Maternal Health Service Delivery Research Articles

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.

Capacity and quality of maternal and child health services delivery at the subnational primary healthcare level in relation to intermediate health outputs: a cross-sectional study of 12 low-income and middle-income countries

ObjectivesTo examine the capacity and quality of maternal and child health (MCH) services at the subnational primary healthcare (PHC) level in 12 low-income and middle-income countries (LMICs) and its association...

Scaling up the “24/7 BHU” strategy to provide round-the-clock maternity care in Punjab, Pakistan: a theory-driven, coproduced implementation study

BackgroundPakistan’s maternal mortality rate remains persistently high at 186/100,000 live births. The country’s government-run first-level healthcare facilities, the basic health units (BHUs), are an important source of maternity care for rural women. However,BHUsonly operate on working days from 8:00 am to 2:00 pm. Recognizing that this severely constrains access to maternity services, the government is implementing the “24/7 BHU” initiative to upgrade BHUs to provide round-the-clock care. Although based on a successful pilot project, initial reports reveal challenges in scaling up the initiative. This implementation research project aims to address a key concern of the Government of Punjab: How can the 24/7 BHU initiative be successfully implemented at scale to provide high-quality, round-the-clock skilled maternity care in rural Punjab?MethodsThe project consists of two overlapping work packages (WP). WP1 includes three modules generating data at the directorate, district and BHU levels. Module 1 uses document analysis and policy-maker interviews to explicateprogrammetheory and begin to build a system model. Module 2 compares government-collected data with data generated from a survey of 1500 births to assess BHU performance. Module 3 uses institutional ethnographies in 4–5 BHUs in three districts to provide a detailed system for understanding and identifying processes that influence scale-up. WP2 includes two modules. First, two workshops and regular meetings with stakeholders integrate WP1 findings, identify feasible changes and establish priorities. Next, “change ideas” are selected for testing in one district and 2–3 BHUs through carefully documented pilots using the PDSA (plan–do–study–act) improvement approach. An integrated knowledge translation approach will engage key policy and practice stakeholders throughout the project.DiscussionThis theory-driven implementation research project willcoproducesignificant new understandings of the wider system in which the 24/7 BHU initiative is being implemented, and actionable knowledge that will highlight ways the implementation processes might be modified to enable BHUs to meet service provision goals. This study will also produce insights that will be relevant for other South Asian and low- and middle-income countries (LMICs) that experience similar challenges of programme scale-up and delivery of maternal health services to remote and marginalized communities.

Impact of the COVID-19 pandemic on expectant and new parents’ experience of pregnancy, childbirth, breast feeding, parental responsiveness and sensitivity, and bonding and attunement in high-income countries: a systematic review of the evidence

ObjectivesTo review the evidence on how pregnancy, birth experience, breast feeding, parental responsiveness and sensitivity, and bonding and attunement were impacted by COVID-19.MethodsWe searched eight literature databases and websites of...

Maturity Level of Digital Reproductive, Maternal, Newborn, and Child Health Initiatives in Jordan and Palestine.

While there is a rapid increase in digital health initiatives focusing on the processing of personal data for strengthening the delivery of reproductive, maternal, newborn, and child health (RMNCH) services in fragile settings, these are often unaccompanied at both the policy and operational levels with adequate legal and regulatory frameworks. The main aim was to understand the maturity level of digital personal data initiatives for RMNCH services within fragile contexts. This aim was performed by choosing digital health initiatives from each country (two in Jordan and three in Palestine) based on RMNCH. A qualitative study design was adopted. We developed a digital maturity assessment tool assessing two maturity levels: the information and communications technology digital infrastructure, and data governance and interoperability in place for the five selected RMNCH initiatives in Jordan and Palestine. Overall, the digital infrastructure and technological readiness components are more advanced and show higher maturity levels compared with data governance and interoperability components in Jordan and Palestine. In Jordan, the overall Jordan stillbirths and neonatal deaths surveillance initiative maturity indicators are somehow less advanced than those of the Electronic Maternal and Child Health Handbook-Jordan (EMCH-J) application. In Palestine, the Electronic Maternal and Child Health-registry initiative maturity indicators are more advanced than both Avicenna and EMCH-Palestine initiatives. The findings highlighted several challenges and opportunities around the application and implementation of selected digital health initiatives in the provision of RMNCH in Jordan and Palestine. Our findings shed lights on the maturity level of these initiatives within fragile contexts. The maturity level of the five RMNCH initiatives in both countries is inadequate and requires further advancement before they can be scaled up and scaled out. Taking the World Health Organization recommendations into account when developing, implementing, and scaling digital health initiatives in low- and middle-income countries can result in successful and sustainable initiatives, thus meeting health needs and improving the quality of health care received by individuals especially those living in fragile contexts.

Assessment of diagnostic accuracy and adherence to maternal and child health guidelines as a measure of clinical competence of frontline healthcare workers in Nigeria.

Clinical competence of primary healthcare (PHC) workers is important in the delivery of maternal and child health care and services. In this cross-sectional study, we investigated the diagnostic accuracy and adherence to clinical guidelines for the management of some clinical conditions such as malaria, diarrhea, pneumonia, neonatal asphyxia and postpartum hemorrhage, as a proxy to measure the clinical competence of frontline health workers in PHCs in selected states in Nigeria. Ninety PHC facilities were randomly selected in each State and the FCT. Of the 3330 health workers, only 36.0% were able to correctly diagnose the five selected medical conditions. There was a significant difference in the diagnostic accuracy of the health workers with the doctors having highest diagnostic accuracy (65.5%) compared to other health workers (p <0.001). Adherence to the management guidelines was generally poor across all cadres of health workers and this pattern appear similar across the geopolitical regions in the country. The highest adherence to guidelines was observed among medical doctors (38.2%). The diagnostic accuracy and adherence to national guidelines for managing patients was poor among health workers, particularly, among other cadres except doctors. PHC workers in Nigeria need continuous training to enhance their clinical competence to improve quality of maternal and child health care.

Exploring ethics in the implementation of the Community Health Worker programmes in India.

The public health machinery in India is largely driven by the frontline community health workers (CHWs), namely the Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs), Anganwadi Workers (AWWs) and other multipurpose health workers. They play a vital role as intermediaries between the community and the health system. The ANMs perform important tasks such as spreading health promotion messages, supporting behavioural change, surveillance of diseases, delivery of maternal and child health services at the doorsteps of beneficiaries, prevention of common minor ailments and other public health tasks, as and when the need arises [1]. The ASHAs are trained female health workers who mobilise people to utilise health services and also provide basic primary healthcare.

Perceived Barriers and Facilitators to Implementation of Maternal and Child Health Care by Community Health Workers in Rwanda: A Qualitative Study

The motivations and barriers experienced by community health workers (CHWs) during the delivery of maternal and child health (MCH) services are less documented in Rwanda. This study aimed to explore the barriers and facilitators of implementing MCH care as perceived by CHWs. A descriptive qualitative study was conducted, and Semi-structured interviews with flow-up probing questions were used to collect data. A number of 24 interviews were conducted with CHWs from three selected sectors of the Gicumbi district including four supervisors of CHWs from each selected health center and one at the district hospital. Three focus group discussions with CHWs from each site were also conducted. Ethical approval was obtained from Mount Kenya University and permission to collect data from the study sites was granted. NVIVO software was used for analysis, and then the content analysis was adopted to identify themes merging from the interviews and focus group discussions. The study findings revealed emerged factors that facilitate the CHWs to deliver MCH services to their communities: liking their work, trust by the community, respect from the community, the willingness to help, desire to gain knowledge, being human, and sacrifice for the wellness of the community. On another hand, the findings indicated that the work of CHW has various barriers including working many hours, lack of equipment, lack of knowledge, unsatisfactory salary, heavy workload, lack of working space, lack of facilitation for communication, family conflicts, lack of specified working time, and believes.

Opportunities to Strengthen Women's Nutrition Within Maternal Health Service Delivery: Reflections From Global Health Implementation.

Opportunities to Strengthen Women's Nutrition Within Maternal Health Service Delivery: Reflections From Global Health Implementation.

Addressing the need for an appropriate skilled delivery care workforce in Burundi to support Maternal and Newborn Health Service Delivery Redesign (MNH-Redesign): a sequential study protocol.

Background Despite Burundi having formed a network of 112 health facilities that provide emergency obstetric and neonatal care (EmONC), the country continues to struggle with high rates of maternal and newborn deaths. There is a dearth of empirical evidence on the capacity and performance of EmONC health facilities and on the real needs to inform proper planning and policy. Our study aims to generate evidence on the capacity and performance of EmONC health facilities in Burundi and examine how the country might develop an appropriate skilled delivery care workforce to improve maternal and newborn survival. Methods We will use a sequential design where each study phase serially inputs into the subsequent phase. Three main study phases will be carried out: i) an initial policy document review to explore global norms and local policy intentions for EmONC staffing and ii) a cross-sectional survey of all EmONC health facilities to determine what percent of facilities are functional including geographic and population coverage gaps, identify staffing gaps assessed against norms, and identify other needs for health facility strengthening. Finally, we will conduct surveys in selected schools and ministries to examine training and staffing costs to inform staffing options that might best promote service delivery with adequate budget impacts to increase efficiency. Throughout the study, we will engage stakeholders to provide input into what are reasonable staffing norms as well as feasible staffing alternatives within Burundi's budget capacity. Analytical models will be used to develop staffing proposals over a realistic policy timeline. Conclusion Evidence-based health planning improves cost-effectiveness and reduces wastage within scarce and resource-constrained contexts. This study will be the first large-scale research in Burundi that builds on stakeholder support to generate evidence on the capacity of designated EmONC health facilities including human resources diagnosis and develop staffing skill-mix tradeoffs for policy discussion.

Addressing the need for an appropriate skilled delivery care workforce in Burundi to support Maternal and Newborn Health Service Delivery Redesign (MNH-Redesign): a sequential study protocol

Background Despite Burundi having formed a network of 112 health facilities that provide emergency obstetric and neonatal care (EmONC), the country continues to struggle with high rates of maternal and newborn deaths. There is a dearth of empirical evidence on the capacity and performance of EmONC health facilities and on the real needs to inform proper planning and policy. Our study aims to generate evidence on the capacity and performance of EmONC health facilities in Burundi and examine how the country might develop an appropriate skilled delivery care workforce to improve maternal and newborn survival. Methods We will use a sequential design where each study phase serially inputs into the subsequent phase. Three main study phases will be carried out: i) an initial policy document review to explore global norms and local policy intentions for EmONC staffing and ii) a cross-sectional survey of all EmONC health facilities to determine what percent of facilities are functional including geographic and population coverage gaps, identify staffing gaps assessed against norms, and identify other needs for health facility strengthening. Finally, we will conduct surveys in schools and different ministries to examine training and staffing costs to inform staffing options that might best promote service delivery with adequate budget impacts to increase efficiency. Throughout the study, we will engage stakeholders to provide input into what is reasonable staffing norms as well as feasible staffing alternatives within Burundi’s budget capacity. Analytical models will be used to develop staffing proposals over a realistic policy timeline. Conclusion Evidence-based health planning improves cost-effectiveness and reduces wastage within scarce and resource-constrained contexts. This study will be the first large-scale research in Burundi that builds on stakeholder support to generate evidence on the capacity of designated EmONC health facilities including human resources diagnosis and develop staffing skill-mix tradeoffs for policy discussion.

Evidence of Interventions and Strategies to Bridge the Quality Improvement Gap Led by HCW at the Frontline in SSA: A Scoping Review

Abstract Introduction Poor quality health care is a significant cause of preventable deaths, especially in low- and middle-income countries (LMICs). Quality improvement is multifaceted and includes strategies such as standard setting, quality assurance and clinic audits. In order to move quality improvement in health care into every day practice it is essential to fully engage the frontline where health care is delivered. The objective of this scoping review is to investigate front line health care worker line led quality improvement in Sub Saharan Africa (SSA). Methods We conducted a scoping review to identify, map and synthesize evidence on health care worker led quality improvement initiatives in Sub Sahara Africa using electronic databases PubMed, Cochrane, Embase, CINAHL, Scopus and Psychinfo to identify peer-reviewed literature published between January 2000 and January 2021. To identify grey literature, we used the same search terms in google search to a maximum of 10 pages or when there was no new information. All evidence was scored based on the 6 criteria described by Backhouse et al., which clearly distinguish quality improvement from clinical audit and research. Inclusion criteria were studies that involved frontline health care workers to test “change ideas” and used data systems to measure improvement in service delivery. Results A total of 75 records were identified and including 52 from the peer review search and 23 records from the grey literature search. Only 15 of 47 countries had publications (peer-review or grey literature) describing QI initiatives. Most quality improvement (QI) initiatives were multicomponent and included knowledge transfer, skills building, mentorship and learning visits. Most publications reported QI initiatives aimed at reproductive, maternal, neonatal and child health (n=23) and HIV (n=14) service delivery. Only 6 had experimental designs. No publications were identified prior to 2012 and a rapid escalation of published quality improvement initiatives from 2012 to 2020 was seen. Conclusion QI is in the very nascent stage in SSA. Most large-scale public health QI initiatives are sector specific, siloed, and donor driven. QI initiatives within sector specific programs have not moved horizontally and have had limited ability to change the broader system. Energy must be exerted to change the status quo. Making health care safer and more effective is not spontaneous.

Addressing the need for an appropriate skilled delivery care workforce in Burundi to support Maternal and Newborn Health Service Delivery Redesign (MNH-Redesign): a sequential study protocol

Background Despite Burundi having formed a network of 112 health facilities that provide emergency obstetric and neonatal care (EmONC), the country continues to struggle with high rates of maternal and newborn deaths. There is a dearth of empirical evidence on the capacity and performance of EmONC health facilities and on the real needs to inform proper planning and policy. Our study aims to generate evidence on the capacity and performance of EmONC health facilities in Burundi and examine how the country might develop an appropriate skilled delivery care workforce to improve maternal and newborn survival. Methods We will use a sequential design where each study phase serially inputs into the subsequent phase. Three main study phases will be carried out: i) an initial policy document review to explore global norms and local policy intentions for EmONC staffing and ii) a cross-sectional survey of all EmONC health facilities to determine what percent of facilities are functional including geographic and population coverage gaps, identify staffing gaps assessed against norms, and identify other needs for health facility strengthening. Finally, we will conduct surveys in schools and different ministries to examine training and staffing costs to inform staffing options that might best promote service delivery with adequate budget impacts to increase efficiency. Throughout the study, we will engage stakeholders to provide input into what is reasonable staffing norms as well as feasible staffing alternatives within Burundi's budget capacity. Analytical models will be used to develop staffing proposals over a realistic policy timeline. Conclusion Evidence-based health planning improves cost-effectiveness and reduces wastage within scarce and resource-constrained contexts. This study will be the first large-scale research in Burundi that builds on stakeholder support to generate evidence on the capacity of designated EmONC health facilities including human resources diagnosis and develop staffing skill-mix tradeoffs for policy discussion.

Perceptions and Experiences of Health Care Workers on Accountability Mechanisms for Enhancing Quality Improvement in the Delivery of Maternal Newborns and Child Health Services in Mkuranga, Tanzania

BackgroundMaternal mortality estimates globally show that by 2017 there were still 211 deaths per 100,000 live births; more strikingly, 99% of them happen in low and middle-income countries, including Tanzania. There has been insufficient progress in improving maternal and newborn health despite the efforts to strengthen the health systems, to improve the quality of maternal health in terms of training and deploying human resources for health, constructing health facilities, and supplying medical products. However, fewer efforts are invested in enhancing accountability toward the improvement of the quality of maternal health care. This the study was conducted to explore the perceptions of healthcare workers regarding accountability mechanisms for enhancing quality improvement in the delivery of maternal newborn and child health services in Tanzania.MethodsWe adopted phenomenology as a study design to understand how health workers perceive accountability and data were collected using semi-structured interviews. We then used thematic analysis to analyze themes and sub- themes.ResultsThe study revealed four categories of perceptions namely, differences in the conceptualization of accountability and accountability mechanisms, varied opinions about the existing accountability mechanisms, perceived the usefulness of accountability mechanisms, together with perceived challenges in the enforcement of accountability mechanisms.ConclusionPerceived variations in the understanding of accountability among healthcare workers signaled a proper but fragmented understanding of accountability in maternal care. Accountability mechanisms are perceived to be useful for enhancing hard work in the provision of maternal health services. Moreover, inadequate motivation resulting from health system bottlenecks tend to constrain enforcement of accountability in the provision of maternal care services. Thus, we recommend that the government should deal with health system constraints and enforce regular monitoring and supervision.

The impact of training on self-reported performance in reproductive, maternal, and newborn health service delivery among healthcare workers in Tanzania: a baseline- and endline-survey

BackgroundDelivery of quality reproductive health services has been documented to depend on the availability of healthcare workers who are adequately supported with appropriate training. However, unmet training needs among healthcare workers in reproductive, maternal, and newborn health (RMNH) in low-income countries remain disproportionately high. This study investigated the effectiveness of training with onsite clinical mentorship towards self-reported performance in RMNH among healthcare workers in Mwanza Region, Tanzania.MethodsThe study used a quasi-experimental design with pre-and post-intervention evaluation strategy. The baseline was compared with two endline groups: those with intervention (training and onsite mentorship) and those without. The differences among the three groups in the sociodemographic characteristics were analyzed by using chi-square test for categorical variables, independent-sample t-test for continuous variables and Mann–Whitney U test for ordinal or skewed continuous data. The independent sample t-test was used to determine the effect of the intervention by comparing the computed self-reported performance on RMNH services between the intervention and control groups. The paired-samples t-test was used to measure the differences between before and after intervention groups. Significance was set at a 95% confidence interval with p ≤ 0.05.ResultsThe study included a sample of 216 participants with before and after intervention groups comprising of 95 (44.0%) and 121 (56.0%) in the control group. The comparison between before and after intervention groups revealed a statistically significant difference (p ≤ 0.05) in all the dimensions of the self-reported performance scores. However, the comparison between intervention groups and controls indicated a statistical significant difference on intra-operative care (t = 3.10, df = 216, p = 0.002), leadership skills (t = 1.85, df = 216, p = 0.050), Comprehensive emergency obstetric and newborn care (CEMONC) (t = 34.35, df = 216, p ≤ 0.001), and overall self-reported performance in RMNH (t = 3.15, df = 216, p = 0.002).ConclusionsThis study revealed that the training and onsite clinical mentorship to have significant positive changes in self-reported performance in a wide range of RMNH services especially on intra-operative care, leadership skills and CEMONC. However, further studies with rigorous designs are warranted to evaluate the long-term effect of such training programs on RMNH outcomes.

Type of occupation and early antenatal care visit among women in sub-Saharan Africa

BackgroundType of occupation has been linked to early antenatal care visits whereby women in different occupation categories tend to have different timing for antenatal care visits. Different occupations require varying levels of commitment, remuneration and energy requirements. This study, therefore, sought to investigate the association between the type of occupation and early antenatal care visits in sub-Saharan Africa.MethodsThis is a secondary analysis of Demographic and Health Survey data from 29 countries in sub-Saharan Africa conducted between 2010 and 2018. The study included 131,912 working women. We employed binary logistic regression models to assess the association between type of occupation and timely initiation of antenatal care visits.ResultsThe overall prevalence of early initiation of antenatal care visits was 39.9%. Early antenatal care visit was high in Liberia (70.1%) but low in DR Congo (18.6%). We noted that compared to managerial workers, women in all other work categories had lower odds of early antenatal care visit and this was prominent among agricultural workers [aOR = 0.74, CI = 0.69, 0.79]. Women from Liberia [aOR = 3.14, CI = 2.84, 3.48] and Senegal [aOR = 2.55, CI = 2.31, 2.81] had higher tendency of early antenatal care visits compared with those from Angola.ConclusionThe findings bring to bear some essential elements worth considering to enhance early antenatal care visits within sub-Saharan Africa irrespective of the type of occupation. Women in the agricultural industry need much attention in order to bridge the early antenatal care visit gap between them and workers of other sectors. A critical review of the maternal health service delivery in DR Congo is needed considering the low rate of early antenatal care visits.

Health Systems Response to Routine Maternal and Child Health Service Delivery Amidst COVID -19 Pandemic at Kanyama 1st Level Hospital - Lusaka District

Aim: To ascertaining the health systems response to routine maternal and child health services amidst the COVID -19 pandemic at Kanyama 1st Level Hospital – Lusaka, Zambia. Method: A qualitative research study was conducted on Antenatal Clinic and Post Natal Clinic mothers as targets; Community Health Workers, Health Care Workers, and policy makers as key informants, utilizing five (5) Focused group discussion to reach saturation. &nbsp;Data was collected using topic guides and analyzed manually by transcribing and coding it. Sample size for participants were selected using simple random sampling on ANC/ PNC mothers, while the three categories of key informants were purposefully selected. The indirect effects of COVID-19 pandemic framework which mirrors the WHO six building blocks adopted from the Global Health Life Saving Tools was used to analyze the health system’s readiness amidst the COVID-19 pandemic at Kanyama 1st Level Hospital – Lusaka, Zambia. Results Findings were that the facility had challenges with regards to health workforce, supplies and equipment, which ultimately affected quality provision of maternal health services as outreach services were disrupted. Although the health facility responded well in providing alternative schedule to cope with the influx of mothers at the center from the closed outreach posts, the epidemic preparedness in responding to the epidemic was not up to the expected standards. Later, reduction in PNC and ANC attendance was noted, and home deliveries and deaths suddenly increased. The HCW, CHWs also had challenges ranging from lack of psychosocial support / Personal Protection Equipments, and inadequate training.&nbsp; In addition, frontline workers had inadequate knowledge on triaging a Covid-19 suspected pregnant mothers. Also findings such as lack of tracking system for follow up on mothers who missed appointments due to fear of contracting COVID -19; and essential drug stock out&nbsp; was noted during the pandemic. Monitoring and evaluation system was in place but irregular and not in tandem with prompt feedback that was required. On the other hand, the &nbsp;study results also revealed one positive aspect of ANC/PNC &nbsp;mothers having knowledge on the importance of maternal services despite fears for COVID – 19 ,&nbsp; facility delivery, signs and symptoms of COVID -19 infections and preventive measures. However, the end users expressed myths on the transmission of the virus and the testing process.&nbsp; Conclusion: the research revealed lack of epidemic preparedness at Kanyama 1st level hospital that would allow the continuation of maternal and child health services amidst the COVID-19 outbreak.&nbsp; The facility had needed a timely and comprehensive health system response to the epidemic that is elaborate and specific to respond to all specifics of the health system in relation to maternal services verses COVID -19 which would have been the answer to this call.

Conceptualising and assessing health system resilience to shocks: a cross-disciplinary view.

Health systems worldwide face major challenges in anticipating, planning for and responding to shocks from infectious disease epidemics, armed conflict, climatic and other crises. Although the literature on health system resilience has grown substantially in recent years, major uncertainties remain concerning approaches to resilience conceptualisation and measurement. This narrative review revisits literatures from a range of fields outside health to identify lessons relevant to health systems. Four key insights emerge. Firstly, shocks can only be understood by clarifying how, where and over what timescale they interact with a system of interest, and the dynamic effects they produce within it. Shock effects are contingent on historical path-dependencies, and on the presence of factors or system pathways (e.g. financing models, health workforce capabilities or supply chain designs) that may amplify or dampen impact in unexpected ways. Secondly, shocks often produce cascading effects across multiple scales, whereas the focus of much of the health resilience literature has been on macro-level, national systems. In reality, health systems bring together interconnected sub-systems across sectors and geographies, with different components, behaviours and sometimes even objectives - all influencing how a system responds to a shock. Thirdly, transformability is an integral feature of resilient social systems: cross-scale interactions help explain how systems can show both resilience and transformational capability at the same time. We illustrate these first three findings by extending the socioecological concept of adaptive cycles in social systems to health, using the example of maternal and child health service delivery. Finally, we argue that dynamic modelling approaches, under-utilised in research on health system resilience to date, have significant promise for identification of shock-moderating or shock-amplifying pathways, for understanding effects at multiple levels and ultimately for building resilience.

Community-based management of chronic obstructive pulmonary disease in Nepal-Designing and implementing a training program for Female Community Health Volunteers.

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality in Nepal. Female community health volunteers (FCHVs) have proven effective in the delivery of reproductive, maternal, and child health services in Nepal and recently in the prevention and management of hypertension and type 2 diabetes. Evidence on their roles in COPD management is not yet available. The aim of this study was to develop, implement, and evaluate a training program for FCHVs regarding COPD prevention and management. The training program was part of a cluster-randomized trial of a 12-month intervention to improve COPD outcomes in a semi-urban area of Western Nepal. A six-day workshop consisting of thirty hours of training was developed for FCHVs. Training materials incorporated introduction to COPD, risk factors and symptoms, COPD status assessment guide for FCHVs, guidance on breathing techniques, and exercises for people living with COPD. Pre- and post-test questionnaires were administered to assess the change in knowledge of FCHVs, post training skills assessment followed by semi-structured interviews assessed FCHVs' satisfaction with the training program. The findings of the pre- and post- test assessments showed a significant improvement in FCHVs' COPD-related knowledge from a median (interquartile range) score of 12 (3-16) before to 21 (21-22) (p<0.001) after the training program. The qualitative assessment revealed the feasibility of FCHVs' training on COPD and their acceptability to deliver the intervention package within the community. It also indicated that implementing future training with an extended period and a few days break in-between could enhance the effectiveness. Training of FCHVs in COPD management is feasible and leads to improvement in knowledge. The motivation shown by FCHVs to deliver the intervention could inform and guide community programs and policies for COPD prevention and management in Nepal and similar settings.

Climate change impacts on maternal and new-born health in Africa: Intervention options

Abstract Rising global temperatures raise several health concerns, especially in areas where access is limited to air conditioning and other forms of cooling. Anatomical and physiological changes during pregnancy increase vulnerability of women and foetuses to heat exposure. High temperatures can overwhelm thermoregulation in pregnant women, cause dehydration and endocrine dysfunction, and affect placental function. Clinical consequences include preeclampsia, preterm birth, stillbirth and prolonged labour. Additionally, high ambient temperatures increase risks for several infections and affect health worker performance. There are a range of adaptation options to reduce heat exposure or impacts of exposure during pregnancy. Adaptations can be categorised as behavioural changes, interventions at the health service level, public health measures, building modifications and nature-based solutions, and structural interventions to enhance resilience. Existing maternal and child health services delivery platforms are adept at absorbing new health interventions and could play a key role in new programmes for responding to climate change. We need robust advocacy now more than ever to prevent further environmental harms.