jordan and mapping relevant information from identified initiatives. Information was collected from several resources, including relevant available documents and personal communications with stakeholders. A total of 11 digital health initiatives in Palestine and 9 in Jordan were identified, including: 6 health information systems, 4 registries, 4 health surveillance systems, 3 websites, and 3 mobile-based applications. Most of these initiatives were fully developed and implemented. The initiatives collect patients' personal data, which are managed and controlled by the main owner of the initiative. Privacy policy was not available for many of the initiatives. Digital health is becoming a part of the health system in Palestine and Jordan, and there is an increasing use of digital technology in the field of RMNCH services in both countries, particularly expanding in recent years. This increase, however, is not accompanied by clear regulatory policies especially when it comes to privacy and security of personal data, and how this data is governed. Digital RMNCH initiatives have the potential to promote effective and equitable access to services, but stronger regulatory mechanisms are required to ensure the effective realization of this potential in practice.

The impacts of COVID-19 and its policy response on access and utilization of maternal and child health services in Tanzania: A mixed methods study.

The SARS-Cov-2 virus (COVID-19) has had a global social and economic impact. Despite the growing evidence, its effects on access and delivery of maternal and child health services in low-income countries are still unclear. This cross-sectional case study was conducted in Mjini Magharibi, Chake Chake, and Ilala districts in Tanzania to help fill this gap. The study combined qualitative and quantitative data collection methods, providing an account of the evolution of the pandemic and the associated control measures in Tanzania. We drew from 34 in-depth interviews, 60 semi-structured interviews, and 14 focus group discussions with key informants, patients, and health providers, and complemented the findings with a review of pandemic reports and health facility records. We followed the Standards for Reporting Qualitative Research (SRQR) to provide an account of the findings. Our account of the pandemic shows that there was at times an inconsistent policy response in Tanzania, with diverse control measures adopted at various stages of the epidemic. There was a perception that COVID-19 services were prioritized during the epidemic at the expense of regular ones. There were reports of reorganisation of health facilities, reallocation of staff, rescheduled antenatal and postnatal clinics, and reduced time for health education and child monitoring. Scarcity of essential commodities was reported, such as vaccines, equipment, and medical supplies. Such perceptions were in part supported by the routine utilization evidence in the three districts, showing a lower uptake of antenatal, postnatal, family planning, and immunization services, as well as fewer institutional deliveries. Our findings suggest that, although the policy response in Tanzania was erratic, it was rather fear of the pandemic itself and diversion of resources to control COVID-19, that may have contributed most to lower the utilization of mother and child services. For future emergencies, it will be crucial to ensure the policy response does not weaken the population's demand for services.

Community and Health Care Provider Perspectives on Barriers to and Enablers of Family Planning Use in Rural Sindh, Pakistan: Qualitative Exploratory Study.

Unmet need for family planning in Pakistan is high, with 17% of all married women wanting to avoid or delay pregnancy. However, they cannot owing to a lack of access to modern contraception and sociocultural hindrances. With the modern contraceptive prevalence rate stagnant at approximately 25% over the last 5 years, it is important to explore barriers and enablers to modern contraception uptake to reduce maternal and child mortality and improve reproductive health outcomes for young girls and women. A formative research approach was taken to explore community member and health care provider perspectives on access to and use of family planning methods in 2 rural districts of Sindh, Pakistan. The broader goal of this study was to provide evidence to design and implement a socioculturally appropriate family planning intervention within the existing service delivery platforms to increase modern contraceptive uptake in the context of rural Sindh. A qualitative exploratory design was used. Between October 2020 and December 2020, 11 focus group discussions and 11 in-depth interviews were conducted. Focus group discussions were held with men and women from the community, including adolescents, to build an understanding of community beliefs and concepts regarding modern contraceptive methods. In-depth interviews were conducted with health care workers and explored intersections between family planning and reproductive health service delivery at the facility and outreach levels. The findings revealed that limited financial autonomy, restricted women's mobility, discriminatory gender norms, and cultural practices left women with little opportunity for independent decision-making on the use of modern contraceptive methods. Furthermore, facility-level and supply-side barriers, including frequent stock-outs of modern contraceptives combined with a lack of capacity of health workers to provide quality family planning services and counseling, played an important role in demotivating women from seeking services. In addition, a lack of integration of family planning with maternal and child health service delivery at the health system level was emphasized as a major missed opportunity for contraceptive uptake. Several demand-side barriers to family planning uptake were also highlighted. These included husbands' or in-laws' disapproval, social stigma, and perceived fear of side effects regarding modern family planning method use. More importantly, a lack of adolescent-friendly reproductive health services and spaces for counseling was identified as a critical intervention area. This study provides qualitative evidence on issues related to the effectiveness of family planning interventions, specifically in the context of rural Sindh. The findings emphasize the need to design socioculturally appropriate and health system-relevant family planning interventions-the effectiveness of which can be improved through their integration with maternal and child health service delivery mechanisms, consistent service provision, and opportunities for the capacity building of the health care workforce. RR2-10.2196/35291.

Clients' perspectives on the utilization of reproductive, maternal, neonatal, and child health services in primary health centers during COVID-19 pandemic in 10 States of Nigeria: A cross-sectional study.

Reports from various parts of the world suggest that the COVID-19 pandemic may have severe adverse effects on the delivery and uptake of reproductive health, maternal, neonatal, and child health (RMNCH) services. The objective of the study was to explore women's experiences with utilization of RMNCH services during the COVID-19 pandemic in Nigeria, and to elicit their perceptions on ways to sustain effective service delivery during the pandemic. A cross-sectional survey of 2930 women using primary health care facilities for antenatal, delivery, postnatal, and child care services before and after the onset of the pandemic in 10 States of Nigeria were interviewed with a semi-structured questionnaire. Data were collected on women's socio-demographic characteristics and pregnancy histories, the services they sought before and after the pandemic, the challenges they faced in accessing the services, their use of alternative sources of health care, and their recommendations on ways to sustain RMNCH service delivery during the pandemic. The data were analyzed with descriptive statistics, and multivariable logistic regression using SPSS 20.0. All the statistical analyses were two-tailed with a 95% confidence interval, and the p-value was set at 0.05. The logistic regression results showed that women were at least 56% more likely to report that they used family planning, antenatal, and delivery services before the pandemic than after the pandemic started, but 38% less likely to report use of postnatal services. The experience of difficulty accessing RMNCH services was 23% more likely after the pandemic started than before the pandemic. Three categories of recommendations made by the respondents on measures to sustain RMNCH delivery during the pandemic included 1) facility improvement, and staff recruitment and re-training; 2) free and readily accessible PHC services, and 3) the provision of social safety nets including transportation and palliatives. We conclude that the COVID-19 pandemic limited women's access to antenatal, delivery, and childcare services offered in PHCs in Nigeria. Addressing the recommendations and the concerns raised by women will help to sustain the delivery of RMNCH services during the COVID-19 pandemic and future epidemics or health emergencies in Nigeria.

Compliance toward key elements of kangaroo mother care and its predictors among postnatal mothers with preterm and/or low birth weight newborns in southern Ethiopia, 2021: A count analysis.

Although kangaroo mother care has been field-tested and found to be effective for preterm and/or low birth weight newborns at the health facility and community level, implementation and scale-up in low-income countries, including Ethiopia, have proven difficult. There was a dearth of evidence that shows compliance of mothers toward components of the kangaroo mother care. Hence, this study aimed at assessing the compliance of postnatal mothers toward World Health Organization-recommended elements of kangaroo mother care and the factors that influence it in southern Ethiopia, 2021. A hospital-based cross-sectional study was conducted among 257 mothers with preterm and low birth weight newborns from 1 July to 30 August 2021. A pretested, structured, interviewer-administered questionnaire and document review were used to collect data. The practice of kangaroo mother care was considered as a count variable. Analysis of variance and independent t-tests were used to examine the variation in the mean score of kangaroo mother care across covariates, and variables with a p value of 0.05 were eligible for the multivariable generalized linear regression model. The effect of each independent variable on the dependent variable was examined using multivariable generalized linear regression with a negative binomial log link. The mean (±standard deviation) practice score of kangaroo mother care items was 5.12 (±2.39), with 2 and 10 as the minimum and maximum item scores, respectively. Place of residence (adjusted odds ratio = 1.55; 95% confidence interval:1.33-2.29), mode of delivery (adjusted odds ratio = 1.37; 95% confidence interval: 1.11-2.21), birth preparedness and complication readiness plan (adjusted odds ratio = 1.63; 95% confidence interval:1.32-2.26), maternal knowledge of kangaroo mother care (adjusted odds ratio = 1.40; 95% confidence interval: 1.05-1.87), and place of delivery (adjusted odds ratio = 0.67; 95% confidence interval: 0.48-0.94) were identified as significant predictors of compliance toward key elements of kangaroo mother care. The overall practice of mothers toward key elements of kangaroo mother care was low in the study area. Health care providers who work in the maternal and child health service delivery points should pay special attention to women who come from rural areas and have had cesarean sections, by encouraging and guiding them to practice kangaroo mother care. Women should be counseled during antenatal care and after delivery to improve their knowledge of kangaroo mother care. Health workers in antenatal care clinics should place a strong emphasis on enhancing birth preparedness and complication readiness plans.